Antimicrobial Resistance Surveillance in Hospital andCommunity-Issues for Human Population MedicineKurt B. Stevenson MD MP...
Disclosures     No financial disclosures or conflicts of interest      relative to this presentation.2
Time Magazine-Feb 25, 1966     “Nearly all experts agree that (by the year 2000)      bacterial and viral diseases will h...
Rene Dubos-1941     “...the readiness with which microorganisms      selectively change their enzymatic constitution in  ...
Critical impact of antimicrobial resistance    “If we do not act to address the problem of AR, we       may lose quick and...
Antimicrobials present unique management    challenges     200-300 million antibiotics are prescribed      annually      ...
Science 2008;321:356-3617
Science 2008;321:356-3618
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings   Selection for antimicrobial-        resistant Strain...
ESKAPE pathogens        Enterococcus faecium (VRE)        Staphylococcus aureus (MRSA)        Klebsiella pneumonia (ESB...
Emerging antimicrobial resistance of     importance in human medicine      Methicillin-Resistant Staphylococcus aureus   ...
Emerging antimicrobial resistance of     importance in human medicine      Epidemic strains of C. difficile      Vancomy...
Definitions of antimicrobial resistance     MDRO=multidrug resistant organisms      Resistant to more than one class of a...
Definitions of antimicrobial resistance     MDRO=multidrug resistant organisms      Facility specific parameters        ...
Clin Microbiol Infect 2012:18:268-28115
Abbreviations      MDR=multidrug-resistant      XDR=extensively drug-resistant      PDR=pandrug-resistant16
Clin Microbiol Infect 2012:18:268-28117
Genotyping         PFGE                       Epidemiologic and     Sequence-based         typing        Multi-Drug    ris...
Methicillin-resistant S. aureus (MRSA)      A group of anti-penicillinase antibiotics were       developed in the 1960s t...
MRSA      Historically, MRSA has been isolated almost       exclusively in healthcare settings, suggesting       that tra...
Community-associated MRSA      Increasing reports of MRSA occurring in patients       with little or no direct contact wi...
MRSA      Hospital-acquired                Community-acquired        Large SCCmec A (types            Small SCCmecA (T...
Genotyping   PFGE                       Epidemiologic and  RepPCR                       risk factor data Spa Typing      M...
MRSA Surveillance Study     Funded by CDC Prevention Epicenter Program       Ohio State Health Network        Objectives...
MRSA Project Process Flow                                        Each hospitals sends                                     ...
Web portal-Outreach Hospital
Study Design      Retrospective analysis of OSUMC banked isolates       (projected ~450 isolates) Study period 1/1/07-10/...
Emerg Infect Dis 2012;18:1557-156528
Results      Among 1286 MRSA isolates collected as part of       the MRSA surveillance project there were 78       (6%) i...
ST 239      Demonstrated epidemic/outbreak potential-       caused a 2 year ICU outbreak in London      Healthcare-assoc...
Emerg Infect Dis 2012;18:1557-156531
Emerg Infect Dis 2012;18:1557-156532
Pseudomonas aeruginosa      Gram-negative, non-fermenting bacillus      Common environmental pathogen, especially in    ...
Clinical Infections      Bacteremia in neutropenic patients; more       common in the 1980’s, decreasing in past       de...
Imipenem-resistant Pseudomonas     aeruginosa      University of Pennsylvania      1991 to 2000, significant increase in...
Extended spectrum β-lactamases      K. pneumoniae, E. coli      Also reported with       Salmonella, Proteus, Enterobact...
ESBLs      Phenotype: resistance to 3rd generation       cephalosporins and monobactams      Their proliferation is a gl...
Clin Infect Dis 2006;42:S15338
Clin Infect Dis 2006;42:S15339
Carbapenemases      Carbapenemases are enzymes which can       inactivate a wide range of antibiotics including       the...
KPC      96 isolates from 10 Brooklyn hospitals      All resistant to carbapenems and most other       antibiotics     ...
