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Background: The Centers for Disease Control and Prevention’s Emerging Infections Program conducts active laboratory- and population-based surveillance for carbapenem-resistant Enterobacterales (CRE) and extended spectrum beta-lactamase-producing Enterobacterales (ESBL-E). To better understand the U.S. epidemiology of these organisms among children, we determined the incidence of pediatric CRE and ESBL-E cases and described their clinical characteristics. Methods: Surveillance was conducted among children <18 years of age for CRE from 2016–2020 in 10 sites, and for ESBL-E from 2019–2020 in 6 sites. Among catchment-area residents, an incident CRE case was defined as the first isolation of Escherichia coli, Enterobacter cloacae complex, Klebsiella aerogenes, K. oxytoca, or K. pneumoniae in a 30-day period resistant to ≥1 carbapenem from a normally sterile site or urine. An incident ESBL-E case was defined as the first isolation of E. coli, K. pneumoniae, or K. oxytoca in a 30-day period resistant to any third-generation cephalosporin and non-resistant to all carbapenems from a normally sterile site or urine. Case records were reviewed. Results: Among 159 CRE cases, 131 (82.9%) were isolated from urine and 19 (12.0%) from blood; median age was 5 years (IQR 1–10) and 94 (59.1%) were female. Combined CRE incidence rate per 100,000 population by year ranged from 0.47 to 0.87. Among 207 ESBL-E cases, 160 (94.7%) were isolated from urine and 6 (3.6%) from blood; median age was 6 years (IQR 2–15) and 165 (79.7%) were female. Annual ESBL incidence rate per 100,000 population was 26.5 in 2019 and 19.63 in 2020. Incidence rates of CRE and ESBL-E were >2-fold higher in infants (children <1 year) than other age groups. Among those with data available, CRE cases were more likely than ESBL-E cases to have underlying conditions (99/158 [62.7%] versus 59/169 [34.9%], P<0.0001), prior healthcare exposures (74/158 [46.8%] versus 38/169 [22.5%], P<0.0001), and be hospitalized for any reason around time of their culture collection (75/158 [47.5%] versus 38/169 [22.5%], P<0.0001); median duration of admission was 18 days [IQR 3–103] for CRE versus 10 days [IQR 4–43] for ESBL-E. Urinary tract infection was the most frequent infection for CRE (89/158 [56.3%]) and ESBL-E (125/169 [74.0%]) cases. Conclusion: CRE infections occurred less frequently than ESBL-infections in U.S. children but were more often associated with healthcare risk factors and hospitalization. Infants had highest incidence of CRE and ESBL-E. Continued surveillance, infection prevention and control efforts, and antibiotic stewardship outside and within pediatric care are needed
Background: Morbidity and mortality associated with invasive fungal infections and concerns of emerging antifungal resistance have highlighted the importance of optimizing antifungal therapy among hospitalized patients. Little is known about antifungal stewardship (AFS) practices among acute-care hospitals. We sought to assess AFS activities within Connecticut and to identify opportunities for improvement. Methods: An electronic survey assessing AFS practices was distributed to infectious disease physicians or pharmacy antibiotic stewardship program leaders in Connecticut hospitals. Survey questions evaluated AFS activities based on antibiotic stewardship principles, including several CDC Core Elements. Questions assessed antifungal restriction, prospective audit and feedback practices, antifungal utilization measurements, and the perceived utility of a local or statewide antifungal antibiogram. Results: Responses were received from 15 respondents, which represented 20 of 31 hospitals (65%); these hospitals made up the majority of the acute-care hospitals in Connecticut. Furthermore, 18 of these hospitals (58%) include antifungals in their stewardship programs. Also, 16 hospitals (52%) conduct routine review of antifungal ordering and provide feedback to providers for some antifungals, most commonly for amphotericin B, voriconazole, micafungin, isavuconazole, and flucytosine. All hospitals include guidance on intravenous (IV) to oral (PO) conversions, when appropriate. Only 14 of hospitals (45%) require practitioners to document indication(s) for systemic antifungal use. Most hospitals (17, 55%) provide recommendations for de-escalation of therapy in candidemia, though only 4 (13%) have institutional guidelines for candidemia treatment, and only 11 hospital mandates an infectious diseases consultation for candidemia. Assessing outcomes pertaining to antifungal utilization is uncommon; only 8 hospitals (26%) monitor days of therapy and 5 (16%) monitor antifungal expenditures. Antifungal susceptibility testing on Candida bloodstream isolates is performed routinely at 6 of the hospitals (19%). Most respondents (19, 95%) support developing an antibiogram for Candida bloodstream isolates at the statewide level. Conclusions: Although AFS interventions occur in Connecticut hospitals, there are opportunities for enhancement, such as providing institutional guidelines for candidemia treatment and mandating infectious diseases consultation for candidemia. The Connecticut Department of Public Health implemented statewide Candida bloodstream isolate surveillance in 2019, which includes antifungal susceptibility testing. The creation of a statewide antibiogram for Candida bloodstream infections is underway to support empiric antifungal therapy.
