CARAlert Summary Report - BMJ Quality & Safety · 4/1/2017 · The National Alert System for Critical Antimicrobial Resistances (CARAlert) was established by the Australian Commission

February 2018

CARAlert Summary Report

1 April 2017–30 September 2017

CARAlert Summary Report April 2017–September 2017 2

Published by the Australian Commission on Safety and Quality in Health Care Level 5, 255 Elizabeth Street, Sydney NSW 2000 Phone: (02) 9126 3600 Fax: (02) 9126 3613 Email: [email protected] Website: www.safetyandquality.gov.au

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Australian Commission on Safety and Quality in Health Care. CARAlert Summary Report 1 April 2017–30 September 2017. Sydney: ACSQHC; 2018

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Summary The National Alert System for Critical Antimicrobial Resistances (CARAlert) was established by the Australian Commission on Safety and Quality in Health Care (the Commission) in March 2016 to collect surveillance data on priority organisms with critical resistance to last-line antimicrobial agents. In its second year of operation CARAlert is providing regular and timely antimicrobial resistance data to states and territories and nationally. For the six-month period 1 April 2017 to 30 September 2017, azithromycin non-susceptible Neisseria gonorrhoeae were the most frequently reported CAR of all CAR types (46.6%), followed closely by carbapenemase-producing Enterobacteriaceae (CPE) either alone (41.4%) or in combination with ribosomal methyltransferases (RMT) (2.4%). Fifty-three percent of CARs were detected from patients in the community (non-hospital patients or aged care home residents). There was an increase in the number of CARs reported compared to the same period last year (742 versus 423). This was due almost entirely to increases in azithromycin non-susceptible N. gonorrhoeae and an outbreak of OXA-48 producing Escherichia coli ST38 that was detected in Queensland, where 80 cases were reported between May 2017 and July 2017. In response to the identification of the index case, the hospital where the outbreak occurred implemented a program that included:

Identifying and screening contacts of the index case and newly admitted patients to identify others infected or colonised with OXA-48 producing E. coli ST38

Ensuring the appropriate use of standard and contact infection control precautions

Environmental cleaning and disinfection

Reviewing and implementing appropriate antimicrobial stewardship measures The outbreak was largely confined to a single facility, and was controlled within two months. Queensland Health hospitals have strategies in place to ensure early detection of any future CPE cases, and control and prevention of transmission. The frequency of reporting of azithromycin non-susceptible N. gonorrhoeae has increased over the last two years. This has occurred in the context of significant increase in notifications of N. gonorrhoeae; and a decline in the proportion of isolates with elevated minimum inhibitory concentration (MIC) values to ceftriaxone in Australia. The frequency of reporting of CPE, and the Queensland outbreak, highlight the importance of the implementation of the Commission’s Recommendations for the control of carbapenemase-producing Enterobacteriaceae: A guide for acute health facilities. 1 The Commission continues to monitor records from CARAlert, prepare summary reports and ensure regular discussion with state and territory health departments about trends and potential CAR outbreaks to inform quality improvement initiatives and policies to reduce antimicrobial resistance.

1 Australian Commission on Safety and Quality in Health Care. Recommendations for the control of

carbapenemase-producing Enterobacteriaceae (CPE). A guide for acute care health facilities. Sydney: ACSQHC, 2017

https://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/cpe-guide/



Background

The Australian Commission on Safety and Quality in Health Care (the Commission) established the National Alert System for Critical Antimicrobial Resistances (CARAlert) in March 2016 as part of the Antimicrobial Use and Resistance in Australia (AURA) Surveillance System.

Critical antimicrobial resistances (CARs) are defined as resistance mechanisms, or profiles, known to be a serious threat to the effectiveness of last-line antimicrobial agents. They can result in significant morbidity and mortality in healthcare facilities, and in the community. The CARs reported under CARAlert are listed in Table 1. The CARs were drawn from the list of high-priority organisms and antimicrobials which are the focus of the AURA Surveillance System.2

The CARAlert system is based on the following routine processes used by pathology laboratories for identifying and confirming potential CARs:

Collection and routine testing – the isolate is collected from the patient and sent to the originating laboratory for routine testing

Confirmation – if the originating laboratory suspects that the isolate is a CAR, it sends the isolate to a confirming laboratory that has the capacity to confirm the CAR

Submission to the CARAlert system – the confirming laboratory advises the originating laboratory of the result of the test, and the originating laboratory reports back to the health service that cared for the patient from whom the specimen was collected; the confirming laboratory then submits the details of the resistance and organism into the secure CARAlert web portal.

