Summary Report on Antimicrobial Resistant Organisms Surveillance Data from January 1, 2011 to December 31, 2015

Table of contents

Introduction

Introduction

This report entitled Canadian Nosocomial Infection Surveillance Program (CNISP) summary report for ARO data from January 1, 2011 to December 31, 2015 was produced by the Centre for Communicable Diseases and Infection Control of the Public Health Agency of Canada (PHAC). The report provides a review of available ARO data in Canada and responds to the requests from hospitals to have access to this data in a timely manner.

The Centre for Communicable Diseases and Infection Control (CCDIC) coordinates the data collection and is responsible for the data management, analysis and report production related to this summary report. CCDIC supports the use of these data to inform public health and policy action. In addition, PHAC is committed to improving data quality, as well as defining and setting surveillance standards.

PHAC collects national data on various healthcare-associated infections, including AROs through the Canadian Nosocomial Infection Surveillance Program (CNISP), a collaborative effort of CCDIC, the National Microbiology Laboratory (NML) and sentinel hospitals across Canada who participate as members of the Canadian Hospital Epidemiology Committee (CHEC), a subcommittee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. Their ongoing contributions to national ARO surveillance are gratefully acknowledged.

 

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Organization:

Public Health Agency of Canada

Date published: 2017-09-21

As of December 2015, CNISP conducted surveillance in 64 acute-care hospitals in Canada (Appendix A). Of these, 13 are large acute, tertiary care hospitals with more than 500 beds available within the facility; 32 hospitals are of intermediate size (201 to 500 beds) while the remaining 19 hospitals are smaller facilities with less than 200 beds. Acute tertiary care hospitals are major hospitals that offer a range of specialist services such as burn units, transplant units, trauma centres, specialized cardiac surgery etc. to which patients are referred from smaller hospitals. General urban acute-care hospitals provide overall medical and surgical services but do not always have specialised sub-specialities. There are 33 adult-only hospitals, 23 hospitals which treat both adult and children, and the remaining 8 hospitals are stand-alone pediatric facilities (Appendix A). Surveillance of AROs at participating hospitals is considered to be within the mandate of hospital infection prevention and control programs and does not constitute human research. The ability for a hospital to participate in CNISP ARO surveillance is based on the site capacity for data collection, access to hospital laboratory services and their operational capacity to participate in a given year.

CNISP surveillance provides key information that informs the development of federal, provincial, territorial and local infection prevention and control programs and policies. When carried out in a uniform manner, surveillance provides a measure of the burden of illness, establishes benchmark rates for internal and external comparison, identifies potential risk factors, and allows assessment of specific interventions. Surveillance for AROs is considered an important measure of the quality of patient care.

This report provides case counts and rates based on data from January 1, 2011 to December 31, 2015.  The report includes rates for healthcare-associated Clostridium difficile infection (HA-CDI), methicillin-resistant Staphylococcus aureus (MRSA) including healthcare- and community-associated MRSA and MRSA bacteremias, vancomycin-resistant Enterococci (VRE), carbapenemase-producing organisms (CPO) including carbapenemase-producing Enterobacteriaceae(CPE) and carbapenemase-producing Acinetobacter (CPA).

Where possible, rates are provided by region and include Western (British Columbia, Alberta, Saskatchewan and Manitoba), Central (Ontario and Quebec), and Eastern Regions (Nova Scotia, New Brunswick, Prince Edward Island and Newfoundland and Labrador). The territories do not currently submit data to PHAC.

National and regional infection rates are based on the total number of cases reported divided by the total number of patient admissions multiplied by 1,000 or patient days multiplied by 10,000. This report also provides strain type and antimicrobial resistance data for HA-CDI, MRSA, VRE and CPO.

The 2015 case definitions and eligibility criteria for these surveillance programs are provided in Appendix B. Case definitions and eligibility criteria are reviewed each year prior to the start of the surveillance year by the CNISP working group responsible for overseeing each ARO surveillance activity.  CNISP working groups are comprised of members of CHEC and PHAC technical experts from CCDIC and NML.   Case definitions and eligibility criteria may vary from one surveillance year to another as the surveillance protocols are reviewed and updated by the applicable CNISP working group.

This report supersedes the data in previous ARO reports. The most current report should be considered the most accurate. Data from 2015 are considered preliminary. Results are subject to change as updated data are made available by the participating hospitals. Note that for all years, only hospitals that submitted both numerator and denominator data are included in the rate calculations.

For questions or more information on these rates or for a copy of the most recent PHAC surveillance report, please contact the Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada by sending an email to ccdic-clmti@phac-aspc.gc.ca.

Results

1. Healthcare-associated Clostridium difficile Infection (HA-CDI)

Table 1.1 Number of HA-CDI from CNISP reporting hospitals onlyTable 1.1 - Footnote ǂ, cases and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of HA-CDI cases 3,417 3,482 3,160 2,870 2,930
Rate per 1,000 pt admissions 5.17 4.8 3.99 3.43 3.34
Rate per 10,000 pt days 6.64 6.03 5.19 4.39 4.33
No. of reporting hospitalsTable 1 - Footnote a 54 54 54 60 62
West
No. of HA-CDI cases 1,241 1,282 1,198 1,121 1,318
Rate per 1,000 pt admissions 4.72 4.76 3.61 3.1 3.35
Rate per 10,000 pt days 5.75 5.7 4.82 4.1 4.41
Central
No. of HA-CDI cases 2,075 1,997 1,732 1,510 1,356
Rate per 1,000 pt admissions 5.87 5.31 4.56 3.9 3.43
Rate per 10,000 pt days 7.86 7.14 6.08 5.13 4.62
East
No. of HA-CDI cases 101 203 230 243 256
Rate per 1,000 pt admissions 2.2 2.55 2.86 2.75 2.91
Rate per 10,000 pt days 2.88 2.8 3.07 2.81 3.06

Graph 1.1 HA-CDI from CNISP reporting hospitals onlyǂ, national and regional incidence rates per 10,000 patient days

 

ǂ HA-CDI from CNISP reporting hospitals only: includes all cases identified within a CNISP hospital only. HA-CDI as per the case definition in Appendix B.

