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Background: Due to limited therapeutic options and potential for spread, carbapenem-resistant Enterobacteriaceae (CRE)-producing New Delhi metallo-β-lactamases (NDMs) are a public health priority. We investigated the epidemiology of NDM-producing CRE reported to the CDC to clarify its distribution and relative prevalence. Methods: The CDC’s Antibiotic Resistance Laboratory Network supports molecular testing of CRE for 5 carbapenemases nationally. Although KPC is the most common carbapenemase in the United States, non-KPC carbapenemases are a growing concern. We analyzed CRE with any of 4 non-KPC plasmid-mediated carbapenemases (NDM, VIM, IMP, or OXA-48 type) isolated from specimens collected from January 1, 2017, through June 30, 2019; only a patient’s first isolate per organism–carbapenemase combination was included. We excluded isolates from specimen sources associated with colonization screening (eg, perirectal). We compared the proportion of NDM-producing CRE to all non-KPC–producing CP-CRE between period A (January to June 2018) and period B (January to June 2019). Health departments and the CDC collected additional exposure and molecular information in selected states to better describe current NDM-producing CRE epidemiology. Results: Overall, 47 states reported 1,013 non–KPC-producing CP-CRE (range/state, 1–109 isolates; median, 11 isolates); 46 states reported 631 NDM-producing CRE (range/state, 1–84; median, 6). NDM-producing CRE increased quarterly from the third quarter of 2018 through the second quarter of 2019; CP-CRE isolates with other non-KPC carbapenemases remained stable (Fig. 1). In period A, 124 of 216 emerging CP-CRE had NDM (57.1%), compared with 255 of 359 emerging CP-CRE (71.0%) during period B (P = .1179). Among NDM-producing CRE, the proportion of Enterobacter spp increased from 10.5% in 2018 to 18.4% in 2019 (P = .0467) (Fig. 2). In total, 18 states reported more NDM-producing CRE in the first 6 months of 2019 than in all of 2018. Connecticut, Ohio, and Oregon were among states that conducted detailed investigations; these 3 states identified 24 NDM-producing CRE isolates from 23 patients in period B. Overall, 5 (21.7%) of 22 patients with history available traveled internationally ≤12 months prior to culture; 17 (73.9%) acquired NDM-producing CRE domestically. Among 15 isolates sequenced, 8 (53.3%) carried NDM-5 (6 E. coli, 1 Enterobacter spp and 1 Klebsiella spp) and 7 (46.7%) carried NDM-1 (6 Enterobacter spp and 1 Klebsiella spp). Species were diverse; no single strain type was shared by >2 isolates. Conclusions: Detection of NDM-producing CRE has increased across the AR Lab Network. Among states with detailed information available, domestic acquisition was common, and no single variant or strain predominated. Aggressive public health response and further understanding of current US NDM-CRE epidemiology are needed to prevent further spread.
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: 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.
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