Laboratory Coordination for Public Health Reporting: …stewardship education across the provider spectrum.” Strategic Goal #1: Raise consumer awareness of appropriate antibiotic

Laboratory Coordination for Public Health Reporting: Part 1

Wednesday, December 12, 201812:00 – 1:00 p.m.

www.ldh.la.gov/HAI

Objectives

• Describe the public health importance of national/state MDRO surveillance

• Differentiate the purpose of facility diagnostics from national/state testing

• Identify which organisms need to be reported to Infectious Disease Epidemiology Section and sent to the State Public Health Laboratory

• Describe the appropriate packaging and forms necessary for isolate submission

• Describe methods use for antibiotic sensitivity testing at the Louisiana Public Health Laboratory

Epi and Lab Coordination

“Detecting and preventing HAI/AR is a cross-cutting federal priority. Key strategies to prevent and reduce HAI/AR include containing emerging threats from antibiotic resistant organisms.” – CDC Epidemiology and Laboratory Capacity Cooperative Agreement, BP5 Narrative

Lab Partners:

Jean-Jacques Aucoin, ManagerMicrobiology Laboratory

Stephanie Kleinpeter, SupervisorMicrobiology Laboratory

Detect Respond Contain Prevent

Erica Washington (HAI Program Coordinator) and Stephanie

Kleinpeter (LA-PHL Microbiology Supervisor) at the CDC Antibiotic

Resistance Laboratory Meeting in Nashville, TN. June 28, 2018

2018 - 2019 STRATEGIC PRIORITIES

Goal 1:

Raise consumer awareness of

appropriate antibiotic prescribing

in 3 years.

Goal 2:

Improve facility and public health

coordination for detection and

response to novel, drug-resistant

threats within 24h of receipt of

report(s).

Goal 3:

Increase facilities with fully

competent antibiotic stewardship

programs by 30% in 3 years.

Goal 4:

Reduce HAI incidence by 20% in

3 years.

Goal 5:

Communicate HAI and AR

progress with stakeholders

annually.

“The mission of the Louisiana Healthcare-Associated Infections and Antibiotic Resistance Program is to protect patients by preventing healthcare-associated infections and the proliferation of resistant organisms through surveillance, outbreak response, and promoting infection control and antibiotic

stewardship education across the provider spectrum.”

Strategic Goal #1: Raise consumer awareness of appropriate antibiotic prescribing in 3 years.

Strategic Goal #2: Improve facility and public health coordination for detection and response to novel, drug-resistant threats within 24h of receipt of report(s).

Strategic Goal #3: Increase facilities with fully competent antibiotic stewardship programs by 30% in 3 years.

Strategic Goal #4: Reduce HAI incidence by 20% in 3 years.

Strategic Goal #5: Communicate HAI and AR progress with stakeholders annually.

1.1. Hold four, quarterly MAG meetings and get 70% attendance at each meeting.

1.2. Enact a statewide messaging campaign that impacts 30% of pediatric, primary care, emergency department, and outpatient settings.

1.3. Measure consumer attitudes of antibiotics through the Behavioral Risk Factors Surveillance Survey bi-annually (every other year).

2.1. Train all regional epidemiologists in multi drug-resistant organisms (MDRO) response annually and include in outbreak investigations.

2.2. Test all available CRE isolates within two days of receipt to the Louisiana Public Health Laboratory.

2.3. Increase facility detection of reporting of outbreaks to health department for appropriate response within 24 hours.

3.1. Reduce incidence of Clostridium difficile by 20% in 3 years by holding a prevention collaborative for 10 nursing homes annually.

3.2. Produce quarterly nursing home and antibiotic stewardship newsletters.

3.3. Sponsor web-based trainings for 30% of hospital pharmacists annually.

3.4. Annually validate 30% of hospital antibiotic stewardship programs.

3.5. Reduce Fluoroquinolone use by 20% among inpatient providers and penicillin by outpatient providers by 20%.

4.1. Have five acute care hospitals go through the TAP Strategy annually for CLABSI, CAUTI, and CDI, respectively.

4.2. Evaluate infection control and antibiotic stewardship trainings within one month of activity to assess practice changes.

