Screening for carbapenemase-producing Enterobacteriaceae in previous carriers readmitted to hospital: evaluation of a change in screening policy.

Carbapenemase-producing Enterobacteriaceae (CPE) are a growing problem in UK hospitals. Preventing transmission requires early detection. This study evaluates a new screening policy for patients with a history of blaKPC-associated CPE (KPC-CPE) in a higher incidence hospital. Previous policy assumed 'once positive always positive'. New policy uses rapid screening and risk assessment. Results show that most (76.5%) patients with a history of KPC-CPE do not have detectable KPC-CPE on readmission or during their subsequent hospital stay but that repeat screening after an initial negative result is required. The new policy takes a risk-based approach while prioritizing isolation facilities in a higher incidence trust.

A Large, Refractory Nosocomial Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Escherichia coli Demonstrates Carbapenemase Gene Outbreaks Involving Sink Sites Require Novel Approaches to Infection Control.

Carbapenem-resistant Enterobacteriaceae (CRE) represent a health threat, but effective control interventions remain unclear. Hospital wastewater sites are increasingly being highlighted as important potential reservoirs. We investigated a large Klebsiella pneumoniae carbapenemase (KPC)-producing Escherichia coli outbreak and wider CRE incidence trends in the Central Manchester University Hospital NHS Foundation Trust (CMFT) (United Kingdom) over 8 years, to determine the impact of infection prevention and control measures. Bacteriology and patient administration data (2009 to 2017) were linked, and a subset of CMFT or regional hospital KPC-producing E. coli isolates (n = 268) were sequenced. Control interventions followed international guidelines and included cohorting, rectal screening (n = 184,539 screens), environmental sampling, enhanced cleaning, and ward closure and plumbing replacement. Segmented regression of time trends for CRE detections was used to evaluate the impact of interventions on CRE incidence. Genomic analysis (n = 268 isolates) identified the spread of a KPC-producing E. coli outbreak clone (strain A, sequence type 216 [ST216]; n = 125) among patients and in the environment, particularly on 2 cardiac wards (wards 3 and 4), despite control measures. ST216 strain A had caused an antecedent outbreak and shared its KPC plasmids with other E. coli lineages and Enterobacteriaceae species. CRE acquisition incidence declined after closure of wards 3 and 4 and plumbing replacement, suggesting an environmental contribution. However, ward 3/ward 4 wastewater sites were rapidly recolonized with CRE and patient CRE acquisitions recurred, albeit at lower rates. Patient relocation and plumbing replacement were associated with control of a clonal KPC-producing E. coli outbreak; however, environmental contamination with CRE and patient CRE acquisitions recurred rapidly following this intervention. The large numbers of cases and the persistence of blaKPC in E. coli, including pathogenic lineages, are of concern.

An evaluation of a toolkit for the early detection, management, and control of carbapenemase-producing Enterobacteriaceae: a survey of acute hospital trusts in England.

BACKGROUND: Following hospital outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), Public Health England published a toolkit in December 2013 to promote the early detection, management, and control of CPE colonization and infection in acute hospital settings. AIM: To examine awareness, uptake, implementation and usefulness of the CPE toolkit and identify potential barriers and facilitators to its adoption in order to inform future guidance. METHODS: A cross-sectional survey of National Health Service (NHS) acute trusts was conducted in May 2016. Descriptive analysis and multivariable regression models were conducted, and narrative responses were analysed thematically and informed using behaviour change theory. FINDINGS: Most (92%) acute trusts had a written CPE plan. Fewer (75%) reported consistent compliance with screening and isolation of CPE risk patients. Lower prioritization and weaker senior management support for CPE prevention were associated with poorer compliance. Awareness of the CPE toolkit was high and all trusts with patients infected or colonized with CPE had used the toolkit either as provided (32%), or to inform (65%) their own local CPE plan. Despite this, many respondents (80%) did not believe that the CPE toolkit guidance offered an effective means to prevent CPE or was practical to follow. CONCLUSION: CPE prevention and control requires robust IPC measures. Successful implementation can be hindered by a complex set of factors related to their practical execution, insufficient resources and a lack of confidence in the effectiveness of the guidance. Future CPE guidance would benefit from substantive user involvement, processes for ongoing feedback, and regular guidance updates.

Active case finding for carbapenemase-producing Enterobacteriaceae in a teaching hospital: prevalence and risk factors for colonization.

BACKGROUND: Over the past decade, the prevalence of carbapenemase-producing Enterobacteriaceae (CPE) has increased. Whilst basic infection prevention and control practices reduce the risk of transmission, cases of unrecognized carriage pose a potential risk of transmission. AIM: To estimate the prevalence of CPE and explore risk factors associated with colonization within a large teaching hospital with an established CPE outbreak. METHODS: All inpatients that had not previously tested positive for CPE were offered testing. Demographic and hospital episode data were also collected, together with antibiotic and proton pump inhibitor (PPI) use in the preceding 24h. FINDINGS: This study identified 70 CPE-positive cases (26 newly identified and 44 previously known) and 592 CPE-negative cases, giving a combined prevalence of 11% [95% confidence interval (CI) 8-13]. Medication (antibiotic and PPI use), previous admission, ethnicity and length of stay were assessed as risk factors for colonization, and none were found to be independently associated with CPE colonization. Using logistic regression, age [odds ratio (OR) 1.03, 95% CI 1.01-1.07] and antibiotic use (OR 2.55, 95% CI 1.08-6.03) were the only risk factors significantly associated with CPE colonization. CONCLUSION: This study has added to the evidence base by estimating the prevalence of CPE among inpatients in an acute hospital with an established CPE outbreak. A case-finding exercise was feasible and identified a number of new cases. Despite a small sample size, increasing age and prescription of an antibiotic on the day of testing were significantly associated with CPE colonization.

