5 results
Concurrent transmission of multiple carbapenemases in a long-term acute-care hospital
- Danielle A. Rankin, Maroya Spalding Walters, Luz Caicedo, Paige Gable, Heather A. Moulton-Meissner, Allison Chan, Albert Burks, Kendra Edwards, Gillian McAllister, Alyssa Kent, Alison Laufer Halpin, Christina Moore, Tracy McLemore, Linda Thomas, Nychie Q. Dotson, Alvina K. Chu
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 45 / Issue 3 / March 2024
- Published online by Cambridge University Press:
- 10 January 2024, pp. 292-301
- Print publication:
- March 2024
-
- Article
-
- You have access Access
- Open access
- HTML
- Export citation
-
Objective:
We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying blaVIM (VIM-CRPA) and Enterobacterales carrying blaKPC (KPC-CRE) at a long-term acute-care hospital (LTACH A).
Methods:We defined an incident case as the first detection of blaKPC or blaVIM from a patient’s clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing.
Results:From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had blaKPC, 11 had blaVIM, and 7 had blaVIM and blaKPC. Also, blaKPC were identified from 7 Enterobacterales, and all blaVIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates.
Conclusions:Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. Epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of VIM-CRPA and KPC-CRE and to the transfer of carbapenemase genes across different bacteria species and strains. Improved infection control, including interventions that minimized potential spread from wastewater premise plumbing, stopped transmission.
Evaluation of Patient Risk Factors for Carbapenemase-Producing Organism Colonization
- Carolyn Stover, Allison Chan, Snigdha Vallabhaneni, Allison Brown, Amelia Keaton, Alicia Shugart, Nychie Dotson, Sebastian Arenas, Marion Kainer, Maroya Walters
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s229-s230
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Carbapenemase-producing organisms (CPOs) are a growing antibiotic resistance threat. Colonization screening can be used to identify asymptomatically colonized individuals for implementation of transmission-based precautions. Identifying high-risk patients and settings to prioritize screening recommendations can preserve facility resources. To inform screening recommendations, we analyzed CPO admission screens and screening conducted on point-prevalence surveys (PPSs) performed through the Antibiotic Resistance Laboratory Network’s Southeast Regional Laboratory (SE AR Lab Network). Methods: During 2017–2019, the SE AR Lab Network collected data via a REDCap survey for a subset of CPO screens on a limited set of easily determined patient risk factors. Rectal swabs were collected and tested with the Cepheid Carba-R. Specimens collected within 2 days of admission were classified as admission screening and the remainder were classified as PPS. Index cases were excluded from analyses. Odd ratios (ORs) and 95% confidence intervals were calculated, and a value of 0.1 was used for cells with a value of zero. Results: In total, 520 screens were conducted, which included 366 admission screens at 2 facilities and 154 screens from 27 PPSs at 8 facilities. CPOs were detected in 14 (2.7%) screens, including in 10 (2.7%) admission screens and in 4 (2.6%) contacts during PPSs; carbapenemases detected were Klebsiella pneumoniae carbapenemase (KPC) (n = 12), New Delhi Metallo-β-lactamase (NDM) (n = 1) and Verona Integron-Encoded Metallo-β-lactamase (VIM) (n = 1). One long-term acute care hospital (LTACH) performed universal admission screening, which accounted for 96% of admission screens and all 10 CPOs detected by admission screening. Mechanical ventilation (OR, 5.0; 95% CI, 1.4–18.0) and the presence of a tracheostomy (OR, 5.4; 95% CI, 1.5–19.4) were associated with a positive admission screen. Moreover, 8 facilities conducted PPSs: 4 acute care hospitals, 2 long-term acute care hospitals, and 2 nursing homes. CPO prevalence in long-term acute care hospitals was 4.8% (2 of 42), 2.4% (1 of 41) in acute care hospitals, and 1.5% (1 of 69) in nursing homes. Requiring assistance with bathing (OR, 4.8; 95% CI, 1.6–8.0) and stool incontinence (OR, 16.6; 95% CI, 13.4–19.8) were associated with a positive screen on PPSs. All 7 roommates of known cases tested negative for CPO colonization. Conclusions: Findings suggest that patients with certain easily assessed characteristics, such as mechanical ventilation, tracheostomy, or stool incontinence or who require bathing assistance, may be associated with CPO positivity during screening. Further data collection and analysis of such risk factors may provide insight for the development of more targeted admission and contact screening strategies.