Table 1: List of critical antimicrobial resistances

Species Critical Resistance

Enterobacteriaceae Carbapenemase-producing, and/or ribosomal methyltransferase-producing

Enterococcus species Linezolid non-susceptible

Mycobacterium tuberculosis Multidrug-resistant – resistant to at least rifampicin and isoniazid

Neisseria gonorrhoeae Ceftriaxone or azithromycin non-susceptible

Salmonella species Ceftriaxone non-susceptible

Shigella species Multidrug-resistant

Staphylococcus aureus Vancomycin, linezolid or daptomycin non-susceptible

Streptococcus pyogenes Penicillin reduced susceptibility

2 Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2017: Second

Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2017.


Results

This six-monthly report provides details on confirmed CARs collected between 1 April 2017 and 30 September 2017 and the results reported into CARAlert by 31 October 2017. It complements the CARAlert updates and reports published on the Commission’s website to date.

As there is a time-lag in confirmation for some isolates, the cut-off date for data included in Commission updates and reports is four weeks after the end of each reporting period. The data in each update and report are based on the date that the isolate with a confirmed CAR was collected.

Critical antimicrobial resistances reported by state and territory

Between 1 April 2017 and 30 September 2017, 742 results from 65 originating laboratories across Australia were entered in the CARAlert system (Table 1). Azithromycin non-susceptible Neisseria gonorrhoeae were the most frequently reported CAR of all CAR types (46.6%), followed closely by carbapenemase-producing Enterobacteriaceae (CPE) either alone (41.4%) or in combination with ribosomal methyltransferases (RMT) (2.4%). No ceftriaxone non-susceptible N. gonorrhoeae, vancomycin non-susceptible Staphylococcus aureus or linezolid non-susceptible S. aureus were reported during this reporting period.

The majority of CARs continue to be reported from the three most populous states – New South Wales (28%), Victoria (35%) and Queensland (25%). CARs were the lowest in the Northern Territory (2), Tasmania (4) and South Australia (5); with only 1.5% (11/742) of all CARs reported from these states and territories. State or territory of residence was not available for two CPE reports that were subsequently found to have originated from New South Wales and Victoria. Five reports were from overseas residents; three azithromycin non-susceptible (low-level resistance [LLR], minimum inhibitory concentration [MIC] < 256 mg/L) N. gonorrhoeae, one CPE and one multidrug-resistant Mycobacterium tuberculosis.

There was a 75% increase in the total number of CARs reported for the corresponding reporting period in 2016. This was due to a significant increase of 182% in azithromycin non-susceptible (LLR < 256 mg/L) N. gonorrhoeae (121 to 342; P=<0.001) and an increase of 59% in the number of CPE that was not statistically significant (193 to 307). The context for these increases is discussed in the conclusion.

https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/what-is-aura/national-alert-system-for-critical-antimicrobial-resistances-caralert/

Table 2: Number of critical antimicrobial resistance isolates, by state and territory, 1 April 2017 to 30 September 2017

Critical antimicrobial resistance NSW Vic Qld SA WA Tas NT ACT OS Unk 2017 Apr–Sep

2017 YTD

2016 Apr–Sep

2016 Mar–Dec*

Trend† 16–Q4 17–Q3

Azithromycin non-susceptible (LLR < 256 mg/L) Neisseria gonorrhoeae

120 160 28 0 29 1 1 0 3 0 342 591 121 225

Carbapenemase-producing Enterobacteriaceae 71 66 136 3 12 2 1 13 1 2 307 418 193 312

