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Outbreak of Carbapenem-Resistant Enterobacteriaceae at a Long-Term Acute Care Hospital: Sustained Reductions in Transmission through Active Surveillance and Targeted Interventions

Part of: BARRY FARR AWARD RECIPIENTS

Published online by Cambridge University Press:  02 January 2015

Amit S. Chitnis ,
Pam S. Caruthers ,
Agam K. Rao ,
JoAnne Lamb ,
Robert Lurvey ,
Valery Beau De Rochars ,
Brandon Kitchel ,
Margarita Cancio ,
Thomas J. Török  and
Alice Y. Guh
...Show all authors
Amit S. Chitnis*
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia Office of Workforce and Career Development, Epidemic Intelligence Service, CDC, Atlanta, Georgia
Pam S. Caruthers
Affiliation:
Division of Infection Prevention, Kindred Hospital Bay Area-St. Petersburg, St. Petersburg, Florida
Agam K. Rao
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia Office of Workforce and Career Development, Epidemic Intelligence Service, CDC, Atlanta, Georgia
JoAnne Lamb
Affiliation:
Epidemiology Program, Disease Control Division, Pinellas County Health Department, St. Petersburg, Florida
Robert Lurvey
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
Valery Beau De Rochars
Affiliation:
Office of Workforce and Career Development, Epidemic Intelligence Service, CDC, Atlanta, Georgia Division of Disease Control, Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida
Brandon Kitchel
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
Margarita Cancio
Affiliation:
Division of Infection Prevention, Kindred Hospital Bay Area-St. Petersburg, St. Petersburg, Florida
Thomas J. Török
Affiliation:
Division of Disease Control, Bureau of Epidemiology, Florida Department of Health, Tallahassee, Florida Career Epidemiology Field Office Program, Office of Public Health Preparedness and Response, CDC, Atlanta, Georgia
Alice Y. Guh
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
Carolyn V. Gould
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
Matthew E. Wise
Affiliation:
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
*
1600 Clifton Road, MS A-24, Atlanta, GA 30333 (amit.chitnis@cdph.ca.gov)
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Abstract

Objective.

To describe a Klebsiella pneumoniae carbapenemase (KPC)–producing carbapenem-resistant Enterobacteriaceae (CRE) outbreak and interventions to prevent transmission.

Design, Setting, and Patients.

Epidemiologic investigation of a CRE outbreak among patients at a long-term acute care hospital (LTACH).

Methods.

Microbiology records at LTACH A from March 2009 through February 2011 were reviewed to identify CRE transmission cases and cases admitted with CRE. CRE bacteremia episodes were identified during March 2009–July 2011. Biweekly CRE prevalence surveys were conducted during July 2010–July 2011, and interventions to prevent transmission were implemented, including education and auditin? of staff and isolation and cohorting of CRE patients with dedicated nursing staff and shared medical equipment. Trends were evaluated using weighted linear or Poisson regression. CRE transmission cases were included in a case-control study to evaluate risk factors for acquisition. A real-time polymerase chain reaction assay was used to detect the blaKPC gene, and pulsed-field gel electrophoresis was performed to assess the genetic relatedness of isolates.

Results.

Ninety-nine CRE transmission cases, 16 admission cases (from 7 acute care hospitals), and 29 CRE bacteremia episodes were identified. Significant reductions were observed in CRE prevalence (49% vs 8%), percentage of patients screened with newly detected CRE (44% vs 0%), and CRE bacteremia episodes (2.5 vs 0.0 per 1,000 patient-days). Cases were more likely to have received β-lactams, have diabetes, and require mechanical ventilation. All tested isolates were KPC-producing K. pneumoniae, and nearly all isolates were genetically related.

Conclusion.

CRE transmission can be reduced in LTACHs through surveillance testing and targeted interventions. Sustainable reductions within and across healthcare facilities may require a regional public health approach.

Infect Control Hosp Epidemiol 2012;33(10):984-992

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 33 , Issue 10 , October 2012 , pp. 984 - 992
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