Background: Automated testing instruments (ATIs) are commonly used by clinical microbiology laboratories to perform antimicrobial susceptibility testing (AST), whereas public health laboratories may use established reference methods such as broth microdilution (BMD). We investigated discrepancies in carbapenem minimum inhibitory concentrations (MICs) among Enterobacteriaceae tested by clinical laboratory ATIs and by reference BMD at the CDC. Methods: During 2016–2018, we conducted laboratory- and population-based surveillance for carbapenem-resistant Enterobacteriaceae (CRE) through the CDC Emerging Infections Program (EIP) sites (10 sites by 2018). We defined an incident case as the first isolation of Enterobacter spp (E. cloacae complex or E. aerogenes), Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or K. variicola resistant to doripenem, ertapenem, imipenem, or meropenem from normally sterile sites or urine identified from a resident of the EIP catchment area in a 30-day period. Cases had isolates that were determined to be carbapenem-resistant by clinical laboratory ATI MICs (MicroScan, BD Phoenix, or VITEK 2) or by other methods, using current Clinical and Laboratory Standards Institute (CLSI) criteria. A convenience sample of these isolates was tested by reference BMD at the CDC according to CLSI guidelines. Results: Overall, 1,787 isolates from 112 clinical laboratories were tested by BMD at the CDC. Of these, clinical laboratory ATI MIC results were available for 1,638 (91.7%); 855 (52.2%) from 71 clinical laboratories did not confirm as CRE at the CDC. Nonconfirming isolates were tested on either a MicroScan (235 of 462; 50.9%), BD Phoenix (249 of 411; 60.6%), or VITEK 2 (371 of 765; 48.5%). Lack of confirmation was most common among E. coli (62.2% of E. coli isolates tested) and Enterobacter spp (61.4% of Enterobacter isolates tested) (Fig. 1A), and among isolates testing resistant to ertapenem by the clinical laboratory ATI (52.1%, Fig. 1B). Of the 1,388 isolates resistant to ertapenem in the clinical laboratory, 1,006 (72.5%) were resistant only to ertapenem. Of the 855 nonconfirming isolates, 638 (74.6%) were resistant only to ertapenem based on clinical laboratory ATI MICs. Conclusions: Nonconfirming isolates were widespread across laboratories and ATIs. Lack of confirmation was most common among E. coli and Enterobacter spp. Among nonconfirming isolates, most were resistant only to ertapenem. These findings may suggest that ATIs overcall resistance to ertapenem or that isolate transport and storage conditions affect ertapenem resistance. Further investigation into this lack of confirmation is needed, and CRE case identification in public health surveillance may need to account for this phenomenon.
