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2019 HSR&D/QUERI National Conference Abstract

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1108 — Impact of Varying Federal Definitions on Carbapenem-Resistant Enterobacteriaceae Prevalence in Veterans with Spinal Cord Injury

Lead/Presenter: Margaret Fitzpatrick,  COIN - Hines
All Authors: Fitzpatrick MA (Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL; Loyola University Chicago Stritch School of Medicine, Chicago, IL), Suda KJ (Center of Innovation for Complex Chronic Healthcare (CINCCH), , Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA; University of Illinois-Chicago, College of Pharmacy, Department of Pharmacy, Systems, Outcomes, and Policy, Chicago, Illinois, USA ) Jones M (Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA; Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA) Burns SP (Spinal Cord Injury Service, Department of Veterans Affairs, VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Department of Rehabilitation Medicine, Seattle, WA, USA) Poggensee L (Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA) Ramanathan S (Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA) Evans M (Department of Veterans Affairs, Lexington VA Medical Center, Lexington, KY, USA; MRSA/MDRO Program Office, National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, OH, USA; University of Kentucky School of Medicine, Department of Medicine, Division of Infectious Diseases, Lexington, KY, USA) Evans CT (Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA; Northwestern University, Department of Preventive Medicine and Center for Health Care Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Chicago, IL, USA)

Objectives:
Carbapenem-resistant Enterobacteriaceae (CRE) are one of the most difficult multi-drug resistant organisms (MDROs) to treat. Both VA and the Centers for Disease Control and Prevention (CDC) have established guidelines for CRE surveillance and infection prevention practices within healthcare facilities, with recent updates to both guidelines. Accurate and easily applied definitions are critical to identify CRE. Patients with spinal cord injury (SCI) have an increased risk for MDROs, including CRE. This study describes CRE and associated characteristics in Veterans with SCI per CDC and VA definitions.

Methods:
Retrospective cohort of Veterans with SCI and > 1 culture with Escherichia coli, Klebsiella, and/or Enterobacter between 2012-2013. Antibiotic susceptibility criteria of pre-2015 (CDC1) and post-2015 (CDC2) CDC definitions and pre-2017 (VA1) and post-2017 (VA2) VA definitions were used to identify CRE. CRE prevalence and facility characteristics are described for isolates meeting each definition, and agreement among definitions was assessed with Cohen's kappa.

Results:
21,514 isolates cultured from 6,974 Veterans were reviewed; 423 (2%) isolates met any CRE definition. Although agreement among definitions was high (?range = 0.82-0.93), definitions including ertapenem resistance led to higher CRE prevalence (VA1 = 1.7% and CDC2 = 1.9% vs. VA2 = 1.4% and CDC1 = 1.5%). 44/142 VA facilities had > 1 CRE defined by VA2; 10 facilities accounted for 60% of CRE. VA2 led to a lower overall prevalence of CRE compared to VA1, while the newer CDC2 definition led to a higher number of CRE identified compared to CDC1. Almost all CRE was isolated from high complexity, urban facilities; the South had the greatest proportion of CRE isolates.

Implications:
Varying federal definitions give different CRE frequencies among a high-risk population. Definitions including ertapenem resistance resulted in greater CRE prevalence, but may overemphasize less significant non-carbapenemase producing isolates. Thus, both federal definitions now highlight the importance of carbapenemase testing.

Impacts:
Because some states mandate CRE reporting, the CDC definitions are also used by some VA facilities. Depending on the definition used, more or less isolates will be identified as CRE. This can significantly affect local facility and national surveillance, allocation of infection prevention resources, and the ability to implement prevention strategies to the highest risk patient populations.