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References

1.Richet, HM, Mohammeed, J, McDonald, LC, Jarvis, WR. Building communications networks: international network for the study and prevention of emerging antimicrobial resistance. Emerg Infect Dis 2001;7:319–322.CrossRefGoogle Scholar
2.Pitout, JD, Laupland, KB. Extended spectrum β-lactamase-producing Enterobacteriaceae: an emerging public health concern. Lancet Infect Dis 2008;8:159–166.Google Scholar
3.Patel, G, Huprikar, S, Factor, SH, Jenkins, SG, Calfee, DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008;29:1099–1106.CrossRefGoogle ScholarPubMed
4.Schwaber, MJ, Klarfeld-Lidji, S, Navon-Venezia, S, Schwartz, D, Leavitt, A, Carmeli, Y. Predictors of carbapenem-resistant Klebsiella pneumoniae acquisition among hospitalized patients and effect of acquisition on mortality. Antimicrob Agents Chemother 2008;52:1028–1033.CrossRefGoogle ScholarPubMed
5.Queenan, AM, Bush, K. Carbapenemases: the versatile β-lacta-mases. Clin Microbiol Rev 2007;20:440–458.CrossRefGoogle Scholar
6.Woodford, N, Tierno, PM Jr, Young, K, et al.Outbreak of Klebsiella pneumoniae producing a new carbapenem-hydrolyzing class A β-latctamase, KPC-3, in a New York medical center. Antimicrob Agents Chemother 2004;48:4793–4799.CrossRefGoogle Scholar
7.Bratu, S, Landman, D, Haag, R, et al.Rapid spread of carbapenem-resistant Klebsiella pneumoniae in New York City: a new threat to our antibiotics armamentarium. Arch Intern Med 2005;165:1430–1435.CrossRefGoogle ScholarPubMed
8.Nadkarni, AS, Schliep, T, Khan, L, Zeana, CB. Cluster of bloodstream infections caused by KPC-2 carbapenemase-producing Klebsiella pneumoniae in Manhattan. Am J Infect Control 2009; 37:121–126.CrossRefGoogle ScholarPubMed
9.Munoz-Price, LS, De La Cuesta, C, Adams, S, et al.Successful eradication of a monocolonal strain of Klebsiella pneumonia during a K. pneumoniae carbapenemase-producing K. pneumoniae outbreak in a surgical intensive care unit in Miami, Florida. Infect Control Hosp Epidemiol 2010;31:1074–1077.CrossRefGoogle Scholar
10.Kontopoulou, K, Protonotariou, E, Vasilakos, K, et al.Hospital outbreak caused by Klebsiella pneumoniae producing KPC-2 β-lactamase resistant to Colistin. J Hosp Infect 2010;76:70–73.CrossRefGoogle ScholarPubMed
11.Marchaim, D, Chopra, T, Pogue, JM, et al.Outbreak of colistin-resistant, carbapenem-resistant Klebsiella pneumoniae in metropolitan Detroit, Michigan. Antimicrob Agents Chemother 2011;54:5099–5104.Google Scholar
12.Endimiani, A, Depasquale, JM, Forero, S, et al.Emergence of bla KPC-containing Klebsiella pneumoniae in a long-term acute care hospital: a new challenge to our healthcare system. J Antimicrob Chemother 2009;64:1102–1110.Google Scholar
13.Perez, F, Endimiani, A, Ray, AJ, et al.Carbapenem-resistant Aci-netobacter baumannii and Klebsiella pneumoniae across a hospital system: impact of post-acute care facilities on dissemination. J Antimicrob Chemother 2010;65:1807–1818.CrossRefGoogle ScholarPubMed
14.Won, SY, Munoz-Price, LS, Lolans, K, et al.Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2011;53:532–540.Google Scholar
15.Munoz-Price, LS, Hayden, MK, Lolans, K, et al.Successful control of an outbreak of Klebsiella pneumoniae carbapenemase-producing K. pneumoniae in a long-term acute care hospital. Infect Control Hosp Epidemiol 2010;31:341–347.CrossRefGoogle Scholar
16.Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy, http://www.medpac.gov/documents/mar11_entirereport.pdf. Published 2011. Accessed April 11, 2012.Google Scholar
17.Munoz-Price, LS. Long-term acute care hospitals. Clin Infect Dis 2009;49:438–443.Google Scholar
18.Centers for Disease Control and Prevention. Laboratory Protocol for Detection of Carbapenem-Resistant or Carbapenemase-Producing, Klebsiella Spp. and E. coli for Rectal Swabs, http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf. Accessed April 11, 2012.Google Scholar
19.Clinical and Laboratory and Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing: 18th Informational Supplement. CLSI document M100-S18. Wayne, PA: CLSI, 2008.Google Scholar
20.Centers for Disease Control and Prevention. Multiplex Real-Time PCR Detection of Klebsiella pneumoniae Carbapenemase (KPC) and New Delhi Metallo-β-lactamase (NDM-1). http://www.cdc.gov/HAI/pdfs/labSettings/KPC-NDM-protocol-2011.pdf. Accessed April 11, 2012.Google Scholar
21.Ribot, EM, Fair, MA, Gautom, R, et al.Standardization of pulsed-field gel electrophoresis protocols for the subtyping of Escherichia coli 0157:H7, Salmonella, and Shigella for PulseNet. Food-borne Pathog Dis 2006;3:59–67.Google Scholar
22.Schaberg, DR, Weinstein, RA, Stamm, WE. Epidemics of nosocomial urinary tract infection caused by multiply resistant gram-negative bacilli: epidemiology and control. J Infect Dis 1976;133:363–366.Google Scholar
23.Yoon, HJ, Choi, JY, Park, YS, et al.Outbreak of Serratia marcescens bacteriuria in a neurosurgical intensive care unit of a tertiary care teaching hospital: a clinical, epidemiologic, and laboratory perspective. Am J Infect Control 2005;33:595–601.CrossRefGoogle Scholar
24.Otter, JA, Yezli, S, French, GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol 2011;32:687–699.CrossRefGoogle ScholarPubMed
25.Centers for Disease Control and Prevention. Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR Morb Mortal Wkly Rep 2009;58:256–260.Google Scholar
26.Schwaber, MJ, Lev, B, Israeli, A, et al.Containment of a countrywide outbreak of carbapenem-resistant Klebsiella pneumonia in Israeli hospitals via a nationally implemented intervention. Clin Infect Dis 2011;52:848–852.CrossRefGoogle Scholar
27.Falgas, ME, Rafailidis, PI, Kofteridis, D, et al.Risk factors of carbapenem-resistant Klebsiella pneumoniae infections: a matched case-control study. J Antimicrob Chemother 2007;60:1124–1130.Google Scholar
28.Patel, N, Harrington, S, Dihmess, A, et al.Clinical epidemiology of carbapenem-intermediate or -resistant Enterobacteriaceae. J Antimicrob Chemother 2011;66:1600–1608.Google Scholar
29.Weintrob, AC, Roediger, MP, Barber, M, et al.Natural history of colonization with gram-negative multidrug-resistant organisms among hospitalized patients. Infect Control Hosp Epidemiol 2010;31:330–337.Google Scholar