Graph 1.1 - Text Equivalent
Graph 1.1 HA-CDI from CNISP reporting hospitals only, national and regional incidence rates per 10,000 patient days
Year Region Rate
2011 West 5.75
2011 Central 7.86
2011 East 2.88
2011 National 6.64
2012 West 5.70
2012 Central 7.14
2012 East 2.80
2012 National 6.03
2013 West 4.82
2013 Central 6.08
2013 East 3.07
2013 National 5.19
2014 West 4.10
2014 Central 5.13
2014 East 2.81
2014 National 4.39
2015 West 4.41
2015 Central 4.62
2015 East 3.06
2015 National 4.33
Table 1.2 Attributable mortality rate 30 days after date of first positive CDI test in adults with HA-CDI
  Number of deathsTable 1.2 - Footnote * Mortality rate (%)
2011 36 6.4
2012 24 4.6
2013 21 3.9
2014 22 4.3
2015 16 3.8
Table 1.3 Number and proportion of select healthcare-associated C. difficile NAP strain types
Strain Type 2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
NAP1 152 (31.3) 164 (33.3) 152 (29.6) 114 (23.7) 115 (22.9)
NAP4 93 (19.1) 77 (15.7) 90 (17.5) 92 (19.1) 106 (21.1)
NAP11 24 (5.0) 40 (8.1) 33 (6.4) 62 (12.9) 50 (9.9)
Other NAP typesTable 1.3 - Footnote * 97 (19.9) 91 (18.5) 91 (17.8) 84 (17.4) 94 (18.7)
Other-not assigned 120 (24.7) 120 (24.4) 147 (28.7) 130 (27.0) 138 (27.4)
Table 1.4 Antimicrobial resistance identified for healthcare-associated C. difficile isolatesTable 1.4 - Footnote *
Antibiotics 2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
Clindamycin 122 (25.1) 80 (16.3) 156 (30.5) 209 (43.4) 125 (24.9)
Moxifloxacin 171 (35.2) 192 (39.0) 166 (32.4) 137 (28.4) 138 (27.4)
Rifampin 3 (0.6) 4 (0.8) 13 (2.5) 5 (1.0) 10 (2.0)

Note: All C. difficile strains from 2011 to 2015 submitted to NML were susceptible to metronidazole and tigecycline. Only one isolate had a reduced susceptibility to vancomycin (24 µg/ml) in 2012.

2. Methicillin-Resistant Staphylococcus aureus (MRSA)

Table 2.1 Number of MRSA infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of MRSA infections 1,857 1,787 1,847 1,969 2,103
Rate per 1,000 pt admissions 2.23 2.17 2.11 2.12 2.23
Rate per 10,000 pt days 2.84 2.8 2.83 2.89 3.09
No. of reporting hospitalsTable 2.1 - Footnote b 52 51 53 58 59
West
No. of MRSA infections 891 844 898 949 1,169
Rate per 1,000 pt admissions 2.63 2.42 2.48 2.33 2.74
Rate per 10,000 pt days 3.56 3.3 3.4 3.29 3.72
Central
No. of MRSA infections 720 703 737 802 733
Rate per 1,000 pt admissions 1.79 1.83 1.78 1.91 1.75
Rate per 10,000 pt days 2.26 2.35 2.47 2.68 2.65
East
No. of MRSA infections 246 240 212 218 201
Rate per 1,000 pt admissions 2.63 2.63 2.15 2.18 2.04
Rate per 10,000 pt days 2.83 2.87 2.34 2.32 2.25

Graph 2.1 MRSA national and regional incidence rates per 10,000 patient days

Graph 2.1 - Text Equivalent
Graph 2.1 MRSA national and regional incidence rates per 10,000 patient days
Year Region Rate
2011 West 3.56
2011 Central 2.26
2011 East 2.83
2011 National 2.84
2012 West 3.30
2012 Central 2.35
2012 East 2.87
2012 National 2.80
2013 West 3.40
2013 Central 2.47
2013 East 2.34
2013 National 2.83
2014 West 3.29
2014 Central 2.68
2014 East 2.32
2014 National 2.89
2015 West 3.72
2015 Central 2.65
2015 East 2.25
2015 National 3.09
Table 2.2 Number of Healthcare-associated (HA) MRSATable 2.2 - Footnote * infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of HA-MRSA infections 1,261 1,112 1,137 1,172 1,240
Rate per 1,000 pt admissions 1.51 1.35 1.3 1.26 1.31
Rate per 10,000 pt days 1.93 1.74 1.74 1.72 1.82
No. of reporting hospitalsTable 2.2 - Footnote c 52 51 53 58 59
West
No. of HA-MRSA infections 558 517 554 535 676
Rate per 1,000 pt admissions 1.65 1.48 1.53 1.31 1.59
Rate per 10,000 pt days 2.23 2.02 2.1 1.86 2.15
Central
No. of HA-MRSA infections 486 382 400 460 406
Rate per 1,000 pt admissions 1.21 0.99 0.97 1.09 0.97
Rate per 10,000 pt days 1.53 1.28 1.34 1.54 1.47
East
No. of HA-MRSA infections 217 213 183 177 158
Rate per 1,000 pt admissions 2.32 2.33 1.85 1.77 1.6
Rate per 10,000 pt days 2.5 2.55 2.02 1.89 1.77
Table 2.3 Number of HA-MRSA infections from CNISP reporting hospitals onlyTable 2.3 - Footnote ǂ, cases and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of HA-MRSA infections (CNISP) 914 817 870 869 880
Rate per 1,000 pt admissions 1.10 0.99 1.00 0.94 0.93
Rate per 10,000 pt days 1.40 1.28 1.33 1.28 1.29
No. of reporting hospitalsTable 2.3 - Footnote c 52 51 53 58 59
West
No. of HA-MRSA infections (CNISP) 375 377 423 387 483
Rate per 1,000 pt admissions 1.11 1.08 1.17 0.95 1.13
Rate per 10,000 pt days 1.50 1.47 1.60 1.34 1.54
Central
No. of HA-MRSA infections (CNISP) 357 261 289 331 277
Rate per 1,000 pt admissions 0.89 0.68 0.70 0.79 0.66
Rate per 10,000 pt days 1.12 0.87 0.97 1.11 1.00
East
No. of HA-MRSA infections (CNISP) 182 179 158 151 120
Rate per 1,000 pt admissions 1.95 1.96 1.60 1.51 1.22
Rate per 10,000 pt days 2.09 2.14 1.75 1.61 1.34
Table 2.4 Number of community-associated (CA) MRSA infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CA-MRSA infections 468 539 549 654 734
Rate per 1,000 pt admissions 0.56 0.65 0.63 0.70 0.78
Rate per 10,000 pt days 0.71 0.84 0.84 0.96 1.08
No. of reporting hospitalsTable 2.4 - Footnote d 52 51 53 58 59
West
No. of CA-MRSA infections 303 309 321 380 455
Rate per 1,000 pt admissions 0.89 0.89 0.89 0.93 1.07
Rate per 10,000 pt days 1.21 1.21 1.21 1.32 1.45
Central
No. of CA-MRSA infections 150 216 207 243 244
Rate per 1,000 pt admissions 0.37 0.56 0.50 0.58 0.58
Rate per 10,000 pt days 0.47 0.72 0.69 0.81 0.88
East
No. of CA-MRSA infections 15 14 21 31 35
Rate per 1,000 pt admissions 0.16 0.15 0.21 0.31 0.35
Rate per 10,000 pt days 0.17 0.17 0.23 0.33 0.39
Table 2.5 Number of MRSA bloodstream infections (MRSA-BSI) and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of MRSA BSI 370 325 349 439 491
Rate per 1,000 pt admissions 0.44 0.39 0.40 0.47 0.52
Rate per 10,000 pt days 0.56 0.51 0.53 0.64 0.72
No. of reporting hospitals 52 51 53 58 59
West
No. of MRSA BSI 139 116 128 161 219
Rate per 1,000 pt admissions 0.41 0.33 0.35 0.39 0.51
Rate per 10,000 pt days 0.56 0.45 0.48 0.56 0.70
Central
No. of MRSA BSI 185 164 179 236 221
Rate per 1,000 pt admissions 0.46 0.43 0.43 0.56 0.53
Rate per 10,000 pt days 0.58 0.55 0.60 0.79 0.80
East
No. of MRSA BSI 46 45 42 42 51
Rate per 1,000 pt admissions 0.49 0.49 0.43 0.42 0.52
Rate per 10,000 pt days 0.53 0.54 0.46 0.45 0.57

