Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
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Surveillance <strong>for</strong> Antimicrobial<br />
Resistance at the<br />
<strong>Centers</strong> of <strong>Disease</strong> <strong>Control</strong> <strong>and</strong><br />
<strong>Prevention</strong><br />
Jean B. Patel, PhD, D(ABMM)<br />
Deputy Director<br />
Office of Antimicrobial Resistance<br />
National Center <strong>for</strong> Emerging <strong>and</strong> Zoonotic<br />
Infectious <strong>Disease</strong>s<br />
The findings <strong>and</strong> conclusions in this presentation have not been <strong>for</strong>mally<br />
disseminated by the <strong>Centers</strong> <strong>for</strong> <strong>Disease</strong> <strong>Control</strong> <strong>and</strong> <strong>Prevention</strong> <strong>and</strong> should not be<br />
construed to represent any agency determination or policy
Surveillance <strong>for</strong> Antimicrobial Resistance<br />
(AR)<br />
Viruses<br />
Parasites<br />
Bacteria<br />
Mycobacteria
Surveillance <strong>for</strong> Sentinel Resistance<br />
Events<br />
• Identifying unusual resistance in the healthcare<br />
clinical microbiology laboratory<br />
Appendix A<br />
CLSI M100-S21
Detection of Carbapenem-Resistant<br />
Enterobacteriaceae (CRE)<br />
• Reference laboratory identification of new CRE<br />
• Guidance <strong>for</strong> laboratory detection of CRE
CRE in the United States
AR as a Notifiable <strong>Disease</strong><br />
Carbapenem-Resistant Enterobacteriaceae<br />
(CRE)<br />
“More than 350 cases of carbapenem-resistant Klebsiella<br />
pneumoniae, or CRKP, have been reported at healthcare facilities in<br />
Los Angeles County, mostly among elderly patients at skilled-nursing<br />
<strong>and</strong> long-term care facilities, according to a study by Dr. Dawn<br />
Terashita, an epidemiologist with the Los Angeles County<br />
Department of Public Health.”
AR as a Notifiable <strong>Disease</strong><br />
Vancomycin Resistant Staphlyococcus aureus<br />
Case Year Age Source Diagnosis Underlying Conditions<br />
1 2002 40<br />
Plantar ulcers &<br />
Catheter tip<br />
Plantar soft tissue infection Diabetes, dialysis<br />
2 2002 70 Plantar ulcer Osteomyelitis Obesity<br />
3 2004 63<br />
Urine from a nephrostomy<br />
tube<br />
No infection<br />
Multiple sclerosis,<br />
Diabetes, kidney stones<br />
4 2005 78 Toe wound Gangrene<br />
Diabetes, vascular<br />
disease<br />
5 2005 58<br />
Surgical site wound after<br />
panniculectomy<br />
Surgical site infection Obesity<br />
6 2005 48 Plantar ulcer Osteomyelitis MVA, chronic ulcers<br />
7 2006 43 Triceps wound Necrotizing fasciitis<br />
Diabetes, dialysis,<br />
chronic ulcers<br />
8 2007 48 Toe wound Osteomyelitis<br />
Diabetes, obesity,<br />
chronic ulcers<br />
9 2007 54<br />
Surgical site wound after foot<br />
amputation<br />
Osteomyelitis<br />
Diabetes, hepatic<br />
encephalopathy<br />
10 2009 53 Plantar foot wound Plantar soft tissue infection<br />
11 2010 64 Wound drainage Prosthetic joint infection<br />
Diabetes, obesity, lupus,<br />
rheumatoid arthritis<br />
Diabetes, end-stage<br />
renal disease, dialysis<br />
12 2010 83 Vaginal swab No infection Chronic CDI
Surveillance Networks<br />
• Emerging Infections Program (EIP)<br />
• Population based surveillance in 10 states<br />
• State networks consist of public health <strong>and</strong> academic<br />
partners<br />
• National Healthcare Safety Network (NHSN)<br />
• Web-based surveillance of healthcare-associated<br />
infections (HAI)<br />
• Data from different kinds of healthcare-delivery<br />
facilities<br />
• GISP (Gonococcal Isolate Surveillance Project)<br />
• STD clinics in 29 cities supported by 5 regional labs
Another Network…<br />
• Epidemiology <strong>and</strong> Laboratory Capacity Program<br />
(ELC)<br />
• 50 state health departments, 6 local health<br />
