Carbapenamase Producing Enterobacteriaceae: A Draining Concern

Carbapenamase Producing Enterobacteriaceae: A Draining Concern Heather Candon, B.Sc., M.Sc., MHM, CIC Lorraine Maze dit Mieusement, RN, MN, CIC Natasha Salt, B.Sc., B.A.Sc., CPHI (C), CIC

Introduction What is CPE? Risk factors associated with acquisition What s happening in Ontario Why Canadian hospitals should be concerned 1) Identification 2) Management 3) Mitigation 4) Prevention Take home messaging

CPE: What is it? Enterobacteriaceae - family of bacteria commonly found in human gastrointestinal tract. Sometimes these bacteria can spread outside the gut and cause serious infections, such as urinary tract infections, bloodstream infections, wound infections, and pneumonia. In rare instances can become resistant to a group of antibiotics called carbapenems, often antibiotics of last resort

Carbapenems the Big Guns ertapenem imipenem meropenem doripenem

Know your acronyms and your true Enemies

Gene Warfare CPE are Gram-negative Enterobacteriaceae (e.g., Klebsiella, E.coli) resistant to carbapenem class of antibiotics through a carbapenase enzyme Carbapenemase genes include KPC, NDM-1, IMP, VIM, OXA-48, NMC, VEB, PER, SME, GES Eg: Klebsiella pneumonia KPC or NDM-1 or VIM

Carbapenemases

How does a CPE patient present? Infection versus Colonization A patient with CPE can be either infected or colonized. Invasive infections 50% mortality rate

How do we deal in the hospital? CPE are usually transmitted from person to person, often via the hands of healthcare personnel or via contaminated medical equipment. Prevent transmission Hand hygiene Contact precautions Enhanced environmental cleaning

Risk Factors for CPE Transmission of CPE is increasingly reported in Canadian hospitals Risk factors for acquisition of CPE: Healthcare outside of Canada and/or travel to an Indian Subcontinent Antibiotic receipt Exposure to CPE colonized/infected patients Environmental sources (CPE-colonized sinks) Screening tools often capture healthcare outside of Canada and/or travel to an Indian Subcontinent in the last 12 months: Increasingly, positive patients have had no risk factors other than exposure to a Canadian healthcare facility

International travel is an important risk factor for being colonized or infected with resistant organisms (Laupland, J Infect 2008; Tängdén, Antimicrob Agents Chemother 2010) NDM-1 producing bacteria have been associated with admission to hospitals in south Asia (Kumarasamy, Lancet Infect Dis 2010) Medical Tourism

Ontario Yours to discover CPE

Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database, extracted by Public Health Ontario [2016/02/29]

8/70 had no foreign hospitalization or travel history 5 with previous hospitalization in Canada Source: Public Health Ontario Laboratories, Carbapenemase-producing Enterobacteriaceae database, extracted by Public Health Ontario [2016/02/29]

Identification: Where is CPE coming from?

Carbapenem Resistance Challenges in Management Easy plasmid transmission Widen the net for screening and detection (?) Few treatment options Lack of data re: effective infection control Environmental contamination may be common, unrecognized

Identification: Admission Screening Questions at Triage

Identification: Types of CPE Positive Specimens for First Detection n=23 n=26 n=16 More admission questions = quicker detection via screening specimens rather than clinical isolates

Management: CPE Positive Patient Facility Patient Management Room Management (excluding discharge) Unit Screening Contact Tracing 1 Private room Contact precautions Dedicated equipment Sign posted at sink to prevent dumping AHP in drains weekly Prevalence screen after first nosocomial case identified Flag patient and environmental exposures Screen via rectal swabs and urine cultures at 0, 7, 14, and 21 days 2 Private room Contact precautions Dedicated equipment Twice daily room cleaning Weekly point prevalence while patient admitted Weekly point prevalence x 3 weeks postdischarge Flag patient and environmental exposures Screen via rectal swabs at 0, 7, 14, and 21 days 3 Accelerated Hydrogen Peroxide (AHP) Private room Contact precautions Dedicated equipment Basin-less care Sign posted at sink to prevent dumping AHP in drains weekly Twice daily room cleaning Prevalence screen after first nosocomial case identified Flag patient and environmental exposures Screen via rectal swabs and urine cultures at 0, 7, 14, and 21 days