Graph 2.2 MRSA-BSI National and regional incidence rates per 10,000 patient days

Graph 2.2 - Text Equivalent
Graph 2.2 MRSA-BSI national and regional incidence rates per 10,000 patient days
Year Region Rate
2011 West 0.56
2011 Central 0.58
2011 East 0.53
2011 National 0.56
2012 West 0.45
2012 Central 0.55
2012 East 0.54
2012 National 0.51
2013 West 0.48
2013 Central 0.60
2013 East 0.46
2013 National 0.53
2014 West 0.56
2014 Central 0.79
2014 East 0.45
2014 National 0.64
2015 West 0.70
2015 Central 0.80
2015 East 0.57
2015 National 0.72
Table 2.6 All-cause mortality rate 30 days after date of positive culture per 100 MRSA-BSI cases
  Number of deathsTable 2.6 - Footnote* All-cause mortality rate per 100 MRSA-BSI cases
Table 2.6- Footnote *

All-cause mortality rate based on the number of cases with associated 30-day outcome data.

Return to Table 2.6 - Footnote * referrer

2011 102 27.8
2012 71 22.0
2013 88 25.1
2014 103 24.8
2015 88 19.9
Table 2.7 Number and proportion of select MRSA strain types identified
Strain Type 2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
CMRSA 2 321 (54.5) 271 (50.7) 278 (47.4) 303 (43.9) 205 (36.6)
CMRSA 7 39 (6.6) 28 (5.2) 24 (4.1) 41 (5.9) 44 (7.9)
CMRSA 10 165 (28.0) 179 (33.5) 214 (36.5) 267 (38.7) 233 (41.6)
Other strain typesTable 2.7 - Footnote * 56 (9.5) 53 (9.9) 63 (10.7) 71 (10.3) 58 (10.4)
Unassigned 8 (1.4) 4 (0.8) 6 (1.0) 8 (1.2) 20 (3.6)
Total 589 535 587 690 560
Table 2.8 Antimicrobial resistance identified for MRSA isolates
Antibiotics 2011
No. (%)
N = 527
2012
No. (%)
N = 517
2013
No. (%
N = 558
2014
No. (%
N = 634
2015
No. (%)
N = 496

Note: 2015 MRSA AMR data considered preliminary
Total isolates tested for Ciprofloxacin= 271 (2014)
Total # isolates tested for clindamycin = 381 (2011), 374 (2012), 418 (2013), 572 (2014)
MRSA non-blood isolates (urine, respiratory, wound, surgical site) collected from January to March of every year and blood isolates are collected year round

Clindamycin 341 (89.5) 295 (78.9) 349 (83.5) 374 (65.4) 267 (53.8)
Ciprofloxacin 459 (87.1) 429 (83.0) 479 (85.8) 228 (84.1) Not tested in 2015
Daptomycin 1 (0.2) 0 2 (0.4) 2 (0.3) 0
Erythromycin 459 (87.1) 432 (83.6) 495 (88.7) 535 (84.4) 400 (80.6)
Fusidic acid 33 (6.3) 32 (6.2) 57 (10.2) 91 (14.4) 76 (15.3)
Mupirocin HLR 34 (6.5) 25 (4.8) 15 (2.7) 30 (4.47) 39 (7.9)
Rifampin 7 (1.3) 0 3 (0.5) 3 (0.5) 2 (0.4)
Tetracycline 19 (3.6) 19 (3.7) 25 (4.5) 34 (5.4) 26 (5.2)
Tigecycline 2 (0.4) 2 (0.4) 25 (4.5) 17 (2.7) 4 (0.8)
TMP/SMX 14 (2.7) 12 (2.3) 25 (4.5) 14 (2.2) 12 (2.4)

All MRSA isolates from 2011 to 2015 submitted to NML were susceptible to linezolid and vancomycin.