NDM-1 strain      New Delhi metallo-beta-lactamase-1      Klebsiella pneumoniae and Escherichia coli.      NDM-1 has be...
Lancet Infect Dis 2010;10:597-60244
Lancet Infect Dis 2010;10:597-60245
Lancet Infect Dis 2010;10:597-60246
Acinetobacter baumannii      Acinetobacter baumannii (Ab) is a ubiquitous       encapsulated, aerobic, nonfermentive gram...
Acinetobacter baumannii (Ab)      Major risk factors include invasive procedures       such as using mechanical ventilati...
MDR Ab outbreaks across geographic     distances      Citywide clonal outbreak of MDR-Ab; involved 15       hospitals in ...
Colistin      Mixture of cyclic polypeptides (polymixin A and       B); polycationic with both hydrophilic and       lipo...
Colistin resistance      265 isolates of Acinetobacter from 2 Korean hospitals      Categorized into 3 subgroups:       ...
Emerging antimicrobial resistance of     importance in human medicine      Methicillin-Resistant Staphylococcus aureus   ...
Emerging antimicrobial resistance of     importance in human medicine      Epidemic strains of C. difficile      Vancomy...
Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for ...
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Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for Human Population Medicine

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Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for Human Population Medicine - Dr. Kurt Stevenson, The Ohio State University Medical Center, from the 2012 NIAA One Health Approach to Antimicrobial Resistance and Use Symposium, October 26-27, 2012, Columbus, OH, USA.

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Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for Human Population Medicine

  1. 1. Antimicrobial Resistance Surveillance in Hospital andCommunity-Issues for Human Population MedicineKurt B. Stevenson MD MPHDivision of Infectious DiseasesNovember 13, 2012
  2. 2. Disclosures  No financial disclosures or conflicts of interest relative to this presentation.2
  3. 3. Time Magazine-Feb 25, 1966  “Nearly all experts agree that (by the year 2000) bacterial and viral diseases will have been wiped out. Probably arteriosclerotic heart disease will also have been eliminated.”3
  4. 4. Rene Dubos-1941  “...the readiness with which microorganisms selectively change their enzymatic constitution in response to change in the environment may …be of importance in determining the pathology of infectious diseases.”4
  5. 5. Critical impact of antimicrobial resistance “If we do not act to address the problem of AR, we may lose quick and reliable treatment of infections that have been a manageable problem in the United States since the 1940s. Drug choices for the treatment of common infections will become increasingly limited and expensive - and, in some cases, nonexistent.” -A Public Health Action Plan to Combat Antimicrobial Resistance CDC Underline added5
  6. 6. Antimicrobials present unique management challenges  200-300 million antibiotics are prescribed annually  45% for outpatient use  25-40% of hospitalized patients receive antibiotics  10-70% are unnecessary or sub-optimal  5% of hospitalized patients who receive antibiotics experience an adverse reaction  Antibiotics are unlike any other drugs, in that use of the agent in one patient can compromise its efficacy in another (“Societal Drugs”)  Slide courtesy of Sara Cosgrove, MD Johns Hopkins University6
  7. 7. Science 2008;321:356-3617
  8. 8. Science 2008;321:356-3618
  9. 9. Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Selection for antimicrobial- resistant StrainsResistant Strains Rare Antimicrobial Exposure Resistant Strains Dominant
  10. 10. ESKAPE pathogens  Enterococcus faecium (VRE)  Staphylococcus aureus (MRSA)  Klebsiella pneumonia (ESBL-producing)  Acinetobacter baumannii  Pseudomonas aeruginosa  Enterobacter species Rice LB. J Infect Dis 2008;197:1079-8110
