Oregon? CRE prevention where there is little CRE

Counterintuitive approach to national model

Unlike some major Eastern cities where carbapenem-resistant Enterobacteriaceae (CRE) is an endemic problem, the state of Oregon has seen only a handful of cases. That is why public health officials say it is an ideal place to launch a CRE prevention program that could prove to be a national model.

The biggest concern is that CRE spreads easily across facilities and regions once it enters, says Christopher Pfeiffer, MD, MHS, hospital epidemiologist at Portland VA Medical Center in Portland, OR.

"CRE is a slow killer; an outbreak can occur over several months," Pfeiffer notes.

"But once it’s in a facility, it’s difficult to detect the transmission and the colonization of patients, so it is hard to eradicate; it will pop up every so often," he adds. "This made us highly interested in trying a fairly novel approach at preventing the entry and limiting — early on — the spread of CRE in a region."

CRE has a high mortality rate and can prove difficult to eradicate once established. The 2011 CRE outbreak at the U.S. National Institutes of Health (NIH) Clinical Center in Bethesda, MD, is a good example of that phenomenon, Pfeiffer notes.

Eleven out of 18 infected patients died in the NIH hospital CRE outbreak, which genomic and epidemiological analysis traced to three independent transmissions from a single patient who had been discharged for three weeks before the next case was apparent.¹

The Centers for Disease Control and Prevention (CDC) approved the Oregon Health Authority grant partly because of Oregon’s track record of success in completing large-scale projects, Pfeiffer says.

The CDC-Oregon initiative, called the Drug-Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network, will focus on statewide coordination of prevention and control of multidrug-resistant organisms, starting with CRE.

"We tried to come up with a plan about how to prevent the spread of CRE in Oregon, and we realized one of the best ideas would be to get a sense of the need in Oregon with different groups, including physicians and laboratorians," says Zintars G. Beldavs, MS, manager of the healthcare-associated infections program at the Center for Public Health Practice in Portland.

The DROP-CRE Network is working on these efforts:

• Developing a multidrug-resistant organism database statewide

• Promoting CRE education

• Conducting a rapid regional identification of CRE

• Providing epidemiological outbreak assistance to Oregon facilities with CRE cases

• Tracking CRE statewide across the spectrum of care.

Are nursing homes CRE reservoir?

CDC funding also has helped Oregon enhance its emerging infections program and epidemiology laboratory.

The network’s educational materials, including its 2013 Oregon Toolkit are available for dissemination nationally.²

Education is a chief focus for the network, including educating infection preventionists through the Association for Professionals in Infection Control and Epidemiology (APIC).

"We worried about the lack of education," Pfeiffer notes. "We’ve made extra efforts to present information at Oregon APIC meetings."

They’ve also spread the word about CRE and prevention strategies in hospitals and other health care settings during grand rounds, he adds.

"We also brought in expert speakers, giving talks to infectious diseases physicians and laboratory professionals across the state," Pfeiffer says. "We provide education about CRE for patients and staff at hospitals and created laboratory posters about CRE."

Other outreach includes working with long-term-care facilities and speaking at conferences.

"We’re working to enhance our website and provide more resources," he adds. (See http://1.usa.gov/1hlI6Ti )

CRE incidence rates are now collected by most states, as carbapenem resistance increased from 1% to 4% of Enterobacteriaceae infections in the past decade.³

National Institutes of Health (NIH) data show a high prevalence rate of CRE in long-term care facilities, which appear to be amplifiers of the disease, Pfeiffer says.

In 2012, CRE infection was reported in 4.6% of acute-care hospitals; for long-term acute-care hospitals, that rate was 17.8%.3

"From NIH surveillance data there is good evidence there are pockets of highly-preventable CRE in the Northeast and urban cities," Pfeiffer says. "New York City is the place most commonly cited."

But CRE can be a problem anywhere.

A case study in Denver, Colorado highlights the way CRE can spread once it occurs in a health care setting. In August 2012, the Colorado Department of Public Health learned of two patients at an acute-care hospital in Denver with CRE, specifically Klebsiella pneumoniae. In both patients isolates produced New Delhi metallo-beta-lactamase (NDM). Later a third patient with the same colonization was identified, and active surveillance cultures the next month found another five patients with matching strains. The eight patients ranged in age from 23 to 75 years and had been hospitalized on 11 different units.⁴

"Our biggest concern is the future of CRE -- it’s rapidly transmittable, potentially untreatable, and has a serious potential for a nightmare scenario," Beldavs says.

Reference

1. Snitkin ES, Zelazny AM, Thomas PJ, et al. Tracking a hospital outbreak of carbapenem-resistant Klebsiella pneumonia with whole-genome sequencing. Sci Transl Med 2012:4(128):1-2.
2. Guidance for control of carbapenem-resistant Enterobacteriaceae (CRE): 2013 Oregon toolkit. Oregon Health Authority. Available online at
3. http://public.health.oregon.gov/DiseasesConditions/DiseasesAZ/CRE/Documents/cre_toolkit.pdf
4. Centers for Disease Control and Prevention. Vital signs: carbapenem-resistant Enterobacteriaceae. MMWR 2013;62(9):165-170.
5. Pisney L, Barron M, Janelle SJ. et al. Notes from the field: hospital outbreak of carbapenem-resistant Klebsiella pneumoniae producing New Delhi Metallo-Beta-Lactamase – Denver, Colorado, 2012. MMWR 2013;6202):108.