3. Vancomycin-Resistant Enterococci (VRE)

Table 3.1 Number of VRE infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of VRE infections 379 394 322 293 271
Rate per 1,000 pt admissions 0.45 0.47 0.39 0.33 0.30
Rate per 10,000 pt days 0.58 0.61 0.52 0.45 0.40
No. of reporting hospitalsTable 3.1 - Footnote e 52 53 48 54 54
West
No. of VRE infections 229 223 154 149 142
Rate per 1,000 pt admissions 0.68 0.64 0.52 0.43 0.39
Rate per 10,000 pt days 0.92 0.87 0.72 0.63 0.54
Central
No. of VRE infections 146 168 161 143 127
Rate per 1,000 pt admissions 0.36 0.43 0.37 0.32 0.28
Rate per 10,000 pt days 0.46 0.55 0.51 0.44 0.39
East
No. of VRE infections 4 3 7 1 2
Rate per 1,000 pt admissions 0.04 0.03 0.08 0.01 0.02
Rate per 10,000 pt days 0.05 0.04 0.08 0.01 0.02

Graph 3.1 VRE infections national and regional incidence rates per 10,000 patient days

Graph 3.1- Text Equivalent
Graph 3.1 VRE infections national and regional incidence rates per 10,000 patient days
Year Region Rate
2011 West 0.92
2011 Central 0.46
2011 East 0.05
2011 National 0.58
2012 West 0.87
2012 Central 0.55
2012 East 0.04
2012 National 0.61
2013 West 0.72
2013 Central 0.51
2013 East 0.08
2013 National 0.52
2014 West 0.63
2014 Central 0.44
2014 East 0.01
2014 National 0.45
2015 West 0.54
2015 Central 0.39
2015 East 0.02
2015 National 0.40
Table 3.2 Number of VRE infections from CNISP reporting hospitals onlyTable 3.2 - Footnote ǂ, cases and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015

*Data of where the VRE infection was acquired was not collected during 2011-2013.

National
No. of VRE infections * * * 251 231
Rate per 1,000 pt admissions * * * 0.28 0.25
Rate per 10,000 pt days * * * 0.38 0.34
No. of reporting hospitals Table 3.2 - Footnote f * * * 54 54
West
No. of VRE infections * * * 126 118
Rate per 1,000 pt admissions * * * 0.37 0.32
Rate per 10,000 pt days * * * 0.53 0.45
Central
No. of VRE infections * * * 124 111
Rate per 1,000 pt admissions * * * 0.27 0.25
Rate per 10,000 pt days * * * 0.38 0.34
East
No. of VRE infections * * * 1 2
Rate per 1,000 pt admissions * * * 0.01 0.02
Rate per 10,000 pt days * * * 0.01 0.02
Table 3.3 Number of VRE bloodstream infections (VRE-BSI) and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of VRE-BSI infections 74 92 98 93 88
Rate per 1,000 pt admissions 0.09 0.11 0.12 0.10 0.10
Rate per 10,000 pt days 0.11 0.14 0.16 0.14 0.13
No. of reporting hospitalsTable 3.3 - Footnote g 52 53 48 55 56
West
No. of VRE-BSI infections 32 38 31 35 35
Rate per 1,000 pt admissions 0.09 0.11 0.11 0.10 0.10
Rate per 10,000 pt days 0.13 0.15 0.15 0.15 0.13
Central
No. of VRE-BSI infections 40 53 67 58 52
Rate per 1,000 pt admissions 0.10 0.13 0.15 0.13 0.11
Rate per 10,000 pt days 0.13 0.17 0.21 0.18 0.16
East
No. of VRE-BSI infections 2 1 0 0 1
Rate per 1,000 pt admissions 0.02 0.01 0.00 0.00 0.01
Rate per 10,000 pt days 0.02 0.01 0.00 0.00 0.01

Graph 3.2 VRE-BSI national and regional incidence rates per 10,000 patient days

Graph 3.2 - Text Equivalent
Graph 3.2 VRE-BSI national and regional incidence rates per 10,000 patient days
Year Region Rate
2011 West 0.13
2011 Central 0.13
2011 East 0.02
2011 National 0.11
2012 West 0.15
2012 Central 0.17
2012 East 0.01
2012 National 0.14
2013 West 0.15
2013 Central 0.21
2013 East 0.00
2013 National 0.16
2014 West 0.15
2014 Central 0.18
2014 East 0.00
2014 National 0.14
2015 West 0.13
2015 Central 0.16
2015 East 0.01
2015 National 0.13
Table 3.4 Number and proportion of main VRE-BSI isolate types identified
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
vanA, vanB, Enterococcus faecium 1 (1.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
vanA, Enterococcus faecium 52 (91.2) 65 (90.3) 72 (96.0) 70 (100.0) 75 (100.0)
vanB, Enterococcus faecium 4 (7.0) 7 (9.7) 3 (4.0) 0 (0.0) 0 (0.0)
Total 57 72 75 70 75
Table 3.5 Number and proportion of main VRE-BSI multi-locus sequence types (MLST) identified
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
ST117 18 (32.7) 24 (33.3) 26 (35.6) 16 (22.9) 13 (18.3)
ST18 9 (16.4) 14 (19.4) 15 (20.5) 20 (28.6) 11 (15.5)
ST412 13 (23.6) 10 (13.9) 14 (19.2) 7 (10.0) 12 (16.9)
OthersTable 3.5 - Footnote * 15 (27.3) 24 (33.3) 18 (24.7) 27 (38.6) 35 (49.3)
Total 55 72 73 70 71
Table 3.6 Antimicrobial resistance identified for VRE-BSI
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
*From 2011-2015, only 1 isolate was resistant to Linezolid and none were resistant to Daptomycin.
Ampicillin 57 (100.0) 71 (98.6) 75 (100.0) 70 (100.0) 75 (100.0)
Penicillin 57 (100.0) 71 (98.6) 75 (100.0) 70 (100.0) 75 (100.0)
Vancomycin 57 (100.0) 71 (98.6) 75 (100.0) 70 (100.0) 75 (100.0)
Total 57 72 75 70 75

4. Carbapenem-Resistant Gram Negative Bacilli (CRGN)

Please note that CRGN cases and rates were previously reported as organism-based (cases and rates reflected multiple organisms identified in the same patient and included infections, colonizations and those reported from in-patients, out-patients and the ER). Going forward, we will be reporting individual patient-based cases and rates. This means that a patient identified with multiple CRGN organisms is counted only once and only infections (NOT colonizations) from in-patients are reported. This explains the lower incidence rates presented in this report. Consequently, data from previous years included in this report have been adjusted to reflect this change in reporting.

