Public health priority: Routine
PHU response time: HPNSW will enter confirmed case information from non-ELR laboratories onto NCIMS within 5 working days of notification. Where public health units (PHUs) become aware of a CPE cluster outside of a public health care facility, they should report to the Communicable Disease Branch urgently.
Case management: Primarily the responsibility of the treating doctor and facility infection control team according to Surveillance and Response Guideline for Carbapenemase-producing Enterobacterales (CPE) in NSW Health Facilities.
Contact management: Responsibility of the facility's infection prevention and control team. Community contacts are not generally at high risk of acquiring CPE.
Routine.
HPNSW will enter confirmed case information from non-ELR laboratories onto NCIMS within 5 working days of notification. Where public health units (PHUs) become aware of a CPE cluster outside of a public health care facility, they should report to the Communicable Disease Branch urgently.
Primarily the responsibility of the treating doctor and facility infection control team according to Surveillance and Response Guideline for Carbapenemase-producing Enterobacterales (CPE) in NSW Health Facilities.
Responsibility of the facility's infection prevention and control team. Community contacts are not generally at high risk of acquiring CPE.
Enterobacterales are an order of Gram-negative bacilli that occur naturally in the gastrointestinal tract. They can spread outside the gastrointestinal tract and cause serious infections such as bacteraemia, pneumonia, urinary tract and wound infections.
Carbapenemase-producing Enterobacterales (CPE) are resistant to carbapenem antibiotics by means of an acquired carbapenemase gene. CPE produce carbapenemase enzymes which hydrolyse carbapenems (as well as other β-lactamases, such as penicillins and cephalosporins). CPE infections are therefore often difficult to treat.
There are multiple mechanisms by which Enterobacterales can acquire carbapenemase resistance. Some acquired beta-lactamases (e.g., ESBL and AmpC enzymes) can result in carbapenem-resistant Enterobacterales (CRE) in certain circumstances. Not all acquired carbapenemases result in carbapenem resistance. Thus, CRE are commonly CPE, and CPE are commonly CRE, but neither group is entirely a subset of the other.
There are a number of different types of carbapenemases found in CPE; the five most important globally are:
Each of these has been identified in patients in Australia.
CPE colonisation refers to the presence of the bacteria on a body surface without signs of invasive infection. The primary site of CPE colonisation is usually the lower gastrointestinal tract. Other potential sites for colonisation include the urinary system.
CPE infection refers to the invasion of a person’s bodily tissues by the bacteria and their subsequent multiplication, typically resulting in disease-causing symptoms and the reaction of host tissues to these organisms and the toxins they produce.
Patients who are colonised with, or have clinical infections with CPE, can transmit CPE to other patients in health care settings via direct or indirect contact.
Direct contact: patient-to-patient contact (with contamination from a colonised/infected site.
Indirect contact: could occur via a health care worker whose hands have been contaminated following contact with a patient with CPE, or via a contaminated environmental surface (including basin or toilet) and/or contaminated shared equipment.
Some CPE-positive patients are more likely to transmit CPE than others, including those with:
The natural history and duration of CPE carriage is variable and the incubation period is unclear. In the event that cases need to be interviewed, risk factors for CPE acquisition over the prior 12 months should be initially identified. In some cases, it may be necessary to identify risk factors that predate this.
Colonisation beyond 12 months is well documented. It is unclear whether carriage varies with the nature of the infection, the organism or resistance type.
In Australia, the major risk factor for acquiring CPE is thought to be overseas travel, especially when medical care in an overseas health care facility is involved. Local transmission in health care settings also occurs. Internationally, risk factors associated with an increased risk of CPE acquisition include:
The proliferation of CPE represents a rising public health threat in Australia.
CPE are an infection risk for the following reasons:
Routine prevention activities include:
See Surveillance and Response Guideline for Carbapenemase-producing Enterobacterales (CPE) in NSW Health Facilities for further information.
To monitor the epidemiology of CPE to inform prevention strategies and support control strategies.
CPE infection or colonisation is a laboratory-notifiable condition under Schedule 1, Category 3 of the NSW Public Health Act 2010.
CPE is notifiable by laboratories to NSW Health on detection of a carbapenemase gene in a species of Enterobacterales isolated from a clinical or screening specimen. The laboratory that identifies the relevant gene is responsible for notification.
The laboratory test result should be sent via Electronic Laboratory Reporting (ELR) to NCIMS, or via secure fax or secure file transfer, to NSW Health by the testing laboratory.
HPNSW should enter fax or secure file transfer notifications from non-ELR laboratories into NCIMS within 5 days of notification.
A confirmed case is a person with a species of Enterobacterales isolated from clinical or screening specimens (infection or colonisation) where a carbapenemase gene is detected in a sample or isolate, irrespective of phenotypic susceptibility.
Note: Only molecular test results for confirmed cases are to be notified.
See Surveillance and Response Guideline for Carbapenemase-producing Enterobacterales (CPE) in NSW Health Facilities.
Inform the Communicable Disease Branch (CDB) of any emerging clusters of cases outside of a NSW Health Facility urgently. See section 11. Special situations below.
Investigation of cases of CPE is the responsibility of the LHD facility's infection prevention and control staff. Public health units may assist in the investigation and management of an outbreak.
The Clinical Excellence Commission (CEC) is the lead agency for the state-wide response to CPE in public healthcare facilities in NSW.
PHUs will generally lead an investigation into local community transmission. See section 11. Special situations below.
Responsibility of the treating doctor, who should seek specialist infectious disease and infection control advice.
There is currently no recognised method of decolonisation for CPE.
See Surveillance and Response Guideline for Carbapenemase-producing Enterobacterales (CPE) in NSW Health Facilities and and CPE factsheet.
The management of CPE contacts is generally the responsibility of the LHD facility's infection prevention and control staff.
See Surveillance and Response Guideline for Carbapenemase-producing Enterobacterales (CPE) in NSW Health Facilities, and CPE factsheet.
In the event of a potential cluster (generally 2 or more cases that could feasibly be linked by time or place) in a healthcare facility, the CEC should be consulted by the local infection control team. LHDs may seek PHU advice in the investigation of clusters.
Where HPNSW becomes aware of a CPE cluster outside of a healthcare facility, they will consult with the relevant PHU. PHUs should report a CPE cluster occurring outside of a public health care facility to CDB urgently. In this instance, HPNSW in partnership with the PHU, may convene an Incident Management Team (IMT). PHUs may need to interview cases to identify key risk factors for CPE colonisation or infection over at least the prior 12 months. Due to the unknown nature of the incubation period of CPE, whole genome sequencing (WGS) may assist in determining if cases are linked.