departments, Puerto Rico & Republic of Palau<br />
• National Antimicrobial Resistance Monitoring System<br />
(NARMS)<br />
• Surveillance <strong>for</strong> antimicrobial resistant enteric<br />
pathogens from human specimens<br />
… More to come later
EMERGING INFECTIONS PROGRAMS
Active Bacterial<br />
Core surveillance<br />
(ABCs)<br />
Human Papilloma<br />
Virus (HPV)<br />
surveillance<br />
EIP Project Overview<br />
Foodborne<br />
<strong>Disease</strong> Active<br />
Surveillance<br />
Network<br />
(FoodNet)<br />
Healthcare-Associated<br />
Infections/Community<br />
Interface (HAIC)<br />
Influenza<br />
Hepatitis<br />
surveillance
Active Bacterial Core Surveillance<br />
ABCs<br />
Group A & B<br />
Streptococcus<br />
Streptococcus<br />
pneumoniae<br />
Neisseria meningitidis<br />
Methicillin-resistant<br />
Staphylococcus aureus<br />
Case Definition: Isolation of bacteria from a normally sterile body site. The patient<br />
resides in one of the defined surveillance areas
Identifying New Resistance
Measuring Scope & Magnitude<br />
Characterizing New Epidemiology<br />
USA 300<br />
MRSA causing<br />
healthcareassociated<br />
infections<br />
~ 94,000 serious<br />
MRSA infections<br />
in 2005
Cases per 100,000 population<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Monitoring Trends<br />
The Introduction of a pneumococcal vaccine in 2000 resulted<br />
in decreased cases of resistant invasive pneumococcal<br />
disease among children<br />
45<br />
Not susceptible to 1 or more<br />
antibiotics<br />
Not susceptible to 3 or more<br />
antibiotics<br />
1998 2000 2002 2004 2006 2008
ANTIMICROBIAL RESISTANCE IN<br />
HEALTHCARE SETTINGS
NHSN Enrollment
NHSN: AR in Device Associated<br />
Infections<br />
• Device <strong>and</strong> procedure associated infections<br />
• CLABSI – Central line-associated bloodstream infections<br />
• VAP – Ventilator-associated infections<br />
• CAUTI – catheter-associated urinary tract infections<br />
• SSI – surgical site infections<br />
• DE – dialysis events<br />
Facilities enter pathogen <strong>and</strong><br />
susceptibility data <strong>for</strong> infections
NHSN: Laboratory Identified AR<br />
Events<br />
• Multi-drug resistant infections/Clostridium<br />
difficle-associated disease module<br />
• MDROs (e.g., MRSA, cephalosporin or carbapenemresistant<br />
Klebsiella, carbapenem-R Acinetobacter<br />
spp., VRE)<br />
• <strong>Prevention</strong> process measure surveillance (e.g.<br />
monitoring adherence to h<strong>and</strong> hygiene or adherence<br />
to active surveillance cultures)<br />
Facilities enter pathogen <strong>and</strong><br />
susceptibility data <strong>for</strong> MDRO<br />
infections
Infections per 1,000 device-days<br />
A national focus on MRSA<br />
prevention yields results<br />
0.45<br />
0.4<br />
0.35<br />
0.3<br />
0.25<br />
0.2<br />
0.15<br />
0.1<br />
0.05<br />
0<br />
MRSA CLABSI<br />
MDR EC/KP<br />
CLABSI<br />
MDR EC/KP CAUTI<br />
2000 2001 2002 2003 2004 2005 2006 2007 2008<br />
Year<br />
MRSA CLABSI rates from Burton DC. JAMA 2009; 301:727-36
CRE Surveillance in NHSN<br />
Resistance among catheter-Associated bloodstream infections (CLABSI)<br />
2009 – 2010<br />
Carbapenem-resistant<br />
bacteria<br />
No. Tested No. Resistant % Resistant<br />
Klebsiella 1826 231 12.7<br />
Enterobacter 1035 42 4.1<br />
E. coli 909 17 1.9
NHSN: Measuring Antibiotic Use <strong>and</strong><br />
Resistance<br />
• Revised AUR Module<br />
• Capable of capturing antimicrobial use data<br />
(administered data) from electronic medical records<br />
• Data will be reported as aggregate institutional use<br />
• The purpose of the data are <strong>for</strong> benchmarking <strong>and</strong><br />
analyzing geographical trends in antimicrobial use<br />
• Capable of capturing antimicrobial resistance data<br />
from electronic medical records.
