opportunities for prevention Eli N. Perencevich, MD MS Professor of Medicine University of Iowa, Carver College of Medicine Iowa City, Iowa Friday, 1 July 2011 17:15 Overview MDR-Acinetobacter Some early epidemiological work around Acinetobacter Seasonality Background studies First UMMC study 132-hospital study Acinetobacter Gram-negative coccobacillus Was often viewed as a colonizer HAS ARRIVED as a nosocomial pathogen Acinetobacter baumannii is the most common Outbreak of imipenem-resistant Acinetobacter in New York Difficult to eradicate colonized state Emergence in returning troops from the Middle East
Reference Clinical Setting Cases Attributable Mortality Acinetobacter Infections Compared to Matched Un-infected Controls Grupper (2007) Nosocomial BSI ICU, Israel 52 BSI 36.5% Blot (2003) Nosocomial BSI ICU, Belgium 45 BSI 7.8% Acinetobacter Infections Compared to Matched Controls with Klebsiella Infection Robenshtok (2006) Nosocomial BSI Israel 112 BSI 22.7% Multidrug-Resistant Acinetobacter Infections Compared to Matched Susceptible Controls Kwon (2007) CR-BSI 3* Care, Korea 40 CR- Infections 25-30% Sunenshine (2007) MDR-Infections 3* Care; Baltimore 96 MDR-Infections 8.4% Lee (2007) MRD-Infections 3* Care, Taiwan 48 MDR-BSI 21.8% Multidrug-Resistant Acinetobacter Infections Compared to Matched Un-infected Controls Sunenshine (2007) MDR-Infections 3* Care, Baltimore 96 MDR-Infections 14.8% Playford (2007) CR-Infection/Colonization ICU, Australia 66 CR-Infections or Colonization 20% Bacteria CLABSI (% imipenem resistant) VAP (% imipenem resistant) CAUTI (% imipenem resistant) Pooled (% imipenem resistant) Pseudomonas 23.0% 25.1% 26.4% 25.3% Klebsiella 10.8% 10.1 3.6 Acinetobacter 29.2 25.6 36.8 NHSN: impenem-resistance Why do I care about AB? July 2002, MICU Everyone on vacation, except 5 patients with MDR-AB bacteremia in July 4 in August Control plan Shut MICU Press Ban artificial nails 0 1 2 3 4 5 What happened? Universal gown/glove instituted in MICU and SICU
Active surveillance on all transfers from outside hospitals; isolated until cultures return
Statewide AB surveillance (2010) The Source! 180-bed, UMMC-afilliated LTAC 1 147 patient point prevalence survey (12/05) 28% AB+ (41 patients) Sensitivity by site 22% peri-rectal, 68% sputum, 22% wound 2010 Survey of 57 Maryland Facilities 2 1. Furuno J et al, Am J Infect Control 2008 2. Thom K (unpublished) Transmissibility and Protection Organism HCW Room Entries Hand + Before (%) Gown and/or Glove + After % Hands + After Removal Effectiveness of PPE A. baumannii 1 202 1.5% 38.7% 4.5% 88% P. aeruginosa 1 133 0% 8.2% 0.7% 90% VRE 2 94 0% 9% 0% 100% MRSA 2 81 2% 19% 2.6% 85% 1. Morgan D, et al, Infect Control Hosp Epidemiol July 2010; 31(7):716-21. 2. Snyder G, et al, Infect Control Hosp Epidemiol July 2008; 29(7):584-589 FOR MORE INFO... Add in local hand hygiene adherence rates 0 36% 20% 17% 14% 11% 8% 5% 50% 18% 10% 9% 7% 5% 4% 2% 60% 15% 8% 7% 6% 4% 3% 2% 70% 11% 6% 5% 4% 3% 2% 1% 80% 7% 4% 3% 3% 2% 2% 1% 90% 4% 2.% 2% 1% 1% 1% 1% 100% 0 0 0 0 0 0 0 0 50% 60% 70% 80% 90% 100% Compliance with Gloves (patients on contact precautions)
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Environmental Sampling Percent of rooms with positive environmental cultures for organism known to be colonizing patient (PFGE) 78% Acinetobacter 35% VRE 28% MRSA 22% P. aeruginosa 15% KPC 1. Morgan D, et al, Society for Healthcare Epidemiology of America (SHEA) 2010 FOR MORE INFO... What else? Outbreak in summer Vets returning from Iraq had high incidence of infection with Acinetobacter Tropical climates with more AB infections
Could weather or season play a role? If found, could this alter our infection prevention practices? Seasonal variation Certain infections have seasonal variation Influenza, RSV, Legionella* Seasonal variation in hospital pathogens? Previous studies limited given combined data Seattle summer added to Houston summer Did not look at temperature specifically FOR MORE INFO... Fisman DN, J Infect Dis 2005 Dec 15;192(12):2066-73 Seasonal Variation AB CDC NNIS 1974-1977 hospital-wide data 1 2x increase in late summer vs early winter CDC NNIS 1987-1996, 3447 ICU isolates 2