Daptomycin non-susceptible Staphylococcus aureus

6 15 9 1 12 0 0 0 0 0 43 79 34 62

Carbapenemase and ribosomal methyltransferase-producing Enterobacteriaceae

2 15 1 0 0 0 0 0 0 0 18 21 17 21

Ribosomal methyltransferase-producing Enterobacteriaceae

2 4 3 0 1 0 0 1 0 0 11 16 12 16

Ceftriaxone non-susceptible Salmonella species 2 0 6 1 1 0 0 0 0 0 10 14 11 17

Azithromycin non-susceptible (HLR > 256 mg/L) Neisseria gonorrhoeae

1 2 1 0 0 0 0 0 0 0 4 4 3 4

Multidrug-resistant Shigella species 1 1 0 0 0 1 0 0 0 0 3 8 10 15

Linezolid non-susceptible Enterococcus species 2 0 0 0 1 0 0 0 0 0 3 4 5 9

Multidrug-resistant Mycobacterium tuberculosis 0 0 0 0 0 0 0 0 1 0 1 5 13 20

Ceftriaxone non-susceptible Neisseria gonorrhoeae 0 0 0 0 0 0 0 0 0 0 0 0 4 4

Vancomycin non-susceptible Staphylococcus aureus

0 0 0 0 0 0 0 0 0 0 0 0 0 1

Total (as at 30 September 2017) 207 263 184 5 56 4 2 14 5 2 742 1160 423 706

HLR = high-level resistance; LLR = low-level resistance; OS = overseas; Unk = unknown; YTD = year to date

* CARAlert commenced on 17 March 2016. Data for 2016 are for the period 17 March 2016 to 31 December 2016 † Trend 16–Q4 17–Q3 = Trend Quarter 4 2016 to Quarter 3 2017

CARAlert Six-monthly Report April 2017–September 2017 7

Critical antimicrobial resistances by species and month

The number and distribution of CARs reported nationally, and by state and territory, is shown in Figure 1. There was an average of 124 entries per month (range 84–188), with a peak in May 2017.

Figure 1. Critical antimicrobial resistances, number and distribution reported nationally, by state and territory, and by month, 1 April 2017 to 30 September 2017

Carbapenemase-producing Enterobacteriaceae





Ceftriaxone non-susceptible Salmonella species

Multidrug-resistant Shigella species

Multidrug-resistant Mycobacterium tuberculosis

Linezolid non-susceptible Enterococcus species


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Figure 1. (continued). Critical antimicrobial resistances, number and distribution reported nationally, by state and territory, and by month, 1 April 2017 to 30 September 2017

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Nationally, azithromycin non-susceptible N. gonorrhoeae continued to be the most frequent CAR reported each month, except for June and July 2017, when CPE dominated. The outbreak of OXA-48 producing Escherichia coli detected in Queensland peaked in June 2017, and subsided in July and August; no cases were reported for September 2017.

Daptomycin non-susceptible S. aureus were reported from five states/territories, with 35% (15/43) from Victoria, 28% (12/43) from Western Australia and 21% (9/43) from Queensland.

There was a large increase in the number of reports of azithromycin non-susceptible N. gonorrhoea originating from Victoria in May 2017 (Figure 2). No reports were received from South Australia and the Australian Capital Territory. Four strains with high-level azithromycin non-susceptibility (MIC ≥ 256 mg/L) were confirmed from three states; Queensland (1, April 2017), Victoria (2, May 2017), and New South Wales (1, August 2017).

Figure 2. Neisseria gonorrhoeae, number reported by state and territory, and month of collection*, 1 April 2017 to 30 September 2017

* Where state and territory of residence is unknown, the state of the originating laboratory has been assigned

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Azithromycin (LLR < 256 mg/L) Azithromycin (HLR > 256 mg/L)


Critical antimicrobial resistances by age group

CARs were isolated from patients of all ages, from birth to those aged greater than 80 years, with a median age of 40–49 years (Figure 3). Sixty-three per cent (206/325) of CPE were from people aged 60 years and older. Azithromycin non-susceptible N. gonorrhoeae were the predominant CAR reported among the age groups 15–19 years, 20–29 years, 30–39 years and 40–49 years. Only 3.4% (25/742) of all CARs were reported in children aged less than 15 years; CPE, either alone (48%) or with RMT (8%) were common in this age group. No trends have been observed in the age distribution since the commencement of the program.

