State Public Health Laboratory – NIH-Funded Research Laboratory Collaboration for Carbapenem-Resistant Enterobacteriaceae Surveillance: A Model for Maximizing the Public Health Potential of Taxpayer Money

BACKGROUND:  Public funding for public health activities and scientific research has declined in the past decade. As new public health threats are identified, public health resources are stretched to provide necessary services.  Public Health laboratories must maintain essential high-volume testing capabilities while remaining poised to promptly identify novel health threats. The emergence of novel carbapenem-resistant Enterobacteriaceae (CRE) in Washington prompted an innovative collaboration between the state public health laboratories (PHL) and a National Institutes of Health (NIH)-funded research laboratory (RL) in order to perform low-volume, high-priority testing of bacterial isolates that expand laboratory testing capacity and decrease the investigation and response time for this important new health threat.  The Washington State Department of Health (DOH) PHL and a local NIH-RL devised a laboratory collaboration that meets the PHL goal of rapid, local testing for common carbapenemases, while providing additional specimens to the NIH-RL for in-depth analysis for emerging mechanisms of carbapenem resistance.

METHODS:  Suspected CRE isolates are reportable to DOH by providers, facilities and laboratories, and are submitted to PHL for confirmatory testing. Criteria for reporting and submitting suspect CRE to PHL are: Enterobacteriaceae non-susceptible to any carbapenem and resistant to all 3^rd generation cephalosporins. Isolates undergo confirmatory antimicrobial susceptibility and Modified Hodge Testing at PHL; those confirmed to be carbapenem non-susceptible, using current CLSI breakpoints, are submitted to the NIH-RL for polymerase chain reaction (PCR) for common carbapenemases. Additionally, Enterobacteriaceae with intrinsic carbapenem resistance require non-susceptibility to at least 2 carbapenems. Pending IRB approval, isolates will undergo strain, plasmid, and resistance gene typing which may further knowledge of genetic mechanisms of antibiotic resistance and patient factors associated with acquisition of these resistance mechanisms.

RESULTS:  Confirmed CRE isolates reported and submitted to PHL that undergo PCR for carbapenemase genes with onset from November 1, 2012-April 30, 2013 will be summarized according to case demographics; geographic location of diagnosis; travel and health care exposures in the 12 months prior to onset; underlying conditions; and indwelling devices. Strain, plasmid and gene typing results will be summarized conditional upon IRB approval.

CONCLUSIONS: The appearance in Washington of emerging mechanisms of carbapenem resistance in Enterobacteriaceae prompted a creative collaboration between a public health agency and a research facility in order to meet PHL needs, while advancing research to increase knowledge of carbapenem resistance.  Success of this collaboration is dependent upon IRB approval and laboratory capacity at both facilities.