Why did the Commission establish CARAlert?
The Commission established CARAlert to provide system reporting to complement the existing processes for confirming CARs at an individual patient level. The objective was also to develop a system to provide more timely advice to state and territory health authorities on the occurrence of CARs in their hospitals, and nationally.
While some data on CARs are captured through existing surveillance programs, the CARAlert system is the first nationally coordinated system to support communication of information on confirmed CARs and potential CAR outbreaks, as close as possible to the time of confirmation.
Early advice about potential outbreaks offers the best opportunity to take infection prevention and control measures to minimise patient morbidity.
How does CARAlert work?
The CARAlert system is based on routine processes and practices used by pathology laboratories for identifying a potential critically resistant isolate and referring that isolate to a laboratory with the capacity to confirm the CAR.
Public and private pathology laboratories that have the capacity to confirm CARs were identified via consultation with state and territory health authorities, the Public Health Laboratory Network and the Australian Group on Antimicrobial Resistance. These confirming laboratories have agreed to report confirmed CARs to CARAlert via a specially developed secure web portal, following their routine processes.
The routine reporting practice is for the confirming laboratory to advise the originating laboratory of the result. The originating laboratory subsequently notifies the clinician who referred the specimen that a CAR has been confirmed so that they may take appropriate clinical action, if required.
The CARAlert system ensures that deidentified information on confirmed CARs is also reported to state and territory health authorities and the Australian Government Department of Health, on a weekly basis. In addition, designated staff from each state and territory have secure access to information on the CARs reported for their jurisdiction.
What information is provided to health authorities?
Information that could be used to identify a patient is not entered into CARAlert.
All health authorities are provided with information regarding the state or territory where the CAR isolate originated, the confirmation date and whether the patient who had the infection was in hospital, or in the community, at the time the specimen was collected.
State and territory health authorities are able to access their own jurisdictional data for public hospitals where a patient who had the infection was being cared for at the time the specimen was collected. Designated staff have the capacity to access this information at any time of the day, all days of the week. This enables them to monitor the geographic distribution of CARs and to liaise with hospitals as appropriate, to confirm infection control action has been taken in the event of an outbreak.
Why is it important to monitor CARs?
Antimicrobial resistance is a serious health threat. The loss of effective antimicrobials through increased antimicrobial resistance will compromise Australia’s ability to fight infectious diseases and manage infectious complications common in vulnerable patients such as those undergoing chemotherapy for cancer, dialysis for renal failure, and surgery. Documenting CARs and providing the information about their occurrence, in a timely manner, to those who have the capacity to intervene ensures that outbreaks can be contained and the efficacy of last-line antimicrobials is maintained for as long as possible.
Is confirmation of a CAR important for treatment of an infected patient?
No. Confirmation of a CAR may not occur until after the infected patient has been treated and/or discharged from hospital. The occurrence of possible CARs in an individual patient is communicated to treating clinicians before a CAR is confirmed, so that appropriate treatment and/or infection control measures can be initiated.
The role of CARAlert is to monitor trends in the development of antimicrobial resistance in Australia in near real time, for timely identification of clusters of infections and outbreaks, and for implementation and review of infection control strategies in the event of an outbreak.
The laboratory that performs the initial antimicrobial test (the originating laboratory) will, in accordance with usual processes, have advised the treating doctor, and infection control staff where appropriate, of the antimicrobial susceptibility profile of the isolate to enable timely and appropriate treatment to be prescribed for the infected patient.
Are results from private hospitals included in CARAlert?
Yes. The laboratories that provide pathology services to private hospitals issue reports on the confirmation of CARs in the same way as occurs for public hospitals.
What has been learned from reports of confirmed CARs since CARAlert commenced?
Since December 2016 azithromycin non-susceptible Neisseria gonorrhoeae and carbapenemase-producing Enterobacterales (CPE), either alone or in combination with ribosomal methyltransferases, have been the most frequently reported CARs.
The majority of CARs are reported from the three most populous states – New South Wales, Victoria and Queensland.
The IMP-type carbapenemase (mainly IMP-4) is now endemic on the eastern seaboard of Australia in several species of Enterobacterales, particularly Enterobacter cloacae complex; this means that it is difficult to eliminate, and rigorous control measures are essential. There is no evidence that other carbapenemases have become established in Australia to date.
The number of CPE reported, and the endemicity of IMP-type carbapenemase, highlight the importance of implementing actions outlined within the Commission’s Recommendations for the control of carbapenemase-producing Enterobacterales: A guide for acute health facilities.
The frequency of reporting of azithromycin non-susceptible Neisseria gonorrhoeae has occurred in the context of a significant increase in notifications of N. gonorrhoeae and there have been sporadic cases of ceftriaxone-nonsusceptible or azithromycin-nonsusceptible (high-level resistance) N. gonorrhoeae.
There was a large increase in the number of reports of multidrug-resistant Shigella in 2019. Infections caused by Shigella species are generally food-borne or sexually transmitted and are notifiable nationally. In 2019, New South Wales and Victoria reported increases in MDR Shigella amongst men who have sex with men. In response to the increase, both states issued public health alerts and implemented changes to management recommendations for shigellosis as part of their prevention and control strategies.
The majority of CARs reported from aged care homes in 2019 were daptomycin-nonsusceptible Staphylococcus aureus. Skin and soft tissue infections are commonly caused by S. aureus, which is spread by contact with contaminated surfaces and hands of healthcare workers. It can also be spread from person to person, especially in group living situations such as aged care homes, when people with skin infections may inadvertently share bed linen, towels or clothing. There is a risk of transmission of this CAR within aged care homes, and in hospitals due to the frequent movement of aged care home residents between these two settings.
CARAlert data undergo regular epidemiological analysis; statistical methods for evaluating temporal and spatial trends will be implemented as the data collection matures.
How many CARs have been reported since CARAlert commenced?
Since its inception, over 6,500 CARs have been reported through the CARAlert system.
Have any outbreaks of CARs been detected since CARAlert commenced in March 2016?
A number of CAR outbreaks and periodic increases have been identified since the commencement of CARAlert including:
- An outbreak of OXA-48 producing Escherichia coli ST38 in Queensland – 80 cases were reported between May 2017 and July 2017
- A cluster of IMP-producing Enterobacterales in one institution in New South Wales – detected in the 0-4 year age group between late December 2017 and January 2018
- A three-fold increase in NDM-type CPE from South Australia in 2019 compared to 2018
- An increase in NDM- and IMP-type CPE in New South Wales and Victoria in 2019 compared to 2018
- An increase in reports of multidrug-resistant Shigella species in 2019 compared to 2018, with sharp increases in Queensland (up 261%), Victoria (up 246%) and New South Wales (up 142%).
All of these have been responded to locally by the relevant hospital and/or state or sterritory health authority.
Which types of health service organisations care for patients with CARs?
There are a range of organisations that provide care for patients with CARs including public and private hospitals, community-based health services and aged care homes.