4.3. Train 70% of infection preventionists each year (short- & long-term acute care hospitals, nursing homes, inpatient rehabilitation facilities, dialysis, and ambulatory surgery centers).

5.1. Produce quarterly newsletters (healthcare-associated infections, nursing home, and antibiotic stewardship).

5.2. Provide aggregate data on the HAI page for the Louisiana Department of Health.

5.3. Notify facilities of extremely drug resistant organisms (XDR) that are identified through the National Healthcare Safety Network and internal reporting systems.

5.4. Create a web presence at www.ldh.la.gov/stewardship for provider-based toolkits on antibiotic stewardship for Louisiana.

The Problem• ~2,000,000 people become infected with

antibiotic resistant bacteria each year• 23,000 attributable deaths

• 500,000 Clostridium difficile infections in 2015 • 29,000 patients died within 30 days of initial

diagnosis

• 15,000 deaths directly attributable to C. difficile

• CRE causes 9,300 infections and 600 deaths each year

The Problem

Review on Antimicrobial Resistance (AMR), 2014. Antimicrobial Resistance: Tackling

a crisis for the health and wealth of nations. London, UK http://amr-review.org

Antibiotic Resistance Laboratory Network (ARLN)

Antibiotic Resistance Laboratory Network (ARLN)

• Established in 2016

• Comprehensive lab capacity and infrastructure for antibiotic-resistant pathogens

• Cutting-edge technology, including DNA sequencing• Better understand deadly threats to quickly contain them

• Data to drive response and prevent infections• “Sound the alarm” for a comprehensive local response

Containment Support

Colonization ScreeningDay 1

• CP-CRE identified

• Health Department notified

• ARLN sends swabs to facility

Day 2

• Swabs of contacts collected and sent back to ARLN

Day 3

• Swabs tested at ARLN

*Results reported within 2 working days of specimen receipt

• Strengthen diagnostics by validating lab tests

• Inform research and development• Develop drugs, i.e., antibiotics and antifungals• Develop diagnostic devices, tests, or assays

• Perform testing to ensure drug effectiveness

• Study biology and pathogenic mechanisms

• Detect new and unusual public health resistance threats

• Samples are assembled based on public health

• As of Jan. 2018, the AR Isolate Bank has shipped more than 2,000 isolate panels

The Future of National Surveillance and Response

HP Printers Test for Antibiotic Resistance

• “Prints” drugs rather than ink

• Allows susceptibility testing of organisms before there is commercially available testing

• Will inform treatment with new drugs

• Helps ensure new drugs last longer

Antimicrobial Resistance Laboratory Network (ARLN)

Organisms to be submitted to the LDH OPH Laboratory -• Carbapenem Resistant Enterobacteriaceae (CRE) - Escherichia coli, Klebsiella

oxytoca, Klebsiella pneumoniae, and Enterobacter spp. that are resistant to imipenem, meropenem, doripenem, or ertapenem by standard susceptibility testing methods (i.e., minimum inhibitory concentrations of ≥4 μg/mL for doripenem, imipenem or meropenem or ≥2 μg/mL for ertapenem)

• Carbapenem Resistant Pseudomonas aeruginosa (CRPA) – Non-mucoid P. aeruginosa isolates that are resistant to imipenem, meropenem, or doripenemby standard susceptibility testing methods (i.e., minimum inhibitory concentrations of ≥8 μg/mL). The LDH OPH laboratory will accept up to 10 suspected CRPA isolates from each submitter site per month.

LDH OPH Laboratory Participation in the ARLN:

Antimicrobial Resistance Laboratory Network (ARLN): Isolate Packaging Information for Submitters

Supplies: Screw top specimen canister with Styrofoam insert

Nutrient agar slants or other appropriate medium in glass screw-cap tubes (not supplied by OPH Laboratory)

Large sealable biohazard bag for transport

Green 15 – 30oC label

Packaging:1. Open the primary canister provided and remove the secondary metal canister.

