Antibiotic Resistant Pathogens in ICU Patients NNIS

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Antibiotic Resistant Pathogensin ICU Patients
(NNIS)

• 24.7

VRE
MRSA

• 53.5

MRSE
88.2

3.9
ESBL-E. coli
?
10.4
ESBL-Klebsiella
?
Quinolone-R P.aeruginosa

• 23.0

Resistance
? 1999
1994-1998
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ANTIMICROBIAL RESISTANCE
IN CANADIAN HOSPITALS
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ANTIMICROBIAL RESISTANCEIN CANADIAN HOSPITALS

• MRSA
• VRE
• ESBLs

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ANTIMICROBIAL RESISTANCEIN CANADIAN HOSPITALS

• Prevalence
• Epidemiology
• Impact
• Control

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CHEC/CNISP

• MRSA - prospective since 1995
• VRE - prospective since 1999
• ESBLs - prospective since 2001

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CANADIAN NOSOCOMIAL INFECTION SURVEILLANCE
PROGRAM
22-34 participating hospitals, 9 provinces 30
teaching hospitals 12 with affiliated
LTCFs 13 with pediatrics 5 pediatric
hospitals LCDC, Health Canada
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CHEC / CNISP SURVEILLANCEFOR ANTIMICROBIAL
RESISTANCE

• laboratory - based
• prospective, incidence
• updated hospital profiles
• demographic and clinical data
• laboratory characterization, molecular typing

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MRSA IN CANADA1995-2000
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MRSA IN CANADA
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MRSA IN CANADA1995-2000
Eastern Canada
Western Canada
Central Canada
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MRSA INFECTIONS(1,760 35)

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MRSA IN CANADAACQUISITION

• 87 acute-care hospital
• 7 long-term care facility
• 6 community
• (excluding 17 unknown)

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MRSA IN CANADA

• Proportion of hospital-acquired MRSAthought to
  have been acquired in theindex hospital 86
• Increase in rate of MRSA acquired inindex
  hospital 1997-1999 (plt0.01)1997 - 0.9/1,000
  admissions1998 - 1.4/1,000 admissions1999 -
  2.8/1,000 admissions

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MRSA IN CANADAWhy was the culture done?
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MRSA IN CANADAEpidemiological Link
54 Link
46 No link
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Vancomycin-IntermediateS. aureus

• MRSA strains with vancomycinMIC 8µg/ml
• USA, Europe, Japan, Korea,Brazil
• associated with vancomycinuse, and treatment
  failure

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VRE

• approx. 12 of nosocomial enterococcal infections
  inU.S. hospitals, 1996
• mostly E. faecium, vanA
• 29 urinary isolates18 wound isolates17
  bloodstream isolates

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VRE IN CANADA(CNISP, 1999)

• 0.9 enterococcal isolates0.54 / 1000
  admissions
• 83 screening 17 clinical isolates
• 92 patients colonized

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VRE - ONTARIO
No. patients colonized/infected
718
685
589
445
167
99
2
7
0
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ESBLs

• 25 K. pneumoniae in hospitalized patients in
  France, 1993-1996
• 12 K. pneumoniae in U.S. ICUand 8 non-ICU
  patients (Fridkin 1997)
• 10 K. pneumoniae 3 E. coliresist to 3rd gen.
  cephs U.S. ICUs (NNIS, 1999)

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ESBLs in Canada

• CNISP survey, 15 labs, 19980.1-0.7 E.
  coli0.2-2.5 K. pneumoniae
• Saibil et al, 8 Ont. ICUs, 1999-20008/477
  (1.7) patients colonized12 Klebsiella 1 E.
  coli
• Muller et al, outbreak in Ont. LTCFs2000-01
  gt140 residents colonizedsmall number of
  infections, deaths

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Does antibiotic resistance in nosocomial
pathogens matter?
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HEALTH IMPACT OFANTIMICROBIAL RESISTANCE

• Review of 175 reported outbreaks of infection due
  to antimicrobial resistant or susceptible
  bacteria (S. aureus, Salmonella, Shigella,
  Serratia)
• Approximately 2X greater mortality,
  hospitalization and length of hospital stay
  associated with antibiotic resistant infections
• - Holmberg, 1987

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S. AUREUS BACTEREMIA

• Higher mortality associated with MRSA (49-58)
  than with MSSA (20-32)
• Multivariate logistic regression analysis found
  MRSA infection to be an independent risk factor
  for mortality(OR, 3.0-4.2)
• - Romero-Vivas, 1995
• - Conterno, 1998

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MORTALITY ASSOCIATED WITHS. AUREUS BACTEREMIA
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IMPACT OF MRSA/VREDELAYS IN TRANSFER
Mean no. ALC days prior to transfer 130 days
with MRSA/VRE vs. 69 days for matched
controls - Bryce et al, 2000
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COSTS ASSOCIATEDWITH MRSA

• 14,360/infection for managementof infected
  patients
• 1,363/admission for managementof colonized
  patients

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VRE BACTEREMIA

• Higher mortality associated withVRE than with
  VSE (57 vs. 35 OR 2.1, p0.02)
• VRE also associated with moreprolonged
  hospitalization(median 17 days vs. 3 days
  plt0.001)
• - Linden, 1996
• - Vergis, 2001

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ESBLsImpact

• In most studies, no effect on mortality
• case-control study CAZ-RKlebsiella/E. coli
  bacteremia?mortality if appropriate therapynot
  started in first 3 days (p0.02)(Schiappa, J Inf
  Dis 1996)

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ESBLs

• 56 of ESBL-producing E. coli and Klebsiella in 2
  Philadelphia hospitalswere also resistant to
  ciprofloxacinand/or levofloxacin
• quinolone resistance in ESBLsassociated with
  prior quinoloneuse and residence in a LTCF
• Lautenbach, CID 2001

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STRATEGIES TO MANAGEANTIBIOTIC RESISTANCE

• Surveillance, screening,early detection
• Handwashing and otherinfection control measures
• Appropriate use of antibiotics
• New antimicrobial agents

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Do control measures work?Can antibiotic
resistance be controlled?
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MRSA - DENMARK
1966 - 3 1970 - 15 1991 - 2 Control
surveillance screening strict infection
control restricted antibiotic use
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VRE - ONTARIO
No. patients colonized/infected
718
685
589
445
167
99
2
7
0
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ESBLsEffect of Control Measures
2. Pena et al, AAC 1998 Setting clonal
outbreak ESBL K. pneumoniae 145 patients
1993-95 Intervention June 1993 - inf. control
measures Sept. 1993 - restricted
oxyimino- ?-lactams Result decreased
no. cases after restricted antibiotic use
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Pena, AAC 1998
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ESBLsEffect of Control Measures
3. Lucet et al, CID 1999 Setting French
hospital 140 ESBLs/yr. Intervention ESBL
screening hand hygiene contact
isolation Result ESBL incidence 1992 -
0.56/100 admissions 1995 - 0.06/100 admissions
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HOW TO ACCOUNT FOR VARIABILITYIN ANTIBIOTIC
RESISTANCE INCANADA VS U.S.A.?

• luck
• different strains
• variability in lab detection
• variability in antibiotic utilization
• variability in infection control practices