Management of Extended Spectrum Beta- Lactamase (ESBL) Producing Enterobacteriaceae in health care settings Dr. Mary Vearncombe PIDAC-IPC February 2012
Objectives: To provide an overview of the RP/AP Annex A best practice document with regard to ESBLs To briefly examine Ontario hospital current practice To address questions regarding IP&C management of ESBLs 2
What are ESBLs? β-lactamase is an enzyme produced by some bacteria that inactivares the β-lactam class of antibiotics, e.g., penicillins, cephalosporins; ESBLs inactivate all cephalosporins, including third generation cephalosporins, e.g. cefotaxime, ceftriaxone, ceftazidime Most ESBLs occur in E. coli and Klebsiella ESBLs are plasmid mediated, i.e. resistance is transferrable to other strains or species Several types, designated by acronym, e.g., TEM, SHV, CTX-M 3
What is the difference between ESBL and AmpC? Some genera of Gram negative bacilli are inherently resistant to extended spectrum cephalosporins through inducible chromosomal AmpC enzymes Enterobacter, Citrobacter, Serratia, Morganella, Providencia Inducible: resistance may develop while on treatment Microbiology report will usually have statement for above genera Chromosomal: not transferrable between strains or species Because resistance is not transferrable, do not carry the same IP&C considerations 4
What is the clinical relevance of ESBLs? E. coli and Klebsiella spp. are common causes of infection Resistance to all penicillins and cephalosporins May be treated with β-lactam- β-lactamase inhibitor combinations, aminoglycosides and carbapenems; fluoroquinolones depending on susceptibility results Associated with treatment failure; may have increased mortality if appropriate therapy not started within 3 days Associated with nosocomial outbreaks, particularly ICUs, LTCHs Clonal outbreaks related to cross infection Multi-clonal outbreaks related to selective pressure, i.e., antibiotic use 5
Risk factors for ESBL acquisition: Prior antibiotic use, especially 3 rd generation cephalosporins, fluoroquinolones Prolonged hospital/icu stay Severity of illness Indwelling devices, e.g. urinary catheters 6
Screening patients/residents for ESBLs Each health care facility should have a consistent approach to surveillance Local epidemiology should govern decision making regarding routine screening for ESBLs e.g. if the local incidence is high, there may be value in screening, particularly ICU admissions Screen patients in close proximity to colonized/infected patients, e.g., roommates During an outbreak, all patients/residents with common risk factors should be screened Flag records of known ESBL carriers; place on Contact Precautions and re-screen on readmission 7
Screening specimens for ESBL The primary site of colonization is the bowel Preferred screening specimen is a rectal swab (fecally stained) or stool Urine may also be sent in some clinical situations, e.g. catheterized patient/resident Each health care setting should discuss screening, reporting and interpretation of results with their microbiology laboratory 8
Screening of Staff for ESBLs Routine screening of staff for ESBLs is not recommended There is no evidence that rectal colonization of HCWs contributes to transmission Artificial nails or other nail enhancements have been implicated in outbreaks of Gram negative bacteria and should not be worn by those providing direct patient/resident care 9
Transmission of ESBLs Transmission is via direct and indirect contact HCW hands; medical devices, e.g., urinary catheters, urinary care equipment Site of colonization is the lower gastrointestinal tract Urinary tract is a common secondary site of colonization/infection Although the environment has rarely been implicated in outbreaks, sinks and other environmental surfaces have been implicated in transmission of Klebsiella spp. Acquisition of resistance may also occur by transmission of the mobile genetic element carrying the ESBL gene between different bacterial strains and species 10
Management of patients/residents with ESBLs In acute care: many hospitals use Contact Precautions for known patients In non-acute care: residents with AROs, including ESBLs, should be managed using Routine Practices and adding Contact Precautions (gown and gloves) for direct care Routine Practices: Hand hygiene Use of PPE dependent on risk assessment Cleaning of all equipment used for multiple patients/residents between each patient/resident Direct care: providing hands-on care, e.g., bathing, washing, turning resident, changing clothes, continence care, dressing changes, care of open wounds/lesions, toileting. 11
ESBL Decolonization and Duration of Precautions ESBL decolonization is not effective and is not recommended Duration of bowel colonization with ESBLs is unknown but has been of long duration (years) in some studies Most colonized patients/residents are asymptomatic; bowel colonization may play a significant role in spread In acute care, CP should remain for duration of hospitalization In non-acute care, 3 consecutive sets of negative cultures from all colonized/infected sites (including rectal/stool) taken at least 1 week apart in the absence of antibiotics There is likely little utility in beginning screening until several months have passed, i.e. 6, 12, + 12
Transfer from acute to non-acute care Patients/residents should receive health care based on their overall care needs, independent of colonization with any ARO, including an ESBL i.e., transfer from acute to non-acute facilities should not be denied Bowel colonization will be prolonged and decolonization is not effective and not recommended All non-acute facilities should be able to manage all residents using Routine Practices and residents with an ARO using Contact Precautions for direct care. 13
What are Ontario hospitals doing: QMP-LS Report on AROs in Ontario 2010: (April 2011) 3 rd generation cephalosporin resistance increased for E. coli, remained stable for Klebsiella spp. over 2009; prevalence of resistance highest in GTA Reported screening program: 33%; 60% of these screen roommates Reported IPAC precautions: 59% use additional precautions Single room + contact precautions 77% Contact precautions only 22% Single room only 1% 31% use additional precautions for some patients (e.g. ICU patients, patient soiling environment, clinical isolates only, class A ESBL only) 10% do not use additional precautions
Impact and cost of infection control measures to reduce nosocomial transmission of extendedspectrum -lactamase-producing organisms in a non-outbreak setting L.O. Conterno, J. Shymanski, K. Ramotar, B. Toye, R. Zvonar, V. Roth The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada Journal of Hospital Infection, April 2007; 65(4):354-360
TOH ESBL study conclusions: Use of single rooms for ESBL colonized/infected patients + contact precautions for patients at high risk of transmission: Prevented outbreaks No impact on nosocomial ESBL incidence Combination of control measures required: Active surveillance cultures Others have found high cost/low yield Target population for screening? All admissions? Contact precautions for all colonized/infected patients Antimicrobial stewardship Because of increased community cases, control measures will be most effective if implemented on a regional basis
17