Marked Geographic Variation of CRE in Tennessee and Implications for Prevention (Part 1 of a 3-part Series on the August 2015 Vital Signs: Making Health Care Safer: Stop Spread of Antibiotic Resistance)

August 11, 2015 by CDC's Safe Healthcare Blog

The latest CDC Vital Signs includes mathematical modeling that projects increases in drug-resistant infections and Clostridium difficile (C. difficile) without immediate, nationwide improvements in infection control and antibiotic prescribing. During the next five years, with investments, CDC’s effortsto combat C. difficile infections and antibiotic resistance under the National Strategy to Combat Antibiotic Resistant Bacteria, in collaboration with other federal partners, will enhance national capabilities for antibiotic stewardship, outbreak surveillance, and antibiotic resistance prevention. The proposedState Antibiotic Resistance Prevention Programs (Protect Programs) would implement this coordinated approach.

While the coordinated approach this Vital Signs report describes is a forward-looking approach, some states are already implementing the response in a variety of different ways. This three-part blog series spotlights the current efforts in Tennessee, Illinois and Wisconsin.

Author: Marion A. Kainer, MD, MPH, FRACP, FSHEA, Director, Healthcare-Associated Infections and Antimicrobial Resistance Program, Tennessee Department of Health

Carbapenem-resistant Enterobacteriaceae (CRE) are germs that are difficult to treat because they have high levels of resistance to antibiotics. Infections with these germs can be deadly—one report cites they can contribute to death in up to 50% of patients with blood stream infections.

CDC is working with a number of state health departments to battle CRE in healthcare facilities in their states. In Tennessee, the Department of Health implemented an approach based on analyzing mandated CRE data that are reported through our electronic disease surveillance system, the NEDSS Base System (NBS). We analyzed data for Tennessee residents with specimens collected in 2014 for Klebsiella spp, E. coli andEnterobacter spp. We then applied the new 2015 Council of State and Territorial Epidemiologists (CSTE)definition which includes resistance to any of the carbapenems, including ertapenem.

We populated the data on a map of Tennessee also indicating our eight Emergency Management System (EMS) regions. In Tennessee, the EMS regions reflect referral patterns and correspond to the healthcare coalitions established for emergency preparedness. Through this analysis, we found that there was an enormous geographic variation in the incidence and type of CRE across the state. Surprisingly, the three largest cities in Tennessee – Memphis, Nashville and Knoxville – had lower rates compared to other parts of the state.

By analyzing the data in this way, we are able to see the rates of CRE by region and work with healthcare facilities on interventions specific to the level of CRE in their region. We plan to share these data on an ongoing basis with our partners for situational awareness and targeted interventions.

We hope to gain a better understanding of the degree of connectivity of individual healthcare facilities across the spectrum of healthcare in our state. Understanding connectivity better will likely help us target our interventions even more specifically within those regions. For example, it may turn out that much of the problem is in a subset of facilities that are highly interconnected with regard to sharing of patients, or that there are facilities that seem to be amplifying or disseminating CRE to other facilities in the region.

Check back tomorrow for Part 2 of the blog series from the state of Illinois related to the August 2015 Vital Signs: Making Health Care Safer: Stop Spread of Antibiotic Resistance.

August 11, 2015 by CDC's Safe Healthcare Blog