  11. 11. Emerging antimicrobial resistance of importance in human medicine  Methicillin-Resistant Staphylococcus aureus (MRSA)  Multi-drug resistant gram-negative bacilli  “SPACE” organisms (Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter)  Ciprofloxacin resistance  AmpC/inducible beta-lactamases  Extended spectrum beta-lactamases (ESBLs)  Carbapenem-resistance  Now with colistin resistance11
  12. 12. Emerging antimicrobial resistance of importance in human medicine  Epidemic strains of C. difficile  Vancomycin-resistant Enterococcus ssp. (VRE)  Vancomycin-intermediate Staphylococcus aureus (VISA)  Vancomycin-resistant Staphylococcus aureus (VRSA)12
  13. 13. Definitions of antimicrobial resistance MDRO=multidrug resistant organisms  Resistant to more than one class of antimicrobial agent (IOM, 1998)  Although this definition suggests resistance to only one class, most of the pathogens discussed are resistant to multiple classes  May use more explicit definitions  Epidemiologically important  Known to be transmitted in the healthcare environment  Modifiable risk factors  Effective infection control interventions13
  14. 14. Definitions of antimicrobial resistance MDRO=multidrug resistant organisms  Facility specific parameters  First isolate, newly introduced  Increasing in frequency  Limited treatment options  Associated with poor patient outcomes14
  15. 15. Clin Microbiol Infect 2012:18:268-28115
  16. 16. Abbreviations  MDR=multidrug-resistant  XDR=extensively drug-resistant  PDR=pandrug-resistant16
  17. 17. Clin Microbiol Infect 2012:18:268-28117
  18. 18. Genotyping PFGE Epidemiologic and Sequence-based typing Multi-Drug risk factor data MLST Multi-Drug Resistant Resistant Organism Organisms s (MDRO) (MRSA) Social network Geographic analysis links18
  19. 19. Methicillin-resistant S. aureus (MRSA)  A group of anti-penicillinase antibiotics were developed in the 1960s to treat penicillin- resistant staph (methicillin, nafcillin, oxacillin)  MRSA contains mecA gene which encodes for a modified penicillin-binding protein with reduced binding of methicillin, oxacillin, or nafcillin  Also resistant to cephalosporins  mecA gene is housed within the staphylococcal chromosomal cassette (SCC) which also houses multiple resistance genes19
  20. 20. MRSA  Historically, MRSA has been isolated almost exclusively in healthcare settings, suggesting that transmission has occurred primarily in this environment  Typically, nosocomial MRSA have multi-drug resistance patterns  Risk factors for healthcare-associated MRSA acquisition include hospitalization, antimicrobial exposure, device utilization, hemodialysis, nursing home, open wounds  Healthcare-associated MRSA results in infections at many different clinical sites20
  21. 21. Community-associated MRSA  Increasing reports of MRSA occurring in patients with little or no direct contact with the healthcare system  Interpretation of these reports are complicated by lack of consistent definitions  Phenotypic definition: lack of multi-drug resistance profile  Genotypic definition: presence of type IV SCCmec gene cassette  Typically younger patients and most often associated with skin and soft tissue infections21
  22. 22. MRSA  Hospital-acquired  Community-acquired  Large SCCmec A (types  Small SCCmecA (Type IV) I,II,III)  Typically resistant only to  Multi-drug resistance beta-lactam drugs  Multiple risk factors for  No risk factors for contact contact with the healthcare with healthcare system system  Younger patients  Infections at many sites  Skin and soft tissue (blood, lung, skin, etc) infections  USA 100, 200, 500, 600,  Toxin-producing strains 800 PFGE types (2003)  USA 300, 400 PFGE types22
  23. 23. Genotyping PFGE Epidemiologic and RepPCR risk factor data Spa Typing Multi-Drug HA-MRSA MLST CA-MRSA SCCmecA Resistant MRSA Organism s (MRSA)Social network Geographic analysis links