54% higher during JulyOctober than during NovemberJune (8.0 vs. 5.2 per 10,000 patientdays, p<0.01) Did not control for location, year, temp etc. No variation in Pseudomonas spp 1. Retailliau HF, et al. J Infect Dis 1979;139:37152. 2. McDonald LC et al. Clin Infect Dis 1999;1133-7. FOR MORE INFO... Monthly incidence density of acinetobacter infections: intensive care unit surveillance component, National Nosocomial Infection Surveillance System, 19871996 (white bars, A. baumannii; black bars, all other Acinetobacter species) McDonald LC et al. Clin Infect Dis 1999;1133-7. FOR MORE INFO... Monthly incidence density of Pseudomonas aeruginosa infections: intensive care unit surveillance component, National Nosocomial Infection Surveillance System, 19871996. McDonald LC et al. Clin Infect Dis 1999;1133-7. FOR MORE INFO... Seasonal Variation of Season 2008 FOR MORE INFO... http://www.ncdc.noaa.gov/sotc/index.php?report=national&year=2008&month=ann Study Aim: Assess for seasonal variation in Pseudomonas aeruginosa, Acinetobacter baumannii, Enterobacter cloacae, Escherichia coli, Staphylococcus aureus, and enterococci 8-years of clinical culture data, UMMC Summer: July-September Community-associated <48 hours, HA>48 hours Time-series analysis; Poisson GLM FOR MORE INFO... Perencevich et al. Infect Control Hosp Epidemiol Dec 2008:1124-31 Additional Methods Adjusted for long-term trends Assessed for temperature, humidity and rainfall effects Adjusted for non-weather seasonality >48 hour and <48 hour for community vs. hospital strains r/o intern effects
Cultures and Sources 218,594 admissions 26,624 unique cultures (one per pt / year) 3,373 Pseudomonas aeruginosa (34% urine) 1,444 Acinetobacter baumannii (35% sputum) 1,823 Enterobacter cloacae (27% urine) 6,035 Escherichia coli (74% urine) 7,162 Staphylococcus aureus (39% wound) 6,787 enterococci (51% urine) Community-associated Species % Community-associated (<48 hours) Pseudomonas aeruginosa 37% Acinetobacter baumannii 33% Enterobacter cloacae 33% Escherichia coli 56% Staphylococcus aureus 62% enterococci 39% Seasonal Variation in GNR Seasonal GPC Summer Peaks Additional Studies E. coli BSI in N. Israel Single medical center (HaEmek) 8 years (2001-2008) Winter (Dec-Feb) Transition (Mar, Apr, Nov) and Summer (May-Oct) 983 BSIs, 72% community, 70% UTI IRR summer vs winter 1.21 (95% CI 1.16-1.28) IRR summer vs trans 1.19 (95% CI 1.12-1.26) Within seasons no temperature association FOR MORE INFO... Chazan B. et al. Clin Micro Infect 2010 E. coli BSI in N. Israel FOR MORE INFO... Chazan B. et al. Clin Micro Infect 2010 E. coli BSI in Olmsted County, MN Single county Mayo Med Center and Olmsted Med Center 1998-2007 Summer: June-Sept 461 BSI, 59% community, 80% 1 Urine IRR summer vs other 1.35 (1.12-1.66) 7% increase for each 10 degree rise in temp Did not adjust for month in temp analysis FOR MORE INFO... Al-Hasan et al. Clin Micro Infect 2009;15:947-950 E. coli BSI in Olmsted County, MN FOR MORE INFO... Chazan B. et al. Clin Micro Infect 2010 Repeated analysis in Enterobacter (only 38 isolates) and reported no seasonality Bacteremia England 2004-2008 FOR MORE INFO... Wilson J. et al. Clin Micro Infect 2010 (in press) Klebsiella BSI 4 sites (Durham, NC; Marseille, France; Melbourne, Australia and Taipei, Taiwan) 2001-2006 1189 BSI, ? % community IRR 4 warmest months 1.46 (1.04-2.06) Ranged from 1.41 to 1.49 at 4 sites, all p<0.05 Enterobacter IRR = 1.22 (0.92-1.63) Serratia IRR = 1.23 (0.86-1.77) FOR MORE INFO... Anderson D, et al. J Infect Dis 2008; 197:752-6 Klebsiella, 4 Countries A=Duke B=Marseille C=Melbourne D=Taipei FOR MORE INFO... Anderson D, et al. J Infect Dis 2008; 197:752-6 Klebsiella, 4 Countries Combined FOR MORE INFO... Anderson D, et al. J Infect Dis 2008; 197:752-6 What about MRSA? Rhode Island Hospital All clinical MRSA isolates January 2001 to March 2010 48-hour rule Poisson regression Offset log # admits or ED visits FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 Seasonality CA-MRSA Pediatric patients 1.85 times (95%CI 1.45-2.36, p<0.01) in quarters 3-4 Adult patients 1.14 times (95%CI 1.01-1.29, p=0.03) in quarters 3-4
FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 Seasonality HA-MRSA Pediatric patients 2.94 times (95%CI 1.39-6.21, p=0.015) in quarters 3-4 Adult patients 1.00 times (95%CI 0.89-1.12, p=0.97) in quarters 3-4 FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 Seasonality and S. aureus Mixed Infections, Bacteremia, and Upper Extremity Infections FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 Seasonality and Staphylococcus aureus Skin Infections FOR MORE INFO... Mermel LA et al. PLoS One, March 2011;6(3):e17925 Seasonal and temperature- associated increases in gram-negative bacterial bloodstream infections among hospitalized patients
Seasonality GNR, US 1999-2006 132 US Hospitals, TSN Database Jan 1, 1999 - Sept 30, 2006 Acinetobacter spp, E. coli, K. pneumoniae, P. aeruginosa Enterococcus spp and S. aureus Monthly climate data: National Climactic Data Centers Climate Data Online system ZIP code: mean temp, mean dew point, total precipitation BSI isolates 211,697 BSIs 9,423 hospital-months S. aureus: median 976 BSI/month Acinetobacter: median 67 BSI/month
FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Distribution of Hospitals by Region FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Seasonally adjusted Change in BSI FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. * Controlling for long-term trends, census region BSI and Temperature FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. * Controlling for long-term trends, census region, precipitation and mean relative humidity
BSI and Humidity or Precipitation FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Mean Acinetobacter BSI by Month FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Mean E. coli BSI by Month FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Mean K. pneumonia BSI by Month FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Mean P. aeruginosa BSI by Month FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9):e25298. Epub 2011 Sep 26. Mean BSI by Month for GPC FOR MORE INFO... Eber M et al. PLoS One. 2011;6(9) High-Impact Journal Associate Editor Even if there is seasonality of admissions, and even if such seasonality were deemed to be of practical importance, why should the correlation with temperature be of value? What is the practical public health significance of knowing such correlation (beyond the general idea that number of cases is greater in summer compared to winter) Surely just increasing surveillance of tap water quality in summer is sufficient guidance, regardless of exact atmospheric temperature Even if we faced a new ice age, surely populations would be at risk to these pathogens? Q1: Why would temperature data be of value? Seasons are associated with many changes including staffing changes (new interns), vacations and weather. If temperature was not associated with seasonal peaks, we would want to look at other modifiable factors If higher-temperatures are predicted, surveillance could be altered Data on temperature and increased infections could inform the global climate change debate
Q2: Public health significance of knowing such seasonal correlation? Alter surveillance strategies Cost-effectiveness could target GNR surveillance more intensively in summer Alter empirical therapy decisions Begin other investigations to determine the source of each GNR in summer time Surveillance Source control Q3: Just increase surveillance of tap water quality None of these pathogens have been detected in increased frequency in our tap water Association could be through prolonged environmental contamination of hospitals, colonization of HCW hands or fomites E. coli could be from summer barbecue cookouts or increase sexual activity - UTI Q4: Even if we faced a new ice age, surely populations would be at risk to these pathogens? I have submitted my grant to do a quasi- experimental study of infections before and after an ice age It appears that only eliminating a risk factor and all associated infections is worthwhile then? I disagree! Acknowledgments Anthony Harris Jon Furuno Mary-Claire Roghmann Daniel Morgan Kerri Thom Richard Venezia Kristie Johnson Colin Stine Atlisa Young Lisa Pinelis Michelle Shardell
Marin Schweizer Hannah Day Kristen Kreisel Mary Warren Gwen Smith Mike Eber Jessina McGregor Ramanan Laxminarayan