HAIC<br />
HAI &<br />
Antimicrobial Use<br />
Prevalence Survey<br />
CDI Surveillance<br />
MDR GNB<br />
Surveillance<br />
C<strong>and</strong>idemia<br />
Surveillance<br />
NHSN Networks<br />
Dialysis BSI &<br />
HCV/HBV<br />
Surveillance
• FY2011<br />
HAI Point Prevalence Survey<br />
• One day HAI <strong>and</strong> antibiotic use survey<br />
• Sampling of acute care facilities in EIP<br />
• What data will we get:<br />
• HAI data from all patients<br />
• Data on all HAIs<br />
• Antimicrobial use data from all patients with HAIs
CDI Incidence - PRELIMINARY<br />
Number of Sites 8<br />
Surveillance Period<br />
No. of CDI cases (<strong>for</strong> sites with 12<br />
mo. data)<br />
Estimate 2010 Incidence per 100,000<br />
population<br />
January 2010 to December 2010 (6<br />
sites)<br />
376 to 3,314<br />
61.2 to 215.9<br />
Community associated infections 24 to 52%
NAP12<br />
1%<br />
Pulsed-Field Types by CDI Epidemiologic Class<br />
NAP10<br />
3%<br />
Community-Associated Healthcare-Associated<br />
unnamed<br />
28%<br />
NAP11<br />
8%<br />
NAP9<br />
3%<br />
NAP7<br />
5%<br />
NAP6<br />
9%<br />
CA (N=130)<br />
NAP1<br />
28%<br />
NAP4<br />
10%<br />
NAP5<br />
2%<br />
NAP1related<br />
1%<br />
NAP2<br />
2%<br />
* Cali<strong>for</strong>nia, Connecticut, Minnesota <strong>and</strong> New York<br />
NAP12<br />
1%<br />
unnamed<br />
28%<br />
NAP11<br />
7%<br />
NAP10<br />
2% NAP9<br />
3%<br />
NAP8<br />
1%<br />
NAP7<br />
5%<br />
NAP6<br />
7%<br />
NAP4<br />
7%<br />
NAP5<br />
2%<br />
NAP1<br />
30%<br />
CO-H + HCFO (N=211)<br />
NAP2<br />
1%<br />
NAP3<br />
2%<br />
NAP1-related<br />
4%
GISP – Sentinel AR Surveillance <strong>for</strong><br />
Treatment Guidelines<br />
~ 700,000 new infections each year<br />
Only one class of drug is still active<br />
<strong>for</strong> treatment
GISP – Detecting New Resistance
Preparing <strong>for</strong> Ceftriaxone-Resistant<br />
Neisseria gonorrhoeae
Acknowledgements<br />
• National Center <strong>for</strong> Emerging <strong>and</strong> Zoonotic<br />
Infectious <strong>Disease</strong><br />
• Division of Preparedness <strong>and</strong> Emerging Infections<br />
• Division of Foodborne, Waterborne, <strong>and</strong><br />
Environmental <strong>Disease</strong><br />
• Division of Healthcare Quality Promotion<br />
• National Center <strong>for</strong> Immunization <strong>and</strong><br />
Respiratory <strong>Disease</strong>s<br />
• Division of Bacterial <strong>Disease</strong>s<br />
• National Center <strong>for</strong> HIV/AIDS, Viral Hepatitis,<br />
STD, <strong>and</strong> TB <strong>Prevention</strong><br />
• Division of Sexually Transmitted <strong>Disease</strong> <strong>Prevention</strong>
Thank You
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