Lastly, this report presents carbapenemase-producing Enterobacteriaceae (CPE) and Acinetobacter (CPA) as opposed to carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter (CRA) as previously reported. Note that CPE and CPA estimates do not add up to the number of CPO cases as one patient can be identified as having both a CPE and a CPA.

4.1 Carbapenemase-Producing Organisms (CPO)

Table 4.1.1 Number of CPO infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CPO infections 16 16 22 27 22
Rate per 1,000 pt admissions 0.031 0.027 0.029 0.030 0.024
Rate per 10,000 pt days 0.039 0.034 0.038 0.041 0.033
No. of reporting hospitalsTable 4.1.1 - Footnote h 37 38 45 58 58
West
No. of CPO infections 2 6 9 12 14
Rate per 1,000 pt admissions 0.014 0.040 0.035 0.032 0.036
Rate per 10,000 pt days 0.017 0.048 0.047 0.044 0.048
Central
No. of CPO infections 14 10 12 15 7
Rate per 1,000 pt admissions 0.049 0.029 0.029 0.035 0.016
Rate per 10,000 pt days 0.067 0.039 0.040 0.050 0.023
East
No. of CPO infections 0 0 1 0 1
Rate per 1,000 pt admissions 0.000 0.000 0.011 0.000 0.011
Rate per 10,000 pt days 0.000 0.000 0.012 0.000 0.012

Graph 4.1 CPO infections national and regional incidence rates per 10,000 patient days 

Graph 4.1 - Text Equivalent
Graph 4.1 CPO infections national and regional incidence rates per 10,000 patient days
Year Region Rate
2011 West 0.017
2011 Central 0.067
2011 East 0.000
2011 National 0.039
2012 West 0.048
2012 Central 0.039
2012 East 0.000
2012 National 0.034
2013 West 0.047
2013 Central 0.040
2013 East 0.012
2013 National 0.038
2014 West 0.044
2014 Central 0.050
2014 East 0.000
2014 National 0.041
2015 West 0.048
2015 Central 0.023
2015 East 0.012
2015 National 0.033
Table 4.1.2 Number of CPO colonizations and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CPO colonizations 36 22 25 21 35
Rate per 1,000 pt admissions 0.069 0.037 0.033 0.023 0.039
Rate per 10,000 pt days 0.087 0.047 0.043 0.032 0.052
No. of reporting hospitalsTable 4.1.2 - Footnote i 37 38 45 58 58
West
No. of CPO colonizations 1 2 13 1 11
Rate per 1,000 pt admissions 0.007 0.013 0.050 0.003 0.029
Rate per 10,000 pt days 0.008 0.016 0.067 0.004 0.037
Central
No. of CPO colonizations 35 20 12 20 24
Rate per 1,000 pt admissions 0.123 0.058 0.029 0.046 0.056
Rate per 10,000 pt days 0.167 0.078 0.040 0.066 0.080
East
No. of CPO colonizations 0 0 0 0 0
Rate per 1,000 pt admissions 0.000 0.000 0.000 0.000 0.000
Rate per 10,000 pt days 0.000 0.000 0.000 0.000 0.000
Table 4.1.3 All-cause mortality rate 30 days after date of positive culture per 100 CPO inpatient infected and colonized casesTable 4.1.3 - Footnote *
  No. of deaths/No. of CPO inpatients with outcome data All-cause mortality rate per 100 CPO cases
2011 5/22 22.7
2012 7/56 12.5
2013 6/39 15.4
2014 9/48 18.8
2015 9/33 27.3
Table 4.1.4 Number and proportion of main CPO infection pathogens identified
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
Klebsiella pneumonia 9 (56.3) 4 (25.0) 9 (40.9) 11 (40.7) 7 (31.8)
Serratia marcescens 0 (0.0) 1 (6.3) 6 (27.3) 6 (22.2) 2 (9.1)
Escherichia coli 1 (6.3) 2 (12.5) 1 (4.5) 2 (7.4) 3 (13.6)
Acinetobacter baumannii 1 (6.3) 1 (6.3) 1 (4.5) 3 (11.1) 2 (9.1)
Enterobacter cloacae 3 (18.8) 1 (6.3) 0 (0.0) 2 (7.4) 2 (9.1)
OthersTable 4.1.4 - Footnote * 1 (6.3) 5 (31.3) 5 (22.7) 2 (7.4) 5 (22.7)
Total 16 16 22 27 22
Table 4.1.5 Number and proportion of main CPO colonization pathogens identified
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
Klebsiella pneumonia 14 (38.9) 3 (13.6) 7 (28.0) 9 (42.9) 12 (34.3)
Enterobacter cloacae 7 (19.4) 5 (22.7) 2 (8.0) 7 (33.3) 3 (8.6)
Escherichia coli 2 (5.6) 2 (9.1) 2 (8.0) 1 (4.8) 12 (34.3)
Serratia marcescens 5 (13.9) 3 (13.6) 3 (12.0) 0 (0.0) 0 (0.0)
Enterobacter spp. 3 (8.3) 2 (9.1) 1 (4.0) 0 (0.0) 2 (5.7)
OthersTable 4.1.5 - Footnote * 5 (13.9) 7 (31.8) 10 (40.0) 4 (19.0) 6 (17.1)
Total 36 22 25 21 35
Table 4.1.6 Selected antimicrobial resistance patterns identified for CPO infections
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
Ampicillin 14 (87.5) 12 (75.0) 21 (95.5) 23 (85.2) 20 (90.9)
Piperacillin-Tazobactam 14 (87.5) 16 (100.0) 18 (81.8) 20 (74.1) 20 (90.9)
Cefazolin 14 (87.5) 12 (75.0) 21 (95.5) 23 (85.2) 20 (90.9)
Meropenem 9 (56.3) 15 (93.8) 20 (90.9) 24 (88.9) 18 (81.8)
Ciprofloxacin 9 (6.3) 10 (62.5) 10 (45.5) 18 (66.7) 13 (59.1)
Gentamicin 4 (25.0) 11 (68.8) 11 (50.0) 16 (59.3) 9 (40.9)
Colistin 1 (6.3) 0 (0.0) 2 (9.1) 1 (3.7) 0 (0.0)
Total 16 16 22 27 22
Table 4.1.7 Selected antimicrobial resistance patterns identified for CPO colonizations
  2011
No. (%)
2012
No. (%)
2013
No. (%)
2014
No. (%)
2015
No. (%)
Ampicillin 35 (97.2) 21 (95.5) 20 (80.0) 21 (100.0) 32 (91.4)
Cefazolin 35 (97.2) 21 (95.5) 20 (80.0) 21 (100.0) 32 (91.4)
Ceftriaxone 35 (97.2) 20 (90.9) 21 (84.0) 20 (95.2) 34 (97.1)
Ertapenem 33 (91.7) 20 (90.9) 19 (76.0) 20 (95.2) 31 (88.6)
Ciprofloxacin 25 (69.4) 13 (59.1) 13 (52.0) 8 (38.1) 27 (77.1)
Gentamicin 13 (36.1) 6 (27.3) 12 (48.0) 8 (38.1) 27 (54.3)
Colistin 1 (2.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Total 36 22 25 21 35