Evaluation of patient-held carbapenemase-producing Enterobacteriaceae (CPE) alert card.

Public Health England recommends patient-held cards for those colonized with carbapenemase-producing Enterobacteriaceae (CPE). Alert cards were provided to 104 CPE-positive inpatients, with follow-up at six months. Excluding those who died, the response rate was 39%. Sixteen patients (46%) recalled receiving the card; 13 (81%) of these retained it, most (64%) of whom reported using it. This is the first evaluation of a patient-held alert card for any antimicrobial-resistant (AMR) bacteria in the UK. This study demonstrated that, when retained, CPE alert cards can be an effective communication tool. Further work is required to evaluate effectiveness and improve retention.

Measles outbreak in Greater Manchester, England, October 2012 to September 2013: epidemiology and control.

This paper describes the epidemiology and management of a prolonged outbreak of measles across the 2.7 million conurbation of Greater Manchester in the United Kingdom. Over a period of one year (from October 2012 to September 2013), over a thousand suspected measles cases (n = 1,073) were notified across Greater Manchester; of these, 395 (37%) were laboratory-confirmed, 91 (8%) were classed as probable, 312 (29%) were classed as possible and 275 (26%) excluded. Most confirmed and probable cases occurred in children within two age groups­infants (too young to be eligible for measles-mumps-rubella (MMR) vaccination according to the national immunisation programme) and children aged 10-19 years (low vaccine uptake in this cohort because of unfounded alleged links between the MMR vaccine and autism). During this one year period, there were a series of local outbreaks and many of these occurred within the secondary school setting. A series of public health measures were taken to control this prolonged outbreak: setting up incident management teams to control local outbreaks, a concerted immunisation catch-up campaign (initially local then national) to reduce the pool of children partially or totally unprotected against measles, and the exclusion of close contacts from nurseries and school settings for a period of 10 days following the last exposure to a case of measles.

An outbreak of infectious syphilis among young heterosexuals in an English town.

We describe a recent outbreak of syphilis in young heterosexuals in the north west of England. A cluster of 12 cases of syphilis (7 primary and 5 early latent) was identified in Rochdale in heterosexuals aged 20 or under. Nine were women. Five were asymptomatic at presentation. This outbreak occurred in a group not usually associated with syphilis transmission in the north west. Not all the identified cases could be linked, and so potentially this outbreak is a sentinel of a larger problem.

Mapping of sexual health promotion in North West England, 2008.

OBJECTIVE: To map sexual health promotion activity and resources across North West England. STUDY DESIGN: Survey. METHODS: A survey of all sexual health promotion activity commissioned by primary care trusts (PCTs) was carried out using a self-completion questionnaire for PCT sexual health commissioners in North West England. RESULTS: Sixteen out of 24 PCTs responded. Some PCTs had difficulty in identifying the relevant commissioner. Most activity was focused on young people, especially around the National Chlamydia Screening Programme (NCSP) and teenage pregnancy, and on particular high-risk groups such as lesbian, gay and bisexual people, those living with human immunodeficiency virus and commercial sex workers. All PCTs commissioned education/training and a condom distribution service. Other common activities included outreach work, and producing and disseminating materials. Most services were confined to one PCT. Most PCTs were unable to identify the resources committed to sexual health promotion. The emergent themes in the analysis of service development ideas and comments were all linked to commissioning: commissioning and strategy; funding; needs assessment; service development and provision; contracting and monitoring; evaluation and evidence; and regional perspective. CONCLUSIONS: A simple tool to map sexual health promotion activities commissioned by PCTs was developed. Many PCTs could not identify a commissioner for sexual health or the resources committed to sexual health promotion. Sexual health promotion activity focused on young people (linked to the NCSP and teenage pregnancy) and particular high-risk groups, with resultant gaps and a mismatch with the epidemiology. The most frequently commissioned activities were education/training and condom provision (despite the limited evidence base). A series of recommendations to PCTs, sexual health networks and providers are made.

Studies on the immunoglobulin E responses to Teladorsagia circumcincta in sheep: purification of a major high molecular weight allergen.

Studies on the immunoglobulin (Ig)E immune responses to the gastric nematode, Teladorsagia circumcincta, have demonstrated a major high molecular weight allergen (HMWTc). Cross reactive allergens of similar MW were demonstrated for Trichostrongylus colubriformis and Cooperia curticei, but not for Haemonchus contortus. Purification of HMWTc was achieved by gel-filtration chromatography, and nonreducing SDS-PAGE and Western blot analysis revealed two closely associated bands with a molecular weight of approximately 140-150 kDa. Reduction showed four IgE reactive bands of 120, 50, 45 and 30 kDa, and deglycosylation abrogated the immunoreactivity of the 120 and 30 kDa bands. Ultrastructural immunolocalization by electron microscopy revealed that the IgE reactivity was confined to the cuticular surface of the infective (L3) larvae. ELISA studies to determine the IgE anti-HMWTc responses in lambs during their first grazing season, demonstrated significantly higher IgE antibody in lambs with low accumulative faecal egg count (FEC) compared to animals with high accumulative FEC. These studies provide evidence for a protective function of IgE antibody in Teladorsagia infections in lambs.