Figure 3. Critical antimicrobial resistances by age group, 1 April 2017 to 30 September 2017

CPE = carbapenemase-producing-Enterobacteriaceae; RMT = ribosomal methyltransferase-producing Enterobacteriaceae; CPE+RMT = carbapenemase- and ribosomal methyltransferase-producing Enterobacteriaceae; LNZ ENTE = linezolid non-susceptible Enterococcus species; AZI LLR = azithromycin non-susceptible, low level resistance (LLR, MIC < 256 mg/L) Neisseria gonorrhoeae; AZI HLR = azithromycin non-susceptible, high level resistance (HLR, MIC > 256 mg/L) Neisseria gonorrhoeae; DAP SAUR = daptomycin non-susceptible Staphylococcus aureus; CTR SALM = ceftriaxone non-susceptible Salmonella species; MDR SHIG = multidrug-resistant Shigella species; MDR MTB = multidrug-resistant Mycobacterium tuberculosis

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B. Percentage by age group


Critical antimicrobial resistances by specimen type

Seventy-six per cent of all CARs were from clinical specimens (specimens collected for diagnostic purposes, rather than for screening). These include urine, wound, blood and other (such as genital or respiratory) specimens (Figure 4).

Forty-eight per cent (155/325) of CPE isolates were from clinical specimens; 61% (94/155) of these were from urine, and 8% (12/155) from blood cultures. Urine is an important specimen for certain CARs such as CPE, and the urinary tract is a common site of infection. CPE were the only CAR reported from blood cultures.

Figure 4. Critical antimicrobial resistances, number reported by specimen type, 1 April 2017 to 30 September 2017

Other specimen type: not urine, wound, or blood (for example, genital, faecal, respiratory)


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Critical antimicrobial resistances by facility type

CARs were detected in the community (50%, 371/742), in hospitalised patients or hospital outpatients (46%, 343/742), and in aged care home residents (1%, 9/742) (Figure 5). Facility type for azithromycin non-susceptible N. gonorrhoeae was difficult to obtain as most isolates are referred to a public health laboratory for confirmation, and as such may reflect the facility from which the isolate was sent rather than the facility that the patient attended.

Figure 5. Critical antimicrobial resistances, number reported by facility type, 1 April 2017 to 30 September 2017

Other: Community (non-hospital and non-aged care home)


Carbapenemase-producing Enterobacteriaceae type by state and territory

Six different carbapenemase types (IMP, OXA-48-like, NDM, KPC, VIM, OXA-23, and IMI) were reported throughout Australia. Three carbapenemase types – IMP (44%, 142/325), OXA-48-like (30%, 98/325) and NDM (15%, 49/325) – accounted for 89% of all Enterobacteriaceae with a confirmed carbapenemase.

Regional differences in the carbapenemase types reported are shown in Figure 6. IMP type carbapenemases comprised the majority (>65%) of CPE in New South Wales (66%, 48/73), and the Australian Capital Territory (85%, 11/13). No IMP-producing Enterobacteriaceae

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were reported from South Australia or the Northern Territory. All the strains that have been genetically sequenced in this period (50%, 72/144) are blaIMP-4.

NDM types were found in all states and territories. NDM types contributed to 30% (24/81) of all types in Victoria, 22% (16/73) in New South Wales, and 33% (4/12) in Western Australia. NDM+OXA-48-like (10/60) and NDM+VIM (n=1/60), were reported. Five of the six isolates from New South Wales with NDM+OXA-48-like were found in Klebsiella pneumoniae. Four different NDM genes were found in the strains sequenced to date: blaNDM-1 (47%, 14/30), blaNDM-5 (40%, 12/30), blaNDM-4 (10%, 3/30), and blaNDM-7 (3%, 1/30). NDM types most often have their origin in the Indian subcontinent, and are strongly associated with other last line resistances, including aminoglycosides and fluoroquinolones.

