Public Health Response to Emerging Resistance

Transcription

1 National Center for Emerging and Zoonotic Infectious Diseases Public Health Response to Emerging Resistance Alex Kallen, MD, MPH, FACP Lead Antimicrobial Resistance and Emerging Pathogens Team Prevention and Response Branch Division of Healthcare Quality Promotion, CDC December 1, 2016

2 Public Health Response to Emerging MDROs To date response has varied in different jurisdictions and for different organisms: VRSA CRE Some modeling data suggests that early aggressive response: might be more efficient might lead to more rapid control then later responses Goal to develop a more well-defined and comprehensive approach to identifying and contain transmission of emerging MDROs

3 Program Components Improved detection and surveillance Standardized approach to response Rapid communication/notification Local National Standardized interventions Tiered response depending on local epidemiology Target resources as efficiently as possible Local resources and expertise to perform timely response Led by regional AR programs (Health Departments) Laboratory resources for response Screening Isolate testing (e.g., mechanism testing) Defining/evaluating improved interventions

4 Targeted Pathogens Candida auris mcr-producing Enterobacteriaceae Vancomycin-resistant Staphylococcus aureus Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (particularly non-kpc) Carbapenemase-producing Pseudomonas sp. (primarily VIM) Pan-resistant isolates

5 Improved Detection and Surveillance Improving capacity to understand and identify emerging resistance CRE mechanism testing - State labs CR-Pseudomonas mechanism testing State labs CP-Acinetobacter testing Regional labs Evaluation of unusual isolates for novel resistance Regional labs and CDC Surveillance for resistance seen outside the U.S. mcr-1/2 detection CDC and Regional labs C. auris confirmation - CDC

6 Standardized Approach to Response: Notification

7 Interim Guidance for a Public Health Response to Novel or Targeted Multidrug-resistant Organisms Provide specific/standardized recommendations for public health response: Ensure appropriate control measures are implemented Better characterize organism to guide future response Will be tied to other recommendations Pathogen-specific Environmental sampling

8 Current Pathogen Specific Documents Vancomycin-resistant Staphylococcus aureus: Carbapenem-resistant Enterobacteriaceae: Specific Guidance for Candida auris is under development

9 Organism Tiers Tier 1 resistance mechanisms novel to the United States (i.e., not or only very rarely identified in the United States) or organisms for which no current treatment options exist (pan-resistant) organisms and resistance mechanisms for which experience in the United States is extremely limited and a more extensive evaluation might better define the risk for transmission Examples of organisms in this category include vancomycin-resistant Staphylococcus aureus (VRSA), Candida auris Tier 2 Tier 3

10 Response Tiers Tier 1 Tier 2 MDROs primarily found in healthcare settings but not found regularly in the region; these organisms might be found more commonly in other areas in the United States Examples include carbapenem-resistant Enterobacteriaceae with rare carbapenemases (e.g., New Delhi Metallo-β-lactamase), carbapenemase-producing Pseudomonas spp. Tier 3

11 Response Tiers Tier 1 Tier 2 Tier 3 MDROs targeted by the facility/region that are already established in the United States and have been identified before in the region but are not thought to be endemic Examples include carbapenem-resistant Enterobacteriaceae producing Klebsiella pneumoniae carbapenemase

12 Components Initial investigation Healthcare/community exposures Infection control considerations Contact Investigation Healthcare Healthcare personnel Household Environmental sampling Prospective laboratory surveillance (clinical cultures)

13 Response led by Regional AR Programs Communicating finding within the region Assessing use of infection control precautions Screening contacts Ensuring inter-facility communication F/u screening cultures

14 New Resources to Assist with Response ELC funding (K1 and K2) assist with building capacity and building regional AR control programs State-lab funding (K6) support carbapenemase testing in CRE and CR-Pseudomonas Regional labs (K7) Mobile-CP in Acinetobacter Screening for some AR pathogens (CRE)

15 Gaps/Challenges More complete picture of Emerging MDROs Detecting organisms as close to the source as possible More readily available methodologies for identifying organisms/mechanisms of interest More widespread recognition of targeted MDROs Better ways to target surveillance - specific regions or facility types Resources available to implement control measures Standardizing timely work flow for facilities/health departments for enhanced response Laboratory capacity Improved/more sustainable interventions to control transmission