Funding: None
Disclosures: None
Trimethoprim-Sulfamethoxazole Resistance Patterns Among Methicillin-Resistant Staphylococcus aureus, 2012–2018
- D. Cal Ham, Lucy Fike, Tara Fulton, Nychie Dotson, Rebecca Perlmutter, Ericka Kalp, Joseph Lutgring, Amy Gargis, Alison Laufer-Halpin, Alexander Kallen, Maroya Walters
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s418
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Trimethoprim-sulfamethoxazole is commonly used for the treatment of noninvasive methicillin-resistant Staphylococcus aureus (MRSA) infections. Following a report from 2 facilities of increased trimethoprim-sulfamethoxazole resistance among MRSA infections, we assessed changes in resistance nationally and by state. Methods: We reviewed antibiotic susceptibility testing (AST) data for trimethoprim-sulfamethoxazole among S. aureus isolates associated with surgical site infections (SSIs), central-line–associated bloodstream infections (CLABSIs), and catheter-associated urinary tract infections (CAUTIs) from acute-care hospitals reported to the NHSN Device and Procedure Module from 2012 to 2018. We compared the pooled mean percentage of isolates nonsusceptible to trimethoprim-sulfamethoxazole in 2012 and 2018, stratified by MRSA and methicillin-sensitive Staphylococcus aureus (MSSA). Among MRSA isolates, we compared the percentage nonsusceptible to trimethoprim-sulfamethoxazole by healthcare-associated infection (HAI) type and state in 2012 and 2018. States with ≥20 MRSA isolates with AST reported each year were included in the state-level analysis. Results: Overall, 36,587 MRSA isolates and 46,824 MSSA isolates were reported from 2012 to 2018. Moreover, >80% of MRSA and MSSA isolates had trimethoprim-sulfamethoxazole AST reported each year. Nationally, the percentage of trimethoprim-sulfamethoxazole nonsusceptible among MRSA isolates was 3.9% in 2012 compared to 6.5% in 2018 (P < .001), but it was unchanged among MSSA isolates during the same period (1.1% in 2012 vs 1.4% in 2018; P = .08). Among MRSA surgical site infections (SSIs), the proportion of trimethoprim-sulfamethoxazole nonsusceptible isolates was 3.1% in 2012 versus 6.1% in 2018 (P < .001) but did not change significantly for CLABSIs or CAUTIs (Fig. 1). Among the 32 states that met the inclusion criteria, there were no significant decreases, whereas 4 (12.5%) showed significant increases in the percentage of MRSA that were trimethoprim-sulfamethoxazole nonsusceptible in 2018 compared to 2012: New Jersey (2.4% in 2012 vs 19.3% in 2018; P <.001); Florida (9.1% in 2012 vs 22.4% in 2018; P < .001); Maryland (0.0% in 2012 vs 10.9% in 2018; P < .01); and Pennsylvania (1.7% in 2012 vs 6.5% in 2018; P < .001). Conclusions: Nationally, there was a modest but significant increase in the percentage of MRSA HAI isolates nonsusceptible to trimethoprim-sulfamethoxazole in 2018 compared to 2012; however, 3 of 4 states with significant increases in nonsusceptibility had substantial, potentially clinically relevant increases (>10%). Ongoing characterization of MRSA isolates from Florida and New Jersey may provide insight into the underlying cause of these shifting patterns in trimethoprim-sulfamethoxazole resistance among MRSA. Healthcare personnel should select appropriate antibiotic regimens based on local resistance patterns, should monitor patients for treatment failure, and should report changes in resistance to the appropriate public health department.
Funding: None
Disclosures: None
Regional Public Health Response to Emerging Carbapenamase-Producing Organisms in Central Florida, 2019
- Danielle A. Rankin, Justine M. Celli, Danielle L. Walden, Allison Chan, Albert Burks, Nicole Castro, Sasha Nelson, Marion A. Kainer, Alvina K. Chu, Nychie Q. Dotson, Maroya S. Walters
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s50
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Detection of unusual carbapenemase-producing organisms (CPOs) in a healthcare facility may signify broader regional spread. During investigation of a VIM-producing Pseudomonas aeruginosa (VIM-CRPA) outbreak in a long-term acute-care hospital in central Florida, enhanced surveillance identified VIM-CRPA from multiple facilities, denoting potential regional emergence. We evaluated infection control and performed screening for CPOs in skilled nursing facilities (SNFs) across the region to identify potential CPO reservoirs and improve practices. Methods: All SNFs in 2 central Florida counties were offered a facility-wide point-prevalence survey (PPS) for CPOs and a nonregulatory infection control consultation. PPSs were conducted using a PCR-based screening method; specimens with a carbapenemase gene detected were cultured to identify the organisms. Infection control assessments focused on direct observations of hand hygiene (HH), environmental cleaning, and the sink splash zone. Thoroughness of environmental cleaning was evaluated using fluorescent markers applied to 6 standardized high-touch surfaces in at least 2 rooms per facility. Results: Overall, 21 (48%) SNFs in the 2-county region participated; 18 conducted PPS. Bed size ranged from 40 to 391, 5 (24%) facilities were ventilator-capable SNFs (vSNFs), and 12 had short-stay inpatient rehabilitation units. Of 1,338 residents approached, 649 agreed to rectal screening, and 14 (2.2%) carried CPOs. CPO-colonized residents were from the ventilator-capable units of 3 vSNFs (KPC-CRE=7; KPC-CRPA=1) and from short-stay units of 2 additional facilities (VIM-CRPA, n = 5; KPC-CRE, n = 1). Among the 5 facilities where CPO colonization was identified, the prevalence ranged from 1.1% in a short-stay unit to 16.1% in a ventilator unit. All facilities had access to soap and water in resident bathrooms; 14 (67%) had alcohol-based hand rubs accessible. Overall, mean facility HH adherence was 52% (range, 37%–66%; mean observations per facility = 106) (Fig. 1). We observed the use of non–EPA-registered disinfectants and cross contamination from dirty to clean areas during environmental cleaning; the overall surface cleaning rate was 46% (n = 178 rooms); only 1 room had all 6 markers removed. Resident supplies were frequently stored in the sink splash zone. Conclusions: A regional assessment conducted in response to emergence of VIM-CRPA identified a relatively low CPO prevalence at participating SNFs; CPOs were primarily identified in vSNFs and among short-stay residents. Across facilities, we observed low adherence to core infection control practices that could facilitate spread of CPOs and other resistant organisms. In this region, targeting ventilator and short-stay units of SNFs for surveillance and infection control efforts may have the greatest prevention impact.