Ribosomal methyltransferases were often detected among isolates containing NDM types (22%, 13/60; rmtB [9], rmtC [2], armA [1] and rmtF [1]).

K. pneumoniae carbapenemase (KPC) types were mostly confined to Victoria (81%, 13/16), although there were reports from two other states (New South Wales, n = 2; and Queensland, n = 1).


Figure 6. Carbapenemase-producing Enterobacteriaceae*, by carbapenemase type, number (A) and percentage (B) reported by state and territory, 1 April 2017 to 30 September 2017

* Carbapenemase-producing Enterobacteriaceae (n = 307), carbapenemase- and ribosomal methyltransferase-producing Enterobacteriaceae (n = 18)

The distribution of carbapenemase types by state and territory and month of confirmation is shown in Figure 7. The significant increase noted in May 2017 and June 2017 for Queensland reflects a clonal outbreak of an OXA-48 producing E. coli. The 12-month trend data for the top four carbapenemase types is shown in Figure 8.

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Figure 7. Carbapenemase types, number reported by month and state and territory, 1 April 2017–30 September 2017

OS = overseas; UNK = unknown

Figure 8. Twelve-month trend data for the top four carbapenemase types, by state and territory and nationally, 1 October 2016 to 30 September 2017

Type NSW Vic Qld SA WA Tas NT ACT Australia

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Line graphs for the period 1 October 2016 to 30 September 2017, for each type, with significant trends (2 for

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Carbapenemase-producing Enterobacteriaceae by species and carbapenemase type

Carbapenemases were found in 16 species of Enterobacteriaceae representing eight genera (Citrobacter, Enterobacter, Escherichia, Klebsiella, Morganella, Proteus, Providencia, Serratia). E. coli contributed to 42% (137/325) of all species, with 65% (89/137) containing OXA-48-like carbapenemases (Figure 9). IMP-types accounted for 43.7% (142/325) of all carbapenemases, and were found in 16 different species. E. cloacae complex accounted for 53% (76/142) of all IMP type carbapenemases and 26% (84/325) of all CPE. OXA-48-like and NDM carbapenemase types were found mainly in E. coli (91%, 89/98; 63%, 31/49, respectively); however, when both NDM and OXA-48-like types were found together, they were mainly in K. pneumoniae (80%, 8/10).

Two KPC (12%, 2/16) were found in E. coli in Victoria. IMI was detected for the first time in April 2017, in an E. cloacae complex from a patient residing in New South Wales.


Figure 9. Carbapenemase-producing Enterobacteriaceae*, number reported by (A) species and (B) carbapenemase type, 1 April 2017 to 30 September 2017

* Carbapenemase-producing Enterobacteriaceae (n = 307), carbapenemase- and ribosomal methyltransferase-producing Enterobacteriaceae (n = 18)

Other Critical Antimicrobial Resistance types

Ribosomal methyltransferases were detected in 29 Enterobacteriaceae, across six different species; 62% (18/29) of these isolates also harboured a carbapenemase. Four ribosomal methyltransferase genes were found: rmtB (55%; 16/29); armF (21%, 6/29), armA (17%; 5/29); and rmtC (7%; 2/29).

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Enterobacter asburiae

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IMP

Escherichia coli Enterobacter cloacae complex Klebsiella pneumoniae

Citrobacter freundii Serratia marcescens Klebsiella oxytoca

Morganella morganii Proteus mirabilis Providencia rettgeri

Escherichia hermannii Enterobacter aerogenes Serratia species

Enterobacter gergoviae Enterobacter asburiae Klebsiella variicola

Citrobacter amalonaticus

B. Carbapenemase type by species


Ten ceftriaxone non-susceptible Salmonella species were confirmed from Queensland (6), New South Wales (2), and one each from South Australian and Western Australia. Six had plasmid-borne ampC genes, either alone (4) or with an ESBL (2); and four had ESBLs alone.

There were three reports of multidrug-resistant Shigella species, from patients residing in New South Wales, Tasmania and Victoria.

Three linezolid non-susceptible Enterococcus species were reported, all were E. faecalis.


