ESBL producing E.coli Epidemiology a local overview

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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

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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.

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Shropshire geography
Stoke-on-Trent
WALES
Oswestry
Stafford
Telford
Shrewsbury
Wolverhampton
Worcester
Hereford
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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

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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).

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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.

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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.

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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.

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How many cases since January 2002

• 326 new cases ESBL producing E coli by Mid August
  2004
• 30 other ESBL producers

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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.

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Findings on initial 105 casesNB same age
distribution as routine urines
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August 2004

• 326 cases
• 68 female
• mean age 74 years
• Gen S strains 49 community/51 acute trust
• Gen R Strains 21 HospitalCommunity ratio

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Epidemic Curves
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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

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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

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Response to the outbreak .2

• March 2004 new hospital antibiotic guidelines
  introduced and strongly promoted

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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

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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

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? Community acquired
Patients tested within 3 days of admission
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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

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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

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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

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Early mortality following laboratory diagnosis of
ESBL
 
 
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ESBL survival curves (for cases diagnosed up to
16 August 2004)
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Additional burden?

• Recurrent UTIs
• Treatment failure on nitrofurantoin
• Prolonged faecal carriage (gt14 months)
• Impact on MRSA

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Outstanding issues

• Isolation units
• Funding?
• Where ?
• Screening on admission ?
• Effective faecal clearance?