Funding: None
Disclosures: None
Harnessing Next-Generation Sequence Technology to Elucidate Healthcare-Associated Infection Transmission Pathways
- Paige Gable, Gillian McAllister, Erisa Sula, Danielle A. Rankin, Erin Breaker, Jonathan Daniels, Monica Y. Chan, Nychie Dotson, Maroya Walters, Alison Laufer Halpin
-
- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, p. s66
- Print publication:
- October 2020
-
- Article
-
- You have access Access
- Export citation
-
Background: Carbapenem-resistant Enterobacteriaceae (CRE) are multidrug-resistant bacteria that persist in healthcare environments, particularly in wastewater reservoirs where they can pose risks for patients. Healthcare-associated outbreaks of carbapenemase-producing (CP) CRE can be propagated via a single bacterial strain and/or mobile genetic element (MGEs) harboring a carbapenemase gene. Unlike chromosomally encoded carbapenemases, CP-MGEs can rapidly facilitate the spread of these carbapenemase genes across bacterial strains. From July 2017 to December 2018, the Florida Department of Health in Orange County investigated an outbreak of patients colonized with various bacterial genera of CP-CRE carrying the Klebsiella pneumoniae carbapenemase gene (blaKPC), indicating a potential MGE reservoir. WGS was performed to identify transmission pathways and linked cases, beyond what traditional testing provides. Methods: We selected a subset of blaKPC-harboring isolates for WGS on short- and long-read platforms (MiSeq, PacBio, MinION) to achieve high quality, complete genome and plasmid assemblies. Laboratory, clinical, and epidemiological data were combined to identify possible transmission events, common sources, and common MGEs. Results: Eleven clinical isolates from 5 genera (Citrobacter, Enterobacter, Klebsiella, Morganella, Providencia, and Serratia), and 10 environmental isolates collected from the pharmacy and medication room, ICU, and patient rooms and comprising 4 genera (Citrobacter, Enterobacter, Klebsiella, and Serratia) underwent WGS. Although short-read WGS elucidated additional subsets of closely related strains, high genomic diversity was also observed within some species: Citrobacter freundii: 13,483 single-nucleotide variants (SNVs), 67% core genome; Enterobacter spp: 3–18,563 SNVs; 34%; and K. pneumoniae: 8–18,460 SNVs, 80%. Further analysis using long-read hybrid assemblies revealed 2 unique blaKPC-harboring plasmids. The first plasmid, pDHQP20145-KPC3 (50 kb), contained the blaKPC-3 gene and was detected in both patient and environmental isolates across 3 of the 5 sequenced genera. The second plasmid, pDHQP201745-KPC2 (180 kb), contained the blaKPC-2 gene, and was found across 2 CP-CRE genera isolated from both patients and the environment, including isolates from the medication room sink drain and a patient who received compounded oral medications. Conclusion: WGS identified 2 blaKPC-harboring plasmids, including pDHQP20145-KPC3, which was found across 3 genera of CP-CRE isolated from patients and the environment, supporting prolonged transmission of KPC-producing CRE in this facility, and a CP-MGE driving transmission. The rapid spread of emerging, potentially mobile, antimicrobial resistance has increased our need to further explore the genomic environment of promiscuous MGEs. WGS can contribute to infection control beyond traditional subtyping methods, such as pulsed-field gel electrophoresis (PFGE), as MGEs increasingly represent an important driver of transmission.
Funding: None
Disclosures: None