2. Open the secondary metal canister, remove the small disc shaped foam insert, and place the agar slant(s) into the available slots in the large foam insert within the secondary metal canister.

3. After all tubes have been added to the canister, replace the small disc shaped foam insert over the specimens and secure the lid on the secondary metal canister.

4. Place the secondary metal canister into the primary canister and secure the lid on the primary canister.

5. Place the sealed primary canister(s) and corresponding Lab Form 93 into the large biohazard bag provided and seal the bag. NOTE: PLACE ALL SEALED INDIVIDUAL CANISTERS INTO ONE, SINGLE, LARGE BIOHAZARD BAG.

6. Place a green 15-30°C label indicating the appropriate storage temperature on the large sealed biohazard bag containing the canisters and place the bag at an appropriate, designated storage location (15-30°C).

7. Call the courier using the contact phone number provided and request a pickup for the specimens that have been packaged and stored appropriately.

8. Courier will transport specimens at room temperature. Temperature upon receipt in the laboratory should measure 15-30°C.

Secondary Canister

Primary Canister

15-30°C

LDH OPH Laboratory Courier: Statcourier

Antimicrobial Resistance Laboratory Network (ARLN): Lab Test Request Form Complete Lab Test Request Form Online (Lab Form 93): http://ldh.la.gov/index.cfm/page/1123

For Test Requested, select “Other” and specify CRE/CRPA Confirmation and organism identification

Antimicrobial Resistance Laboratory Network (ARLN)

The LDH OPH Laboratory will be utilizing the following validated test methods for confirmation and molecular characterization of Carbapenem resistant Enterobacteriaceae and Pseudomonas aeruginosa:

1. Identification Confirmation: MALDI-TOF Mass Spectrometry

2. Antimicrobial Susceptibility Testing: Kirby-Bauer Disk Diffusion

Antimicrobials used to confirm and further characterize CRE and CRPA

Drug Class CRE CRPA

Carbapenems Ertapenem, Imipenem, and Meropenem Imipenem and Meropenem

Cephems Ceftriaxone, Ceftazidime, and Cefepime Ceftazidime and Cefepime

B-lactam/B-lactamase inhibitor combinations N/A Piperacillin-Tazobactam

Monobactams Aztreonam Aztreonam

3. Phenotypic Carbapenemase Detection: Modified CarbapenemInactivation Method (mCIM)

Evaluation of the growth of a carbapenem susceptible E. coli isolate in the presence of a carbapenem disk that has been exposed to a possible carbapenemase producer.

Antimicrobial Resistance Laboratory Network (ARLN)

Positive mCIM

Negative mCIM

4. Molecular Detection: Cepheid GeneXpert Carba-R Assay PCR analysis performed on an automated platform.

Detects gene sequences for KPC, NDM, VIM, OXA-48, and IMP

Antimicrobial Resistance Laboratory Network (ARLN)

Detection within 45 minutesSuspension of test isolate added to Carba-R Sample Reagent

Antimicrobial Resistance Laboratory Network (ARLN)

Laboratory Results will include:

1. Identification Confirmation

2. Antimicrobial Susceptibility Results (Disk Diffusion)

3. Phenotypic Carbapenemase Confirmation (mCIM)

4. Molecular Carbapenemase Characterization (KPC, NDM, VIM, OXA48, and IMP)

Note: Laboratory results should only be used to support infection prevention measures and should not be a substitute for diagnostic procedures or used to guide clinical decisions.

Laboratory Result Reporting: The LDH OPH Laboratory will report test results back to the submitting institution via secure fax.

Provide Your Feedback with the Post-Webinar Evaluation: Please respond by Friday, December 14th at 12 noon

Upcoming Laboratory Coordination for Public Health Reporting Webinar Dates (dates subject to change)

February 13, 2019

March 13, 2019

May 15, 2019

https://www.surveymonkey.com/r/labcoordination1

www.ldh.la.gov/HAI