Multi-facility comparison Facility A Facility B Facility C Facility D Facility E Facility F Facility G CPE Cleaning while patient is occupying the room Twice a day using bleach, pour toilet bowl bleach cleaner down all sinks daily. Twice a day using bleach Double clean along with sink with Accelerated Hydrogen peroxide (AHP) Twice daily with AHP, sinks and washroom clean AHP gel Regular daily cleaning; AHP gel poured down the sink twice a week; sinks closed in some ICU settings Twice daily CPE Terminal Clean Protocol Terminal clean x2 with bleach Terminal clean x2 using bleach. Terminal clean x 2 with AHP Terminal clean x2 with AHP, sinks and washroom clean with AHP Gel. Terminal clean x2 with bleach Terminal clean x2 with AHP and AHP gel down the sink Terminal clean x2 (no wall washing in room necessary but walls have to be done in bathroom, curtain need changing) Sink cleaning protocol Bleach toilet bowl cleaner, steam Bleach (still sorting out their cleaning and swabbing protocol) Steam clean AHP Gel bleach toilet bowl cleaner, steam AHP gel AHP gel Do you swab the sink? If yes, who swabs it? Yes, ICP Yes, ICP Yes, mostly by ICP but sometimes by Housekeeping No, only if there s an outbreak Yes, ICP Yes, ICP Yes, ICP Only at our 1 campus as we had some CPE transmission. If yes, when? (pre/post cleaning) Pre-cleaning Pre and post Pre-cleaning N/A Pre-cleaning Post cleaning Post cleaning Do you close the sink pending result? No Yes Yes both sink and room (usually 48 hours) N/A Yes Yes, if it was used while the CPE positive patient was there No Do you repeat the sink swab? No If positive, or if pt in the room/ward/unit positive, repeat swabs every month. 2 and 6 weeks post N/A 2 weeks post 1 week later If swab is positive, what do you do? No experience with this Cleaning done by maintenance/evs remove P trap, remove buildup, scrub with a brush, use AHP gel If positive, try to clean the sink again (double-clean and steam, pouring liquids, etc) we haven t been too successful in getting rid of CPE once in the sink, so generally remove and replace N/A If positive, re-clean with AHP gel may have to remove the P-trap if still positive despite multiple cleaning No experience with this. Likely repeat disinfection and flag patient as a contact and swab Does your sink management differ from ICU and ward No No No No Yes (depending on setting: ICU, Burn and Ward) No

Management: CPE Discharge Process

Biofilm Formation

Mitigation: CPE Positive Discharge Process Sink Cultures Drain and overflow hole (if applicable) cultured post discharge If negative, consider collecting repeat cultures (?) Aerators, faucets, shower heads/drains, toilets, etc?

Mitigation: CPE Positive Discharge Process Drain tool

Mitigation: CPE Positive Discharge Process

Environmental Swabs for CPE 16% conversion 13% conversion

Mitigation: CPE Positive Plumbing P-trap

How did the drains become positive? Environmental scan of body fluid dumping

Hand Hygiene Sink Bath water Body fluids IV fluids Please discard all fluids in the soiled utility room

Prevention: Maintenance of Hospital Drains Ongoing drain cleaning/maintenance Range from none to yearly Update to CSA Plumbing Guidelines for Healthcare Facilities Liquid drain cleaner, foam/liquid, steam Focus in high risk areas i.e., ICUs

Ongoing plumbing replacement not feasible in long term Sink design Drain design Anti-biofilm claims Water-free patient care Moving Forward

Author, Journal, Date Setting, Country Microorgani sm Reservoir Plumbing action Starlander et al., JHI 2012 ICU, Sweden ESBL Klebsiella pneumoniae Four patients epi-linked to the same room over 7-months Hand hygiene sink used for waste disposal Sink replacement Drains tested quarterly for 1 year - negative Unclear how far back plumbing replaced No mention of preventative maintenance Leitner et al., ASM 2015 ICU, hematology, Austria CPE Klebsiella oxytoca Fifteen patients over 2-years Sinks, medication room sink and shower drain Sink replacement - shower? Unclear how far back plumbing replaced No mention of preventative maintenance Palmore et al., HE 2013 ICU, Maryland CPE Klebsiella pneumoniae Eighteen patients over 6-months Removed sinks and cleaned No plumbing replacement PM - Spray bleach down daily Kotsanas et al., MJA 2013 ICU, Australia CPE Serratia marcescens Ten patients over 3-years Hand hygiene sink used for waste disposal Brush, bleach, steam - unsuccessful Sink replacement Unclear how far back plumbing replaced No mention of preventative maintenance Lowe et al., EID 2012 ICU, Stepdown unit, CCU, Canada ESBL Klebsiella oxytoca Sixty-six patients over 5 years Hand hygiene sink used for waste disposal Brush, disinfection, standing - unsuccessful Sink replacement Plumbing to the wall changed (?) No mention of preventative maintenance Hota et al., ICHE 2009 ICU, Canada MDR- Pseudomona s Thirty-six patients over 1.5 years Hand hygiene sink used for waste disposal AHP - unsuccessful Sink replacement Sink traps No mention of preventative maintenance Tofteland et al., PLoS 2013 ICU, Norway CPE Klebsiella pneumoniae Seven patients over 3-years Hand hygiene sink used for waste disposal Sink replacement Sink traps No mention of preventative maintenance Lowe et al., ICHE 2013 Canada CPE Klebsiella pneumoniae Seven patients over 15 months Hand hygiene sink used for waste disposal Disinfection - unsuccessful Sink replacement Sink traps No mention of preventative maintenance

Take Home Messages Contamination of sinks/drains with CPE is an emerging issue The environment may be a possible source of transmission Improper disposal of body fluids in sinks likely contributes significantly to sink/drain contamination The appropriate best practices approach for managing CPE positive drains and preventative maintenance are unknown Drains and sinks for healthcare should be chosen based on a design that minimizes risk to patients We should collectively push manufacturers to develop safer equipment The necessity of sinks in patient care areas should be weighed against potential harm to the patient Future research is needed to establish guidelines

Questions? Heather Candon: heather.candon@mackenziehealth.ca @heathercandon Lorraine Maze dit Mieusement: lorraine.mazeditmieusement@sunnybrook.ca Natasha Salt: natasha.salt@sunnybrook.ca @saltnvs