Erin Epson

Carbapenem-Resistant Enterobacteriaceae Detection Practices in California: What Are We Missing?

Background The Clinical and Laboratory Standards Institute (CLSI) revised the carbapenem breakpoints for Enterobacteriaceae in 2010. The number of hospitals that adopted revised breakpoints and the clinical impact of delayed adoption has not been explored. Methods We performed a cross-sectional, voluntary survey of microbiology laboratories from California acute care hospitals and long-term acute care hospitals (LTAC) to determine use of revised CLSI breakpoints. Carbapenem-resistant Enterobacteriaceae (CRE) clinical isolates from a single tertiary-care hospital from 2013 to 2017 were examined. All isolates with an elevated minimum inhibitory concentration (MIC; ≥2 µg/mL) to imipenem or meropenem were tested for the presence of carbapenemase genes by polymerase chain reaction (PCR). Results We received responses from 128 laboratories that serve 264/393 (67%) of hospitals and LTACs. Current CLSI carbapenem breakpoints for Enterobacteriaceae were used by 92/128 (72%) laboratories. Among laboratories that used current breakpoints, time to implementation varied from 0 to 68 months (mean, 41 months; median, 55 months). Application of historical breakpoints to isolates with a carbapenemase gene detected by PCR resulted in susceptibility rates of 8.9%, 18.6%, and 18.6% to ertapenem, imipenem, and meropenem, respectively. By current breakpoints, <1% of these isolates were susceptible to ertapenem or imipenem and 2.6% to meropenem. Conclusion Clinicians and epidemiologists should be aware that use of outdated MIC breakpoints for Enterobacteriaceae remains common and can result in reports of false susceptibility to carbapenems and missed identification of carbapenemase producers. This misclassification could have consequences for patient care and infection control efforts to address carbapenemase-producing Enterobacteriaceae.

Hemodialyzer Reuse and Gram-Negative Bloodstream Infections.

BACKGROUND Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization. STUDY DESIGN Outbreak investigation, including matched case-control study. SETTING & PARTICIPANTS Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization. PREDICTORS Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice. OUTCOMES Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing. RESULTS 17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facilitys reprocessing procedure. LIMITATIONS Limited statistical power and overmatching; few patient isolates and dialyzers available for testing. CONCLUSIONS This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.

Capacity Building within the Microbiology Laboratory is Needed to Ensure Implementation of Strategies to Control the Spread of CRE

Erin Epson,1 Sam Horwich-Scholefield,1 Romney Humphries2 Janet Hindler,2 Christina Hershey,3,4 Loren G. Miller,3,4 Job Mendez,3 Dawn Terashita,5 Patricia Marquez,5 Sandeep Bhaurla,5 Marcelo Moran,5 Lindsey Pandes,5 James A. McKinnell 3,4 1. California Department of Public Health 2. Department of Pathology and Laboratory Medicine, UCLA, Los Angeles 3. ID-CORE at LA BioMed Research Institute at HarborUCLA 4. David Geffen School of Medicine at University of California, Los Angeles 5. Los Angeles County Department of Public Health Poster 1490: Dr.McKinnell@yahoo.com

Antimicrobial Stewardship Practices Reported by California Hospitals—Annual Hospital Survey Data Submitted via the National Healthcare Safety Network, 2014

Background. Since 2008, California acute care hospitals have been required to develop processes for evaluating the judicious use of antibiotics and to report results to their quality improvement committees. A national survey conducted in 2011 found California hospitals were significantly more likely to have an antimicrobial stewardship policy than hospitals in other states. New California legislation further requires hospitals to implement an antimicrobial stewardship policy in accordance with guidelines and to establish a physician-supervised multidisciplinary committee with at least one physician or pharmacist with specific stewardship training by 1 July 2015. Methods. Beginning in 2014, the National Healthcare Safety Network (NHSN) Annual Hospital Survey included questions about antimicrobial stewardship practices. Annual Hospital Survey data submitted by California acute care hospitals via NHSN were analyzed to determine proportions of hospitals implementing specific antimicrobial stewardship practices. Results. Data were available for all 391 California hospitals reporting to NHSN: 290 (74%) reported having a statement from leadership supporting efforts to improve antibiotic use; 359 (92%) reported a physician or pharmacist leader responsible for outcomes of stewardship; 201 (51%) provide dedicated salary support for stewardship activities. Specific stewardship practices are included in the table. Conclusion. In the setting of state legislative requirements, we document that substantial numbers of California hospitals are engaged in antimicrobial stewardship. These data will be used to identify opportunities for public health to guide programs that promote and support further implementation and advancement of antimicrobial stewardship practices in California hospitals. Table. Stewardship Practice No. (%) Hospitals Responding Yes Requiring prescribers to document indication for all antibiotics 166 (42%) Facility-specific antibiotic treatment recommendations 313 (80%) Antibiotic time-out 133 (34%) Antibiotic pre-approval 275 (70%) Antimicrobial prescription audit with feedback 342 (87%) Providing feedback to prescribers regarding improving antibiotic use 288 (74%) Providing antibiotic stewardship education 278 (71%) Monitoring antibiotic use 310 (79%) View it in a separate window Disclosures. All authors: No reported disclosures.