Trends since March 2016

The proportion of CARs associated with priority organisms since 17 March 2016 is shown in Figure 10. The number of CARs reported by species and month is shown in Figure 11. The number and proportion reported nationally, and by state and territory is shown in Figure 12. The fluctuations in reporting of CARs, particularly CPE and azithromycin non-susceptible N. gonorrhoeae, and state and territory variations have already been noted.

Figure 10. Critical antimicrobial resistances (CARs), as a percentage of all CARs, reported by month, 17 March 2016–30 September 2017

CPE = carbapenemase-producing-Enterobacteriaceae; RMT = ribosomal methyltransferase-producing Enterobacteriaceae; CPE+RMT = carbapenemase- and ribosomal methyltransferase-producing Enterobacteriaceae; LNZ ENTE = linezolid non-susceptible Enterococcus species; AZI LLR = azithromycin non-susceptible, low level resistance (LLR, MIC < 256 mg/L) Neisseria gonorrhoeae; AZI HLR = azithromycin non-susceptible, high level resistance (HLR, MIC > 256 mg/L) Neisseria gonorrhoeae; CTR NGON = ceftriaxone non-susceptible Neisseria gonorrhoeae; DAP SAUR = daptomycin non-susceptible Staphylococcus aureus; VAN SAUR = vancomycin non-susceptible Staphylococcus aureus; CTR SALM = ceftriaxone non-susceptible Salmonella species; MDR SHIG = multidrug-resistant Shigella species; MDR MTB = multidrug-resistant Mycobacterium tuberculosis

47% 46% 46% 58%

49%

28%

47% 55%

35% 34% 32% 28% 21%

32% 37%

60%

46% 35% 33%

29% 37% 19%

20%

24%

46%

29% 23%

46% 45% 55% 58% 65%

49% 51%

32%

40%

51% 57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mar(49)

Apr(70)

May(85)

Jun(64)

Jul(80)

Aug(65)

Sep(59)

Oct(75)

Nov(82)

Dec(77)

Jan(111)

Feb(152)

Mar(155)

Apr(107)

May(188)

Jun(151)

Jul(119)

Aug(84)

Sep(89)

2016 2017

Month (number of CARs)

CPE CPE + RMT AZI LLR DAP SAUR RMT CTR SALM

MDR SHIG MDR MTB LNZ ENTE CTR NGON AZI HLR VAN SAUR


Figure 11. Critical antimicrobial resistances, number reported by species and month, 17 March 2016–30 September 2017

CPE = carbapenemase-producing-Enterobacteriaceae; RMT = ribosomal methyltransferase-producing Enterobacteriaceae; LLR = low level resistance; HLR = high level resistance

Mar

Apr

May

Ju

n

Ju

l

Aug

Sep

Oct

No

v

De

c

Ja

n

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n

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l

Aug

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2016 2017

0

1

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Num

be

r

Multidrug-resistant Shigella

Ceftriaxone non-susceptible Salmonella

0

1

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4

5

Mar

Apr

May

Ju

n

Ju

l

Aug

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v

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c

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n

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Mar

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n

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l

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Sep

2016 2017

Num

be

r

Multidrug-resistant Mycobacteriumtuberculosis

24

33

44 40 42

19

32

43

29 27

36 43

35 37

73

93

59

31 32

Mar

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May

Ju

n

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l

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v

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n

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Sep

2016 2017

0

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Nu

mb

er

Total CPE

Carbapenemase

Carbapenemase and ribosomal methyltransferase

1 2

6

4

7

5 5

3

2 2 2

0

6

5

6

3

7

3

5

0

2

4

6

8

10

12

Mar

Apr

May

Ju

n

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l

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No

v

De

c

Ja

n

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Mar

Apr

May

Ju

n

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l

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Sep

2016 2017

Nu

mb

er

Total RMT

Ribosomal methyltransferase

Ribosomal methyltransferase and carbapenemase

14

26

16 13 19

30

17 17

38 35

61

88

100

52

96

48 48 43

55

Mar

Apr

May

Ju

n

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l

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0

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TotalAzithromycin non-susceptible (LLR)Azithromycin non-susceptible (HLR)Ceftriaxone non-susceptible