  24. 24. MRSA Surveillance Study Funded by CDC Prevention Epicenter Program  Ohio State Health Network  Objectives: Infection Control Collaborative  To compare clinical characteristics and molecular genotypes of MRSA isolates  Use a network of a tertiary medical center and 7 referring community hospitals  To characterize transmission of CA- and HA-MRSA between these 7 Outreach hospitals facilities. 27 to 121 miles from OSU Wexner Medical Center (OSUWMC)24
  25. 25. MRSA Project Process Flow Each hospitals sends +MRSA micro samples OSHNICC with assigned de-identified OSUWMC Clinical Micro Lab code to: (REP-PCR, Storage of Specimens) Each hospital IW de- OSU lab OSU lab collects identifies sends micro ODH sends data and the data, samples sends PCR and PHI on sends a using PFGE PFGE +MRSA code back assigned results results cases and to the de-identified back to using sends to: hospital for code for OSU lab assigned each case PFGE de- testing to: OSUWMC IW identified code to IW (Honest Broker) ODH Lab Potential for MLST IW stores all data in: and spa typing OSU Epicenter Data AnalysisWeb-Based EpicenterData Entry Portal MRSA Database reports back de-identified data to OHSNICC and publishes results
  26. 26. Web portal-Outreach Hospital
  27. 27. Study Design  Retrospective analysis of OSUMC banked isolates (projected ~450 isolates) Study period 1/1/07-10/31/08  Endemic clonal distribution/molecular typing  Geographic distribution  Epidemiologic and Risk factors  Social Networking analysis-social relatedness of cases  Concurrent analysis of OSHNICC hospitals (~1300 isolates) Study period 11/01/08 to 6/30/10  All cases at outreach hospitals  All cases at OSUMC from outreach hospital catchment areas  Sampling of other OSUMC cases  Collect all of the same data elements27
  28. 28. Emerg Infect Dis 2012;18:1557-156528
  29. 29. Results  Among 1286 MRSA isolates collected as part of the MRSA surveillance project there were 78 (6%) isolates that were sequence typed as ST- 239  ST-239 has a history of successful dissemination in many regions but had not been noted to play a predominant role in the US29
  30. 30. ST 239  Demonstrated epidemic/outbreak potential- caused a 2 year ICU outbreak in London  Healthcare-associated with pulmonary and central venous catheter associated bloodstream infections in Korea and China  Highly drug resistant beyond methicillin  Resistant to clindamycin, TMP-SMX, moxifloxacin, gentamicin.30
  31. 31. Emerg Infect Dis 2012;18:1557-156531
  32. 32. Emerg Infect Dis 2012;18:1557-156532
  33. 33. Pseudomonas aeruginosa  Gram-negative, non-fermenting bacillus  Common environmental pathogen, especially in water  Reservoirs for infection can develop, even in intensive care units  One of the most serious causes of ventilator- associated pneumonia (VAP)33
  34. 34. Clinical Infections  Bacteremia in neutropenic patients; more common in the 1980’s, decreasing in past decade  Cystic fibrosis Science 2000:288:1251  Healthcare-associated infections (VAP, bacteremia) Am Surg 1999;65:706 Arch Int Med 1985;145:1621 Crit Care Med 1999;27:887  Community-acquired infections (hot tub folliculitis) J Clin Microbiol 1986;23:65534
  35. 35. Imipenem-resistant Pseudomonas aeruginosa  University of Pennsylvania  1991 to 2000, significant increase in imipenem resistance (p<0.001)  Only independent risk factor for acquisition was prior fluoroquinolone use  Resistant infections resulted in longer hospital stay (15.5 vs 9 days, p=0.02) and increased costs ($81,330 vs $48,381)  Increased mortality rate (31.1 vs 16.7%) Lautenbach E et al. Infect Cont Hosp Epidem 2006;27:893-90035
  36. 36. Extended spectrum β-lactamases  K. pneumoniae, E. coli  Also reported with Salmonella, Proteus, Enterobacter, Citrobacter, S erratia, and Pseudomonas  Plasmid-mediated enzymes able to hydrolyze most penicillins and cephalosporins  Mutated from native β-lactamases, particularly TEM-1, TEM-2, and SHV-1; heterogenous group of enzymes also derived from other β- lactamases-now CTX-M Clin Infect Dis 2006;42:S15336