4.2 Carbapenemase-Producing Enterobacteriaceae (CPE)

Table 4.2.1 Number of CPE infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CPE infections 15 12 20 24 20
Rate per 1,000 pt admissions 0.029 0.020 0.026 0.027 0.022
Rate per 10,000 pt days 0.036 0.026 0.035 0.036 0.030
No. of reporting hospitalsTable 4.2.1 - Footnote j 37 38 45 58 58
West
No. of CPE infections 1 4 9 15 12
Rate per 1,000 pt admissions 0.007 0.027 0.035 0.039 0.031
Rate per 10,000 pt days 0.008 0.032 0.047 0.055 0.041
Central
No. of CPE infections 14 8 10 9 7
Rate per 1,000 pt admissions 0.049 0.023 0.024 0.021 0.016
Rate per 10,000 pt days 0.067 0.031 0.033 0.030 0.023
East
No. of CPE infections 0 0 1 0 1
Rate per 1,000 pt admissions 0.000 0.000 0.011 0.000 0.011
Rate per 10,000 pt days 0.000 0.000 0.012 0.000 0.012
Table 4.2.2 Number of CPE colonizations and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CPE colonizations 36 21 22 21 33
Rate per 1,000 pt admissions 0.069 0.036 0.029 0.023 0.036
Rate per 10,000 pt days 0.087 0.045 0.038 0.032 0.049
No. of reporting hospitals 37 38 45 58 58
West
No. of CPE colonizations 3 1 12 1 11
Rate per 1,000 pt admissions 0.020 0.007 0.046 0.003 0.029
Rate per 10,000 pt days 0.025 0.008 0.062 0.004 0.037
Central
No. of CPE colonizations 33 20 10 20 22
Rate per 1,000 pt admissions 0.116 0.058 0.024 0.046 0.051
Rate per 10,000 pt days 0.157 0.078 0.033 0.066 0.073
East
No. of CPE colonizations 0 0 0 0 0
Rate per 1,000 pt admissions 0.000 0.000 0.000 0.000 0.000
Rate per 10,000 pt days 0.000 0.000 0.000 0.000 0.000

4.3 Carbapenemase-Producing Acinetobacter (CPA)

Table 4.3.1 Number of CPA infections and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CPA infections 1 4 2 3 2
Rate per 1,000 pt admissions 0.002 0.007 0.003 0.003 0.002
Rate per 10,000 pt days 0.002 0.009 0.003 0.005 0.003
No. of reporting hospitalsTable 4.3.1 - Footnote k 37 38 45 58 58
Table 4.3.2 Number of CPA colonizations and incidence rates per 1,000 patient admissions and 10,000 patient days
  2011 2012 2013 2014 2015
National
No. of CPA colonizations 0 1 4 0 2
Rate per 1,000 pt admissions 0.000 0.002 0.005 0.000 0.002
Rate per 10,000 pt days 0.000 0.002 0.007 0.000 0.003
No. of reporting hospitals 37 38 45 58 58

Appendix A

Hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP), as of December 2015

Participating hospitals from the Western region

Vancouver General Hospital, Vancouver, BC
Richmond General Hospital, Richmond, BC
UBC Hospital, Vancouver, BC
Lions Gate Hospital, Vancouver, BC
Powell River Hospital, Powell River, BC
Sechelt Hospital, Sechelt, BC
Squamish Hospital, Squamish, BC
Children’s and Women’s Health Centre, Vancouver, BC
Royal Jubilee, Victoria, BC
Nanaimo Regional General Hospital, Nanaimo, BC
Victoria General Hospital, Victoria, BC
Kelowna Hospital, Kelowna, BC
University of Northern BC, Prince George, BC
Peter Lougheed Hospital, Calgary, AB
Rockyview General Hospital, Calgary, AB
Foothills Hospital, Calgary, AB
South Health Campus, Calgary, AB
Alberta Children’s Hospital, Calgary, AB
University of Alberta Hospital, Edmonton, AB
Stollery Children’s Hospital, Edmonton, AB
Royal University Hospital, Saskatoon, SK
St. Paul’s Hospital, Saskatoon, SK
Regina General Hospital, Regina, SK
Pasqua Hospital, Regina, SK
Children’s Hospital, Winnipeg, MB