0

2

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12

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16

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2016 2017

Num

be

r

Daptomycin Vancomycin

B. Enterobacteriaceae – ribosomal

methyltransferase-producing

D. Salmonella and Shigella species

F. Enterococcus species and Mycobacterium

tuberculosis

C. Neisseria gonorrhoeae

E. Staphylococcus aureus

A. Enterobacteriaceae – carbapenemase-producing


Figure 12. Critical antimicrobial resistances, number and distribution reported nationally, and by state and territory, 16 March 2016 to 30 September 2017










Ceftriaxone non-susceptible Neisseria gonorrhoeae



0%

10%

20%

30%

40%

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60%

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Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

2016 2017

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140

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200

Australia

0%

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2016 2017

0

10

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40

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60

New South Wales


Figure 12 (continued). Critical antimicrobial resistances, number and distribution reported nationally, and by state and territory, 16 March 2016 to 30 September 2017













0%

10%

20%

30%

40%

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60%

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2016 2017

0

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Victoria

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2016 2017

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Queensland















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2016 2017

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2016 2017

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Western Australia















0%

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2016 2017

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Tasmania

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2016

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2016 2017

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6

7

Australian Capital Territory


Conclusion

The establishment of CARAlert in 2016 was a significant enhancement of the AURA Surveillance System, which has provided timely national data on CARs to inform quality improvement initiatives and policies to reduce antimicrobial resistance.

As at 30 September 2017, 85 originating laboratories have contributed CARs that have been reported by the 28 confirming laboratories. All states and territories have had at least one CAR reported.

CPE were the most frequently recorded CAR of all CARs reported until November 2016, either alone or in combination with RMT. From December 2016, azithromycin non-susceptible N. gonorrhoeae were most frequently reported, and have continued to dominate reports until September 2017, except for June 2017 and July 2017, where CPE peaked. This was due to an outbreak of OXA-48 producing E. coli ST38 in Queensland, where 80 cases were reported between May 2017 and July 2017.

In response to the identification of the index case, the hospital where the outbreak occurred implemented a program that included:

Identifying and screening contacts of the index case and newly admitted patients to identify others infected or colonised with OXA-48 producing E. coli ST38

Ensuring the appropriate use of standard and contact infection control precautions

Environmental cleaning and disinfection

Reviewing and implementing appropriate antimicrobial stewardship measures The outbreak was largely confined to a single facility, and was controlled within two months. Queensland Health hospitals have strategies in place to ensure early detection of any future CPE cases, and control and prevention of transmission.

The IMP-type carbapenemase (mainly IMP-4) is clearly well established on the eastern seaboard of Australia in several species of Enterobacteriaceae; particularly E. cloacae, and is appearing intermittently in other states and territories.

The frequency of reporting of CPE and the outbreak in Queensland highlights the importance of the implementation of the Commission’s Recommendations for the control of carbapenemase-producing Enterobacteriaceae: a guide for acute health facilities. 3

The frequency of reporting of azithromycin non-susceptible N. gonorrhoeae has increased over the last 2 years, initially in South Australia in 2016 4 5, then across all jurisdictions in 2017. Azithromycin non-susceptible N. gonorrhoeae are now common in Australia and this likely reflects the emergence and spread of resistance clones. This has occurred in the context of significant increase in notifications of N. gonorrhoeae by 63% (62 to 101 per 100 000) between 2012 and 2016. Azithromycin was added to ceftriaxone as part of a dual treatment strategy to delay the emergence of ceftriaxone non-susceptible N. gonorrhoeae in

3 Australian Commission on Safety and Quality in Health Care. Recommendations for the control of

carbapenemase-producing Enterobacteriaceae (CPE). A guide for acute care health facilities. Sydney: ACSQHC, 2017 4 Lahra MM. Australian Gonococcal Surveillance Program Quarter 3 2017 Report. Communicable

Diseases Intelligence. In press. 5 Lahra M, Ward A, Trembizki E, Hermanson J, Clements E, Lawrence A, et al. Treatment guidelines

after an outbreak of azithromycin-resistant Neisseria gonorrhoeae in South Australia. The Lancet Infectious Diseases 2017; 17(2):133–134.