  37. 37. ESBLs  Phenotype: resistance to 3rd generation cephalosporins and monobactams  Their proliferation is a global concern and results in serious limitations in treatment options  Usually carbapenems are the best and only treatment option37
  38. 38. Clin Infect Dis 2006;42:S15338
  39. 39. Clin Infect Dis 2006;42:S15339
  40. 40. Carbapenemases  Carbapenemases are enzymes which can inactivate a wide range of antibiotics including the carbapenem class, thus rendering the bacteria highly resistant to most treatment modalities  Two current classes noted:  KPC: class A  NDM-1: class B40
  41. 41. KPC  96 isolates from 10 Brooklyn hospitals  All resistant to carbapenems and most other antibiotics  About 50% susceptible to aminoglycosides and 90% to polymixin B; all susceptible to tigecycline.  Therapeutic options: colistin, tigecycline JAC 2005;56:12842
  42. 42. NDM-1 strain  New Delhi metallo-beta-lactamase-1  Klebsiella pneumoniae and Escherichia coli.  NDM-1 has been reported in >37 states within the United States, including Ohio43
  43. 43. Lancet Infect Dis 2010;10:597-60244
  44. 44. Lancet Infect Dis 2010;10:597-60245
  45. 45. Lancet Infect Dis 2010;10:597-60246
  46. 46. Acinetobacter baumannii  Acinetobacter baumannii (Ab) is a ubiquitous encapsulated, aerobic, nonfermentive gram- negative coccobacillus  It is capable of causing both community and healthcare-associated infections involving pulmonary system, urinary tract, bloodstream, and surgical wounds  These organisms have a high propensity to accumulate mechanisms of drug-resistance; large HAI outbreaks with pan resistant strains have been reported Clin Infect Dis 2006;42:692-69947
  47. 47. Acinetobacter baumannii (Ab)  Major risk factors include invasive procedures such as using mechanical ventilation, central venous or urinary catheters, and exposure to broad spectrum antimicrobials  The organisms exist in the environment in both wet and dry conditions and can survive for months on clothing, bedrails, ventilators, and other surfaces Clin Infect Dis 2006;42:692-699 J Clin Microbiol 1996;34:2881-2887 Principles and Practices of Infectious Diseases 2000:2339-234448
  48. 48. MDR Ab outbreaks across geographic distances  Citywide clonal outbreak of MDR-Ab; involved 15 hospitals in Brooklyn (based on ribotyping)  Interhospital transfer of MDR-Ab among 4 hospitals in Johannesburg, South Africa (based on PFGE) Arch Intern Med 2002;162:1515-1520 Am J Infect Control 2004;32:278-28149
  49. 49. Colistin  Mixture of cyclic polypeptides (polymixin A and B); polycationic with both hydrophilic and lipophilic moieties  Disrupts cell membrane  Active against gram negative bacteria esp Pseudomonas and Acinetobacter  Previous concerns for neurotoxicity and nephrotoxicity  Resistance currently has been generally rare50
  50. 50. Colistin resistance  265 isolates of Acinetobacter from 2 Korean hospitals  Categorized into 3 subgroups:  Subgroup I (142 isolates [53.6%])  Subgroup II (54 [20.4%])  Subgroup III (18 [6.8%])  Forty-eight isolates (18.1%) and 74 isolates (27.9%) were resistant to polymyxin B and colistin, respectively. J Antimicrob Chemother. 2007 Aug 2951
  51. 51. Emerging antimicrobial resistance of importance in human medicine  Methicillin-Resistant Staphylococcus aureus (MRSA)  Multi-drug resistant gram-negative bacilli  “SPACE” organisms (Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter)  Ciprofloxacin resistance  AmpC/inducible beta-lactamases  Extended spectrum beta-lactamases (ESBLs)  Carbapenem-resistance  Now with colistin resistance52
  52. 52. Emerging antimicrobial resistance of importance in human medicine  Epidemic strains of C. difficile  Vancomycin-resistant Enterococcus ssp. (VRE)  Vancomycin-intermediate Staphylococcus aureus (VISA)  Vancomycin-resistant Staphylococcus aureus (VRSA)53
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