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Maps as a Tool for Combating Antimicrobial Resistance

Posted By Shannon Harney, Friday, October 2, 2015
Updated: Friday, October 2, 2015
Antimicrobial resistance is a growing concern at the top of many agendas, including for CDC and the White House. Among the multidrug-resistant organisms of greatest concern, are carbapenem-resistant Enterobacteriaceae (CRE), which CDC classified at an “urgent threat level requiring urgent and aggressive action.”


To gain a better understanding of CRE in Tennessee, we described the geographic distribution of cases reported to the state-reportable disease surveillance system in 2014. Cases with carbapenem-resistant Enterobacter spp., Escherichia coli, or Klebsiella spp. were included. A total of 143 cases were identified for 2014, with one person testing positive for two different carbapenem-resistant genera of bacteria.

For reference, below is a map depicting the major cities in Tennessee by population size.

Figure 1. Major Cities in Tennessee
Marked geographic differences were observed in the distribution of cases by genera, with possible clustering of Klebsiella spp. cases in the northeast and Enterobacter spp. cases in the Memphis and western Tennessee areas.
Figure 2. Cases of CRE by County of Residence, By Genera
Cases were further mapped with respect to the county population size to calculate rates, which indicated the greatest burden of CRE was in two counties in western Tennessee, outside of the Memphis metropolitan area.
Figure 3. Annual Incidence Rate by County of Residence, All Genera
The cases also were depicted according to the healthcare facility laboratory responsible for identifying the CRE, which highlighted facilities in western and northeastern Tennessee, as well as in the Chattanooga area.
Figure 4. Cases of CRE by Healthcare Facility Laboratory, All Genera
Based on this information, one of the healthcare facilities with a large case number was selected for further investigation. The facility provided a line list of cases for the 2014 period, specifying if each case was an inpatient (including emergency department patients) or outpatient, and if the cases were nursing home residents. Interfacility transmission is believed to be a key contributor to the spread of multidrug-resistant organisms in healthcare facilities, and therefore investigating the source of each case may be helpful for intervention. Nursing home residents comprised 43% of the inpatient/emergency department patients, and 55% of outpatients tested, suggesting patients from nursing homes may be important to interfacility transmission.
Figure 5. Cases of CRE by Admission Status and Nursing Home Status, Hospital A
To identify which nursing homes could be targeted for enhanced interfacility communication and infection control practices, cases were counted and ordered by nursing home of residence (de-identified).
Figure 6. Cases of CRE by Nursing Home, Hospital A

These two figures highlight the importance of understanding the connectedness of facilities when caring for patients, and of facilities in a region working together to prevent transmission. Furthermore, the collaboration between healthcare providers and public health can enhance our understanding of emerging infections and guide intervention efforts.

Our next steps will include sharing these data with the broader healthcare audience for improved situational awareness among clinicians and public health professionals. These data, along with the pending analysis of the 2015 data, will be used as the foundation to address CRE at a regional level.

Shannon Harney, MPH is a CDC/CSTE Applied Epidemiology fellow in Communicable and Environmental Diseases and Emergency Preparedness for the Healthcare Associated Infections Program at the Tennessee Department of Health. For more information on antibiotic resistance activities, read Marion Kainer and Jeffrey Engel’s article “CSTE Supports Antibiotic Resistance Stewardship.” The Applied Epidemiology Fellowship application opens October 20, 2015. Apply online by January 13, 2016. Prospective host sites may submit an application until October 16, 2015 to host a fellow.

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