BACKGROUND:
Carbapenem-resistant Enterobacteriaceae (CRE) are difficult to treat and associated with increased morbidity and mortality. CRE are an urgent public health threat requiring additional monitoring and prevention activities. CRE reporting is not mandated in Michigan; the incidence of CRE was unknown.
METHODS:
The Michigan Department of Health and Human Services–led CRE Surveillance and Prevention Initiative enrolled 21 facilities across the state. Facilities agreed to voluntarily report cases of Klebsiella pneumoniae and Escherichia coli that met the surveillance definition. Baseline data was collected for 6 months, September 2012–February 2013, followed by an 18 month remeasurement period, March 2013–August 2014. Patient demographic characteristics, microbiological information (i.e., organism and antimicrobial susceptibility results), clinical information, patient history and antimicrobial therapy information were captured via standardized data collection forms. Facilities reported number of admissions and patient-days monthly for rate calculations. P-values were determined using Fisher exact test.
RESULTS:
SURVEILLANCE: Overall, 327 cases of CRE were reported (297 K. pneumoniae, 30 E.coli). CRE case patients had a median age of 66 years and 53% were female. Urine cultures (60%) were the most frequently reported specimen source. Eighty-seven percent of cases were inpatients (38% ICU and 49% Non-ICU). Among cases reported by acute care facilities, the majority of patients were admitted from home (37%), followed by admissions from long-term care/skilled nursing facilities (33%). According to CDC definitions, 64% of cases were categorized as community-onset. Of these, 77% reported healthcare exposure within the previous 90 days. Patient/risk factors included history of cardiovascular disease, renal failure, diabetes, recent infection or colonization with a multidrug-resistant organism and recent antimicrobial exposure.
PREVENTION: Thirty-four different interventions were implemented by the participating facilities. Sixteen (46%) included some procedural change in the facilities followed by education (41%), communication (9%) and compliance (3%).
During baseline, 89 cases over 959,063 patient-days were reported (crude incidence rate of 0.93 cases per 10,000 patient-days). One hundred-ninety-five cases were reported over 2,791,350 patient-days during remeasurement (crude incidence rate of 0.70 cases per 10,000 patient-days, p-value 0.03).
Twelve facilities (57%) were able to decrease their CRE incidence rate; 2 of those facilities experiencing a statistically significant decrease. Participating facilities prevented 86 infections of CRE; 26 of those CRE infections were prevented in LTACs.
CONCLUSIONS:
CRE are found throughout Michigan healthcare facilities. Implementation of a regional, coordinated, voluntary surveillance and prevention initiative led to a statistically significant reduction in statewide CRE incidence.