Background: Little is known about the epidemiology, microbiology, and clinical management of carbapenem-resistant Enterobacteriaceae (CRE) in outpatient settings. In Connecticut, all clinical CRE isolates are submitted to the state public health laboratory (SPHL) for a customized panel of antimicrobial susceptibility and carbapenemase gene testing. We describe all outpatient cases of CRE in Connecticut in 2018, including location of presentation, risk factors, microbiology and aspects of treatment. Methods: Outpatient CRE cases were defined as CRE infection in a patient not hospitalized at the time of positive CRE culture or within 30 days after culture collection. Outpatient cases were identified from routine statewide CRE reporting by reviewing clinical and laboratory data. A questionnaire was sent to outpatient providers who ordered the cultures that yielded CRE to collect additional clinical information. Antimicrobial susceptibility and carbapenemase gene detection results from the SPHL were also summarized. Results: Among 53 outpatient CRE cases (1 blood, 52 urine), the most common organisms were Enterobacter (25, 47%), Klebsiella (12, 23%), and E. coli (11, 21%). Overall, 21 (39.6%) patients presented in primary care settings, 8 (15%) in urology offices, 6 (11%) in women’s health/OBGYN clinics; the remainder presented across various clinical settings (Fig. 1). Of 42 patients for whom clinical data were available, 45% had been hospitalized within the prior year and 19% had a chronic indwelling device. Among outpatient CRE cases, infectious diseases consultation was reported in 9.5% and lab consultation in none. Median patient age was 83 years. Of 36 CRE samples for which lab data were available, 9 (25%) were carbapenemase-producers (CP-CRE), of which 8 were blaKPC positive. Sensitivity rates to oral antimicrobials ranged from 43% to 75% (Table 1). Conclusions: CRE infections occur in several different outpatient settings, and formal ID consultation in the management of these patients is infrequent. These findings highlight the critical need for providers across different outpatient specialties to be familiar with the clinical management and infection control practices needed in caring for patients with CRE. Hospitalization within the year prior to presentation was frequent among patients who developed subsequent CRE-positive cultures. Most outpatient CP-CRE cases in CT are due to KPC production. Overall, sensitivity to oral antimicrobials frequently prescribed in outpatient settings is low, providing additional challenges to the outpatient management of patients with CRE infection. Fosfomycin, though only approved for E. coli infections, may be an acceptable antibiotic choice for the treatment of these patients.
Background: Carbapenem-resistant Acinetobacter baumannii (CRAB), a multidrug-resistant gram-negative bacterium, can cause difficult-to-treat infections with mortality in approximately half of CRAB cases. CRAB can spread among healthcare facilities after transfer of an infected or colonized patient. Strategies to limit CRAB spread include adherence to contact precautions, environmental cleaning with bleach, and screening to identify colonized patients. During July–September 2018, the Connecticut Department of Public Health (DPH) worked with an acute-care hospital (hospital A) to contain an outbreak of OXA-23–producing CRAB (OXA-23 is an enzyme that confers resistance to carbapenems). During November 2018–March 2019, statewide CRAB surveillance identified additional cases of related OXA-23–producing CRAB at other healthcare facilities. DPH, Connecticut State Public Health Laboratory (SPHL), and the Antibiotic Resistance Laboratory Network (ARLN) investigated to prevent additional cases. Methods: Since January 2017, CRAB isolates have been routinely sent to SPHL and ARLN for carbapenemase gene detection and whole-genome sequencing (WGS) to determine isolate relatedness. During November 2018–March 2019, DPH collected patient healthcare history for patients with CRAB isolates to identify outbreaks and provide assistance in infection control and prevention to healthcare facilities reporting CRAB cases. Beginning May 2019, DPH and ARLN offered facilities screening to identify patients colonized with OXA-23–producing CRAB. Results: Of 10 OXA-23–producing CRAB isolates reported to DPH during November 2018–March 2019, 3 were closely related to the 9 isolates from hospital A’s outbreak by WGS (single-nucleotide polymorphism difference range, 1–16). One isolate was from a patient who had been admitted to hospital A during July 2018. All 3 patients with CRAB isolates shared a history of residence at long-term–care facility A (LTCF A). Two patients received a CRAB infection diagnosis upon admission to hospital B after transfer from LTCF A. Both LTCF A and hospital B performed environmental cleaning with bleach and placed CRAB-identified patients on contact precautions. LTCF A declined screening patients for CRAB, whereas hospitals B and C, which receive frequent transfers from LTCF A, screened all patients on admission from LTCF A. During May–September 2019, among 6 patients screened, 1 was colonized with OXA-23–producing CRAB and was placed on contact precautions. Conclusions: Transfer of patients who are infected or colonized with CRAB among hospitals and LTCFs can facilitate the regional spread of CRAB. Strategies for containing the spread of carbapenemase-producing organisms include adherence to contact precautions, colonization screening, interfacility communication, and collaboration with public health.
Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a serious threat to patient safety due to limited treatment options and propensity to spread in healthcare settings. Using Emerging Infections Program (EIP) data, we describe changes in CRAB incidence and epidemiology. Methods: During January 2012 to December 2018, 9 sites (Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee) participated in active laboratory- and population-based surveillance. An incident case was defined as the first isolation of A. baumannii complex, in a 30-day period, resistant to ≥1 carbapenem (excluding ertapenem) from a normally sterile site or urine of a surveillance area resident. Cases were considered hospital-onset (HO) if the culture was collected >3 days after hospital admission; all others were community-onset (CO). Cases were classified as device-associated (DA) if the patient had 1 or more medical devices (ie, urinary catheter, central venous catheter (CVC), endotracheal/nasotracheal tube, tracheostomy, or another indwelling device) present in the 2 days prior to culture collection. Temporal trends were estimated using generalized linear models adjusted for age, race, sex, and EIP site. Results: Overall, 984 incident CRAB cases were identified, representing 849 patients. Among these patients, 291 (34%) were women, 510 (61%) were nonwhite, and the median age was 62 years (mean, 59; range, 0–102). Among the cases, 226 (23%) were HO; 758 (77%) were CO; and 793 (81%) were DA. Overall incidence rates in 2012 and 2018 were 1.58 (95% CI, 1.29–1.90) and 0.60 (95% CI, 0.40–0.67) per 100,000 population, respectively. There was a 15% annual decrease in incidence (adjusted rate ratio [aRR] 0.85; 95% CI: 0.82-0.88, P < .0001). Decreases were observed among sterile site (aRR 0.88; 95% CI, 0.84–0.93) and urine cases (aRR 0.83; 95% CI, 0.80–0.87). Annual decreases occurred for HO cases (aRR, 0.78; 95% CI, 0.73–0.85) and CO cases (aRR, 0.86; 95% CI, 0.83–0.9). The DA cases decreased 16% annually overall (aRR, 0.84; 95% CI, 0.81–0.88). Decreases among cases in patients with CVC (aRR, 0.85; 95% CI, 0.80–0.90) and urinary catheters (aRR, 0.84; 95% CI, 0.80–0.88) were smaller than what was seen in patients with other indwelling devices (aRR, 0.81; 95% CI, 0.77–0.86). Discussion: Overall, from 2012 to 2018, the incidence of CRAB decreased >60%. Decreases were observed in all case groups, regardless of source, infection onset location, or types of devices. Smaller annual decreases in rates of CO-CRAB than HO-CRAB suggest that there may be opportunities to accelerate prevention outside the hospital to further reduce the incidence of these difficult-to-treat infections.
We assessed the appropriateness of initiating antibiotics in 49 nursing home (NH) residents receiving antibiotics for urinary tract infection (UTI) using 3 published algorithms. Overall, 16 residents (32%) received prophylaxis, and among the 33 receiving treatment, the percentage of appropriate use ranged from 15% to 45%. Opportunities exist for improving UTI antibiotic prescribing in NH.
To facilitate surveillance and describe the burden of healthcare-associated infection (HAI) in nursing homes (NHs), we compared the quality of resident-level data collected by NH personnel and external staff.
A 1-day point-prevalence survey
SETTING AND PARTICIPANTS
Overall, 9 nursing homes among 4 Centers for Disease Control and Prevention (CDC) Emerging Infection Program (EIP) sites were included in this study.
NH personnel collected data on resident characteristics, clinical risk factors for HAIs, and the presence of 3 HAI screening criteria on the day of the survey. Trained EIP surveillance officers collected the same data elements via retrospective medical chart review for comparison; surveillance officers also collected available data to identify HAIs (using revised McGeer definitions). Overall agreement was calculated among residents identified by both teams with selected risk factors and HAI screening criteria. The impact of using NH personnel to collect screening criteria on HAI prevalence was assessed.
The overall prevalence of clinical risk factors among the 1,272 residents was similar between NH personnel and surveillance officers, but the level of positive agreement (residents with factors identified by both teams) varied between 39% and 87%. Surveillance officers identified 253 residents (20%) with ≥1 HAI screening criterion, resulting in 67 residents with an HAI (5.3 per 100 residents). The NH personnel identified 152 (12%) residents with ≥1 HAI screening criterion; 42 residents had an HAI (3.5 per 100 residents).
We identified discrepancies in resident-level data collection between surveillance officers and NH personnel, resulting in varied estimates of the HAI prevalence. These findings have important implications for the design and implementation of future HAI prevalence surveys.