eccmid 2014: outbreak of colistin-resistant klebsiella pneumonia carbapenemase (kpc) -producing...
Post on 09-Aug-2015
132 Views
Preview:
TRANSCRIPT
Outbreak of colistin-resistant Klebsiella pneumonia Carbapenemase (KPC) -producing Klebsiella pneumonia in the Netherlands, with
inter-institutional spread
Veronica Weterings1, Esther Weterings1, Erwin Verkade1, Desiree van Stenis2, Elianne Thewessen2, Jan Kluytmans1,3
1 Amphia hospital, Breda2 Riethorst Stromenlanden, Geertruidenberg3 VU university medical center, AmsterdamThe Netherlands
Occurrence of carbapenemase-producingEnterobacteriaceae (CPE) in the Netherlands1
Overall situation CPE
1 Glasner C et al, the European Survey on Carbapenemase-Producing
Enterobacteriaceae (EuSCAPE) working group. Carbapenemase-producing
Enterobacteriaceae in Europe: a survey among national experts from 39 countries,
February 2013 . Euro Surveill. 2013;18(28):pii=20525.
National guideline for Highly Resistant Micro-Organisms (HRMO):
• All patients who have been treated in foreign hospitals are screened on admission
• Pre-emptive contact isolation:o single patient roomo gown and gloves when direct contact
with patient
Nosocomial transmission
Transfer Index patient Dutch hospital
24/6/2013
Jun AugJul Sept - Nov
Contact isolation
1
hospital
Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin
Nosocomial transmission
Transfer Index patient Dutch hospital
24/6/2013
Jun AugJul Sept - Nov
Contact isolation
1
5/7/2013
Second patient; pleural fluid
2
24/6/2013 - 5/7/2013
Outbreak Management Team (OMT)
Strict isolation
Contact tracing
hospital
Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin
Nosocomial transmission
Transfer Index patient Dutch hospital
24/6/2013
Jun AugJul Sept - Nov
Contact isolation
1
5/7/2013
Second patient; pleural fluid
2
24/6/2013 - 5/7/2013
Outbreak Management Team (OMT)
Strict isolation
Contact tracing
Index patient: NHPatient 2: home
5/8/2013
7/11/2013
Third patient; Rectal swab
3
7/11/2013
6/7/2013 - 5/8/2013
hospital
• HRMO• Transmission despite
contact isolationKlebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin
110
109
111 113
107108
112
Transmission nursing home
1
Transfer of index patient to nursing home
Elevator
Shared area
Jun AugJul Sept Oct Nov Dec
Contact isolation:- Single patient room + private sanitary- Contact precautions during care moments- No restrictions
110
109
111 113
107108
112
Transmission nursing home
1
3
Admission patient 3
‘use gowns of room 113’ shared storage of PPE
Elevator
Shared area
Jun AugJul Sept Oct Nov Dec
110
109
111 113
107108
112
Transmission nursing home
1Elevator
Jun AugJul Sept Oct Nov Dec
3
3
OMT NH
Shared area
110
109
111 113
107108
112
Transmission nursing home
13
v
Elevator
Jun AugJul Sept Oct Nov Dec
3
Strict isolation:- Single patient room + private sanitary- Contact precautions and mask before entering the patient room- Patients have to stay in the rooms
Shared area
110
109
111 113
107108
112
Transmission nursing home
13
v
Elevator
Jun AugJul Sept Oct Nov Dec
3
1st Contact tracing (n=23) No new KPC findings
Shared area
110
109
111 113
107108
112
Transmission nursing home
13P
Elevator
Jun AugJul Sept Oct Nov Dec
3
Shared area
110
109
111 113
107108
112
Transmission nursing home
1 3 P
Elevator
Jun AugJul Sept Oct Nov Dec
3
Shared area
110
109
111 113
107108
112
Transmission nursing home
1 3
P
Elevator
Jun AugJul Sept Oct Nov Dec
3
Shared area
110
109
111 113
107108
112
Transmission nursing home
1 3
P
Elevator
Jun AugJul Sept Oct Nov Dec
3
2nd Contact tracing (n=21) TWO new KPC findings
Shared area
c
110
109
111 113
107108
112
Transmission nursing home
1 3
Elevator
4
Jun AugJul Sept Oct Nov Dec
3
2nd Contact tracing (n=21) TWO new KPC findings
Shared area
110
109
111 113
107108
112
Transmission nursing home
1 3
4
5 Elevator
c
Jun AugJul Sept Oct Nov Dec
3
Shared area
Cohort isolation:- Single patient room + private sanitary- Contact precautions and mask before entering the patient room- Patients may not leave the room- Dedicated team
110
109
111 113
107108
112
Transmission nursing home
1 3
4
5 Elevator
c
Jun AugJul Sept Oct Nov Dec
3
3rd Contact tracing (n=18) ONE new KPC finding
c
Jun AugJul Sept Oct Nov Dec
Transmission nursing home
Environmental cultures
• Sterile gauze moistened with sterile saline
18-24h
Colorex KPC1 EbSA 2
TSB-VC 2
1 bioTrading Benelux2 Cepheid
• 25 samples; ‘clean’ and ‘dirty’ site
– Glucose meter
– Door handle - KPC room
– Bedside table (2x) - KPC room
Index patient
+ patient 5
Transmission nursing home27-11-2013
Separate, empty location
• Nursing home:– Cleaning of rehabilitation ward by H2O2
– Environmental cultures (2x) no KPC
– Contact tracing; n=146 (2x) no KPC
Patient Cultures sites KPC positive
Index patient Rectal
[3] Rectal, urine (catheter)
[4] Rectal, urine (catheter), wound
[5] Rectal
[6] Rectal
Separate location
• Dedicated and skilled staff
• Contact precautions during care moments, no further restrictions
• Weekly active surveillance culturing for patientsNo surveillance cultering for healthcare workers
• Environmental cultures:
Highly contaminated patient rooms Low or no contamination in shared areas
Current state KPC positive patients
Patient status
Index patient KPC negative
Patient 2 KPC positive (+ 10 months)
Patient 3 KPC negative
Patient 4 Died
Patient 5 Died
Patient 6 KPC negative
Conclusion
GeneralThe environment served as a reservoir of transmission;
• frequent detection of Klebsiella in the environment in all locations• all secondary cases in the nursing home have a link to room 113 or
shared devices (glucose meter)
Hospital• Despite contact precautions transmission to one patient occurred. • Strict isolation, active screening cultures and education prevented further
transmission
Conclusion
Nursing home
• Infection control measures designed for hospitals cannot be transposed to the setting of nursing homes easily, due to:
‒ long length of stay‒ residential setting ‒ no or poor isolation possibilities‒ education level of staff
• Nursing homes can become important reservoir for KPCs
• Nursing home was notified upon patient transfer, but without ‘active support’ by experts possible this has contributed to the outbreak.
Future question
Is it possible to control the spread of KPC in nursing homes?
Possible solutions:
Define regional location(s) voor KPC positive patients (and
other HRMO)
Adequate decolonisation stategy
Acknowledgements
• Jacobien VeenenmansAmphia Hospital Breda
• My collegues of the Laboratoria Microbiology and Infection Control
Amphia Hospital Breda
• Staff of the nursing home
Riethorst Stromenlanden, Geertruidenberg
• Staff of the Molecular and Sequence Unit for Clinical Bacteriology
University Medical Center Groningen
top related