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ESBL producing E.coli Epidemiology a local overview

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Director of Infection Control, Shrewsbury and Telford NHS Trust: ... Worcester. Hereford. 4. If you do not look you will not find ! ... – PowerPoint PPT presentation

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Title: ESBL producing E.coli Epidemiology a local overview


1
ESBL producing E.coliEpidemiology a local
overview
  • Dr Graham Harvey
  • Director of Infection Control,
  • Shrewsbury and Telford NHS Trust
  • on behalf of the Shropshire Outbreak Control teams

2
Acknowledgements for much help
  • Dr Rod Warren, Director of Pathology, Shrewsbury
    Telford Hospital.
  • Dr Rob Carr HPA CCDC Shropshire,Chair Community
    Outbreak control team.
  • Dr Alex Doroshenko PH SpR WMidlands training
    scheme.
  • Ms Divya Patel for surveillance of deaths.
  • Mrs Karen Howells for much technical work.
  • Dr Patricia ONeill, Consultant microbiologist,
    Shrewsbury Telford Hospital p/t CCDC
    Shropshire.
  • Dr Andrew Pearson, CDSC, Colindale.
  • Dr David Livermore and Dr Neil Woodford.
    Antibiotic Surveillance and Reference Laboratory,
    CPHL,Colindale.

3
Shropshire geography
Stoke-on-Trent
WALES
Oswestry
Stafford
Telford
Shrewsbury
Wolverhampton
Worcester
Hereford
4
If you do not look you will not find !
  • PHL Midlands group adoption of BBL Chromagar for
    urine samples
  • BSAC sensitivity testing 2002
  • Mast zone size readers identification of all
    urine isolates (Oct 02)
  • Cefpodoxime sensitivity testing

5
Start of the Shropshire outbreak
  • May 2003 multi-resistant UTIs noted as emerging
    problem.
  • Two E.coli strains
  • resistant to quinolones, cephalexin and
    trimethoprim.
  • 1 strain gentamicin resistant.
  • Both strains nitrofurantoin susceptible.
  • Cefpodoxime resistant but clavulanate enhanced
    (ESBL).

6
Early findings
  • Gentamicin sensitive strain initially apparent as
    a community problem.
  • samples from GPs and few from psychiatric
    hospital.
  • Only 1 nursing home resident.
  • No apparent serious cases.
  • Gentamicin resistant strain mainly in Telford
    Hospital.

7
Early reference lab. work
  • Both strains serotype O25 CTX-M positive.
  • Gentamicin resistant strain CTX-M-15.
  • Gentamicin sensitive strain initially thought to
    be CTX-M-27. Actually CTX-M-15 with Is26insertion
    between promoter B-lactamase.
  • PFGE 5 inter-related PFGE clones.
  • Groups A D dominant (78) in Shropshire but BE
    also present.

8
Case definition
  • ESBL E coli cases defined as
  • New cases of infection with E. coli
  • Prior to Oct 02 non-identified systemic
    coliforms
  • With ESBL and resistance to quinolones (and
    trimethoprim in urine)
  • Diagnosed in the Shropshire laboratory since
    January 2002.

9
How many cases since January 2002
  • 326 new cases ESBL producing E coli by Mid August
    2004
  • 30 other ESBL producers

10
The evolution of the outbreak Clinical and
epidemiology 1.
  • Elderly patients gt60.
  • In-patient cases initially in Telford area.
  • Later spread across the county
  • No obvious ward focus (21wards)
  • Hospital contact in past 3 years
  • But in 10 cases no local acute hospital contact.

11
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12
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13
Findings on initial 105 casesNB same age
distribution as routine urines
14
August 2004
  • 326 cases
  • 68 female
  • mean age 74 years
  • Gen S strains 49 community/51 acute trust
  • Gen R Strains 21 HospitalCommunity ratio

15
Epidemic Curves
16
Response to the outbreak .1
  • Community/Hospital outbreak team (Aug 03)
  • Letter to consultants/GPs Sept 03
  • Restrictive antibiotic reporting
  • Increased use of carbapenems
  • Cases isolated in side rooms

17
Community strains questionnaire Oct-Dec 2003
  • 16 cases followed up
  • 12 prior Abs in 3 years
  • 15 healthcare contact
  • 8 catheters
  • 3 overseas travel
  • No common food/dairy product/food outlet/ use of
    non-mains water supply

18
Response to the outbreak .2
  • March 2004 new hospital antibiotic guidelines
    introduced and strongly promoted

19
Antibiotic Policy change
  • Nitrofurantoin substituted for quinolones in UTIs
  • Imipenem substituted for quinolones in routine
    reporting serious sepsis
  • Ertapenem introduced
  • Gentamicin substituted for cephalosporins in
    surgical prophylaxis/serious sepsis
  • Return to amoxycillin in chests

20
Response to the outbreak .3
  • Biohazard flagging of patients electronic records
  • Daily search for re-admissions
  • ESBL management unit
  • Open May to June 04
  • Plan to re-open October 04
  • Promote use of hand gel
  • Hand gel by each bedside

21
? Community acquired
Patients tested within 3 days of admission
22
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23
Faecal screening
  • Community and hospital samples
  • positive for ESBL producing E coli
  • Hospital 15/291 5.2
  • Shropshire community 11/475 2.3
  • Powys community 0/51 0

24
Serious infections
  • 20 patients, 22 bacteraemias
  • First isolate in 16 patients
  • 5 patients dead (1,14,28,55,113 days post).
  • 10 patients gentamicin res. strains

25
The evolution of the outbreak Less obvious
serious infections
  • Review. 28 deaths in first 105 cases but only 2
    had confirmed bacteraemias.
  • Initially 26 notes reviewed by 2 CMMs
  • 15 serious underlying diseases
  • Malignancy or dementia
  • 7 diabetics
  • 50 deaths associated with infection

26
Early mortality following laboratory diagnosis of
ESBL
 
 
27
ESBL survival curves (for cases diagnosed up to
16 August 2004)
28
Additional burden?
  • Recurrent UTIs
  • Treatment failure on nitrofurantoin
  • Prolonged faecal carriage (gt14 months)
  • Impact on MRSA

29
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30
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31
Outstanding issues
  • Isolation units
  • Funding?
  • Where ?
  • Screening on admission ?
  • Effective faecal clearance?
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