Australia in 2014 and this has coincided with the decline in the proportion of isolates with elevated MIC values to ceftriaxone in Australia 6 as shown in Figure 11 C.

The data on azithromycin non-susceptible and ceftriaxone non-susceptible N. gonorrhoeae reported to CARAlert complement the comprehensive long term Commonwealth and state and territory systems that monitor and report antimicrobial resistance as part of national surveillance activities to inform treatment guidelines and sexually transmitted infection prevention and control strategies.

Other CARs remain at very low levels, providing reassurance that none have become established in Australia.

A review of CARs reported to CARAlert is planned for early 2018. The review will

Assess the CARs which are currently reported to CARAlert to determine that they continue to be priorities

Identify additional CARs that should be captured by CARAlert

Update the list of laboratories that perform confirmatory testing for CARs

Update the CARAlert Handbook to reflect changes arising from the review.

Enquiries regarding either this report or the CARAlert System should be submitted to [email protected].

6 Lahra MM, Enriquez RP. Australian Gonococcal Surveillance Program Annual Report 2016.

Communicable Diseases Intelligence. In press.

mailto:[email protected]


Glossary of Terms and Abbreviations

Term/Abbreviation Definition

Clinical specimen Clinical specimens are collected for diagnostic purposes. They include urine, wound, blood and other (e.g. genital or respiratory) specimens

Screen specimen Specimens taken for the purpose of screening for resistances

Confirming laboratory The laboratory which performs the necessary confirmatory tests for a CAR. Confirming laboratories:

Notify the originating laboratory of test outcomes through the usual communication channels, regardless of whether a CAR is confirmed or not

Enter data for each confirmed CAR into the CARAlert web-portal.

State and territory health authorities and the Public Health Laboratory Network have contributed to identification of confirming laboratories for the purpose of CARAlert.

Critical Antimicrobial Resistances (CARs)

CARs are resistance mechanisms, or profiles, known to be a serious threat to the effectiveness of last-line antimicrobial agents

Originating laboratory The laboratory to which a specimen is initially referred by a general practice or hospital for routine testing of isolates.

If an originating laboratory identifies an isolate that may have the potential to be a CAR, it:

Notifies the requesting clinician of the test results, and the suspected CAR

Sends the suspected isolate onto a confirming laboratory for confirmation.

AZI (HLR) Azithromycin non-susceptible, high level resistance (HLR, MIC > 256 mg/L) Neisseria gonorrhoeae

AZI (LLR) Azithromycin non-susceptible, low level resistance (LLR, MIC < 256 mg/L) Neisseria gonorrhoeae

CPE carbapenemase-producing Enterobacteriaceae

CPE+RMT carbapenemase- and ribosomal methyltransferase-producing Enterobacteriaceae

CTR NGON ceftriaxone non-susceptible Neisseria gonorrhoeae

CTR SALM ceftriaxone non-susceptible Salmonella species

DAP SAUR daptomycin non-susceptible Staphylococcus aureus

LNZ ENTE linezolid non-susceptible Enterococcus species

MDR MTB multidrug-resistant Mycobacterium tuberculosis

MDR SHIG multidrug-resistant Shigella species

MIC Minimum inhibitory concentration


Term/Abbreviation Definition

RMT ribosomal methyltransferase-producing Enterobacteriaceae

VAN SAUR vancomycin non-susceptible Staphylococcus aureus

CARAlert Six-monthly Report April 2017–September 2017 30

Level 5, 255 Elizabeth Street, Sydney NSW 2000 GPO Box 5480, Sydney NSW 20001

Phone: (02) 9126 3600 Fax: (02) 9126 3613

Email: [email protected] Website: www.safetyandquality.gov.au

Documents

CARAlert Summary Report - BMJ Quality & Safety · 4/1/2017 · The National Alert System for Critical Antimicrobial Resistances (CARAlert) was established by the Australian Commission