Participating hospitals from the Central region

Children’s Hospital of Western Ontario, London, ON
Victoria Hospital, London, ON
University Hospital, London, ON
Toronto Western Hospital, Toronto, ON
Toronto General Hospital, Toronto, ON
Princess Margaret Hospital, Toronto, ON
North York General Hospital, Toronto, ON
The Hospital for Sick Children, Toronto, ON
Mount Sinai Hospital, Toronto, ON
Sunnybrook Health Sciences Centre, Toronto, ON
Kingston General Hospital, Kingston, ON
Hamilton Health Sciences Centre, McMaster, Hamilton, ON
Hamilton Health Sciences Centre, Juravinski Site, Hamilton, ON
Hamilton Health Sciences Centre, General Site, Hamilton, ON
St Joseph’s Healthcare, Hamilton, ON
The Ottawa Hospital, Civic Campus, Ottawa, ON
The Ottawa Hospital, General Site, Ottawa, ON
The Ottawa Hospital, Heart Institute, Ottawa, ON
Children’s Hospital of Eastern Ontario, Ottawa, ON
Sudbury Regional Hospital, Sudbury, ON
Jewish General Hospital, Montréal, QC
Montréal Children’s Hospital, Montréal, QC
Maisonneuve-Rosemont Hospital, Montréal, QC
Montréal General Hospital, Montréal, QC
Royal Victoria Hospital, Montréal, QC
Montréal Neurological Hospital, Montréal, QC
Hôtel-Dieu de Québec de CHUQ, Québec, QC

Participating hospitals from the Eastern region

The Moncton Hospital, Moncton, NB
Queen Elizabeth Hospital, Charlottetown, PEI
Prince County Hospital, Summerside, PEI
QE II Health Sciences Centre, Halifax, NS
IWK Health Centre, Halifax, NS
Health Sciences Centre General Hospital, St. John’s, NL
Janeway Children's Health and Rehabilitation Centre, St. John’s, NL
St. Clare's Mercy Hospital, St. John’s, NL
Burin Peninsula Health Centre, Burin, NL
Carbonear General Hospital, Carbonear, NL
Dr. G.B. Cross Memorial Hospital, Clarenville, NL
Western Memorial Regional Hospital, NL

We gratefully acknowledge the contribution of the physicians, epidemiologists, infection control practitioners and laboratory staff at each participating hospital and the Public Health Agency staff within the Centre for Communicable Diseases and Infection Control and the National Microbiology Laboratory, Winnipeg.  

Appendix B: 2015 Surveillance Case Definitions and Eligibility Criteria

1. Clostridium difficile Infection (CDI)

To be included in the surveillance, a CDI patient must be:

  • ONE year of age and older

Surveillance case definition for info episodes of CDI

  • A “primary” episode of CDI is defined as either the first episode of CDI ever experienced by the patient or a new episode of CDI which occurs greater than eight (8) weeks after the previous confirmed case of CDI in the same patient, i.e. after the first C. difficile toxin-positive assay or PCR test. 

A patient is identified as having CDI if:

  • they have diarrhea* or fever, abdominal pain and/or ileus  AND a laboratory confirmation of a positive toxin assay or positive polymerase chain reaction (PCR) for C. difficile (without reasonable evidence of another cause of diarrhea).

OR

  • they have a diagnosis of pseudomembranes on sigmoidoscopy or colonoscopy (or after colectomy) or histological/pathological diagnosis of CDI.

OR

  • the patient is diagnosed with toxic megacolon (in adult patients only)

* Diarrhea is defined as one of the following:

  • 6 or more watery stools in a 36-hour period
  • 3 or more unformed stools in a 24-hour period and this is new or unusual for the patient (in adult patients only)

NOTE: If the information about the frequency and consistency of diarrhea is not available, a toxin-positive stool or positive PCR will be considered as a case.

Once the patient has been identified with CDI, they will be classified as HA or CA based on the following criteriaFootnote l  and the best clinical judgment of the healthcare and/or infection prevention and control practitioner.

CDI is considered “healthcare-associated from your facility”Footnote m if it meets the following criteria:

  • The patient’s CDI symptoms occur in your healthcare facility 3 or more days after admission, with day of admission being day 1.

OR

  • The patient’s CDI symptoms occur less than three (3) days after admission and are seen in a patient who had been hospitalized at your healthcare facility and discharged within the previous 4 weeks.

CDI is considered “healthcare-associated, another facility”  if it meets the following criteria:

  • The patient’s CDI symptoms occur less than three (3) days after admission and are seen in a patient who is known to have been hospitalized at another healthcare facility and discharged within the previous four (4) weeks.

CDI is considered “community-associated” if it meets the following criteria:

  • Patients seen in the Emergency Department, clinic, or other outpatient areas with positive test results for CDI are included  (if possible at your facility)Footnote n 

OR

  • Patient’s CDI symptoms occur three (3) days or less after admission to a healthcare facility (your facility or another), with the date of admission being day 1;

AND

  • The symptom onset was more than twelve (12) weeks after the patient was discharged from any healthcare facility

CDI is considered “indeterminate” if it meets the following criteria:

  • The patient with CDI does not meet any of the definitions listed above for HA- or CA-CDI. The symptom onset was more than four weeks but less than 12 weeks after the patient was discharged from any healthcare facility.

2. Methicillin-Resistant Staphylococcus aureus (MRSA)

MRSA surveillance inclusion criteria

MRSA case definition:

  • isolation of Staphylococcus aureus from any body site

AND

  • resistance of isolate to oxacillin

AND

  • patient must be admitted to the hospital

AND

  • is a "newly identified MRSA case" at a CHEC facility at the time of hospital admission or identified during hospitalization.

This includes:

  • MRSA cases identified for the first time during this hospital admission
  • Cases that have been previously identified at other non-CHEC sites (since we want newly identified MRSA cases at CHEC sites)
  • Cases that have already been identified at your site but are new cases.  This can only be identified if the previously identified case has another strain.  This means the person was exposed again to MRSA and acquired another strain of it from another source (a new patient identifier should be assigned only if it is an MRSA infection, identified as a clinical isolate or bacteremia).

MRSA surveillance exclusion criteria:

  • MRSA cases previously identified at other CHEC sites
  • Emergency, clinic, or other outpatient cases
  • Cases re-admitted with MRSA (unless it is a different strain) 

Healthcare-associated (HA) case definition:

Once the patient has been identified with MRSA, they will be classified as HA based on the following criteria and the best clinical judgement of the healthcare and/or infection prevention and control practitioner (IPC):

  • Exposure to any healthcare setting (including long-term care facilities or clinics) in the previous 12 monthsFootnote o 

OR

  • Patient is on calendar day 3Footnote p  of their hospitalization

Newborn healthcare-associated (HA) case definition:

A MRSA case in a newborn may be considered as HA if:

  • The newborn is on calendar day 3 of their hospitalization
  • The mother was not known to be a case on admission and there is no epidemiological reason to suspect that the mother was colonized prior to admission, even if the newborn is < 48 hours of age.

In the case of a newborn transferred from another institution, MRSA may be classified as HA if the organism was not known to be present and there is no epidemiological reason to suspect that acquisition occurred prior to transfer.

Community-associated case definition:

  • MRSA identified on admission to hospital (Calendar Day 1 = day of hospital admission) and/or the day after admission (day 2)

AND

  • Has no previous history of the organism

AND

  • Has no prior hospital or long-term care admission in the past 12 monthsFootnote q 

AND

  • Has no reported use of medical devices

MRSA clinical infection

MRSA infection is determined using the 2014 CDC/NHSN surveillance definitions www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf for specific infections, and in accordance with the best judgment of the healthcare and/or IPC practitioner.

The MRSA infection would be considered HA if all elements of a CDC/NHSN site-specific infection criterion were present on or after the 3rd calendar day of admission to the facility (the day of hospital admission is calendar day 1). The MRSA infection would be considered CA if all elements of a CDC/NHSN site-specific infection criterion were present during the two calendar days before the day of admission, the first day of admission (day 1) and/or the day after admission (day 2) and are documented in the medical record.

MRSA Bloodstream infection (bacteremia)

To be considered a MRSA bloodstream infection the patient must have MRSA cultured (lab-confirmed) from at least one blood culture    

To classify the MRSA bloodstream infection as HA or CA, the following criteria taken from Friedman et al, Ann Intern Med 2002 will be used. The MRSA infection would be considered:

HA – your facility MRSA BSI: if the first positive blood culture for MRSA was obtained ≥ 48 hours after admission to your hospital

HA – MRSA BSI: if the first positive blood culture for MRSA was obtained ≥ 48 hours after hospital admission

OR

if the first positive blood culture for MRSA was obtained within 48 hours of admission, the patient meets one of the following criteria:

  • (i) healthcare exposure in the previous 90 days (such as receipt of IV medications, IV chemotherapy, hemodialysis, etc);
  • (ii) was hospitalized in the previous 90 days; or
  • (iii) resides in a long-term care facility or nursing home.

CA – MRSA BSI: if the first positive blood culture for MRSA was obtained prior to hospital admission, or within 48 hours of admission, AND did not meet criteria for HA-BSI. 

3. Vancomycin-Resistant Enterococci (VRE)

VRE infection case definition:

  • Isolation of Enterococcus faecalis or faecium 

AND

  • Vancomycin MIC ≥ 8 ug/ml

AND

  • Patient is admitted to the hospital

AND

  • Is a "newly” identified VRE-infection at a CHEC facility at the time of hospital admission or identified during hospitalization

VRE infection is determined using the January 2015 Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) definitions/criteria for infections, and in accordance with the best judgment of the ICP.  These criteria should be met at the time of the culture that yielded VRE, or within 72 hours of the culture.

www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf

Exclusion criteria:

  • Previously identified at other CHEC sites (to avoid duplicate reporting to CNISP)
  • Identified through emergency, clinic, or other outpatient areas
  • Re-admitted with VRE (UNLESS it is a different strain)

4. Carbapenemase-Producing Organisms (CPO), Carbapenemase-Producing Enterobacteriaceae (CPE) and Carbapenem-Producing Acinetobacter (CPA)

Any patient admitted to participating CNISP hospitals with a hospital laboratory confirmation (and subsequent confirmation by the NML) that tested/screened positive for a least one potential carbapenem-reduced susceptible Enterobacteriaceae and Acinetobacter spp., from any body site that meets the following CLSI criteriaFootnote r .

At least ONE of the following: Enterobacteriaceae:
MIC (μg/ml) Disk diffusionTable - Footnote * (mm)
Imipenem ≥ 2 ≤ 22
Meropenem ≥ 2 ≤ 22
Doripenem ≥ 2 ≤ 22
Ertapenem ≥ 1 ≤ 21
At least ONE of the following: Acinetobacter:
MIC (μg/ml) Disk diffusion (mm)
Imipenem ≥ 4 ≤ 21
Meropenem ≥ 4 ≤ 17
Doripenem ≥ 4 ≤ 17

Carbapenems are a class of broad-spectrum antibiotics recommended as first-line therapy for severe infections caused by certain gram negative organisms and as directed therapy for organisms that are resistant to narrower spectrum antibiotics.

Carbapenem resistance can be due to changes in the permeability of the organism to the antibiotic, the up-regulation of efflux systems that “pump” the antibiotic out of the cell, and more recently due to the hyperproduction of enzymes that break down the carbapenems. This latter subset of carbapenem resistant organisms are called carbapenemase-producing organisms or CPOs and are of particular concern because of their ability to transfer resistance easily across different genus and species of bacteria. They are quickly becoming a public health problem not only because of the ability to cause healthcare-associated infections but because of the potential ease of colonizing both inpatient and outpatient populations creating a reservoir of bacterial resistance. 

CPE represents a subset of CRGN bacilli comprised of Enterobacteriaceae and CPA represents a subset of CRGN bacilli comprised of Acinetobacter identified as carbapenemase producing.  Mechanism may be either by acquisition of a carbapenemase gene e.g. NDM-1, OXA-48, KPC, VIM, IMP or by other cellular mechanisms such as permeability changes (efflux overpression, porin mutations), chromosomal B-lactamase up regulation e.g. E. coli, K. pneumonia, Citrobacter, Enterobacter, Serratia, Morganell, Proteus, Providencia.

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