Environmental contamination withKlebsiella pneumoniae carbapenemase-producing

Klebsiella pneumoniae during an outbreakin The Nederlands

V. Weterings1, E. Thewessen2, J. Kluytmans1,3, J. Veenemans1

1 Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda2De Riethorst Stromenland, Geertruidenberg3Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht

Disclosure of speaker’s interests

(Potential) conflict of interest none

Potentially relevant company relationships in connection

with event 1

N/A

Sponsorship or research funding2

Fee or other (financial) payment3

Shareholder4

Other relationship, i.e. …5

N/A

Outbreak

Transfer Index patient Dutch hospital

24/6/2013

Jun AugJul Nov

5/7/2013

Second patient; pleural fluid

2

Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin

1

Sept Oct

• One transmission was detected despite contact precautions• After upgrading to strict isolation no further spread was found

Outbreak

Transfer Index patient Dutch hospital

24/6/2013

Jun AugJul Nov

5/7/2013

Second patient; pleural fluid

2Index patient: NHPatient 2: home

5/8/2013

1

Sept Oct

Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin

Outbreak

Transfer Index patient Dutch hospital

24/6/2013

Jun AugJul Nov

5/7/2013

Second patient; pleural fluid

2Index patient: NHPatient 2: home

5/8/2013

7/11/2013

Third patient; Rectal swab

31

Sept Oct

Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin

5

Outbreak

Transfer Index patient Dutch hospital

24/6/2013

Jun AugJul Nov

5/7/2013

Second patient; pleural fluid

2Index patient: NHPatient 2: home

5/8/2013

7/11/2013

Third patient; Rectal swab

31 4

Sept Oct

• Despite contact precautions three further transmissions occurred• Cohorting to one side of the ward with dedicated nursing staff

Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin

5

Outbreak

Transfer Index patient Dutch hospital

24/6/2013

Jun AugJul Nov

5/7/2013

Second patient; pleural fluid

2Index patient: NHPatient 2: home

5/8/2013

7/11/2013

Third patient; Rectal swab

31 4 6Sept Oct

Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin

5

Outbreak

Transfer Index patient Dutch hospital

24/6/2013

Jun AugJul Nov

5/7/2013

Second patient; pleural fluid

2Index patient: NHPatient 2: home

5/8/2013

7/11/2013

Third patient; Rectal swab

31 4 6Sept Oct

• Transfer of all five KPC-KP positive residents to a separate facility• Dedicated nursing team

Klebsiella pneumoniae, KPC-2, ST258pan resistant, including colistin

Methods

Nursing home

Nursing home

Rehabilitation ward

Elevator

Shared area

1 34

5

A single measurement - one day after cohort was implemented

48 samples of frequently touched surfaces and equipment o 24 samples on the cohorting site o 24 samples on the non-cohorting site

Separate facility

Separate facility

1 3 6 4

5

Nurse office

Living room

Kitchen

Bedpan washer

Linen room

Two zones:A. Patient rooms

HCWs donned gloves and gown before entering,and removed before leaving room

1 3 6 4

5

Nurse office

Living room

Kitchen

Bedpan washer

Linen room

Two zones:A. Patient rooms

HCWs donned gloves and gown before entering,and removed before leaving room

B. Communal areaStandard precautions

Separate facility

1 3 6 4

5

Nurse office

Living room

Kitchen

Bedpan washer

Linen room

Two zones:A. Patient rooms

HCWs donned gloves and gown before entering,and removed before leaving room

B. Communal areaStandard precautions

Patient rooms and communal area were cleaned daily, anddisinfected 3x per week.

Weekly environmental sampling from predefined items:• Patient rooms (n =3/room)• Communal area (n = 8)

Separate facility

Microbiology

• Sterile gauzes (10x10cm) moistened with sterile saline

• Selective broth enrichment and selective screening agars wereused for KPC detection

Results

Nursing home

Nursing home

Elevator

Shared area

1 34

5

Night cabin

0/24 samples4/24 KPC-KP positive (16,7%)

Night cabin + Door knob

Glucose meter

Separate facility

Patient rooms

1. Bed 2. Door handles bathroom 3. Door handles wardrobe

Index

1 2 3

5-12-2013

10-12-2013

20-12-2013

23-12-2013

01-01-2014

10-01-2014

21-01-2014

7-2-2014

12-2-2014

KPC positive

KPC negative

Not determined

Separate facility

1

3

2

Bed

Door handles wardrobe

Door handles bathroom

Index

1 2 3

5-12-2013

10-12-2013

20-12-2013

23-12-2013

01-01-2014

10-01-2014

21-01-2014

7-2-2014

12-2-2014

[3]

1 2 3

[5]

1 2 3

[4]

1 2 3

[6]

1 2 3

KPC positive

KPC negative

Not determined

Patient rooms

Separate facility

1

3

2

Bed

Door handles wardrobe

Door handles bathroom

Index

1 2 3

5-12-2013

10-12-2013

20-12-2013

23-12-2013

01-01-2014

10-01-2014

21-01-2014

7-2-2014

12-2-2014

[3]

1 2 3

[5]

1 2 3

[4]

1 2 3

[6]

1 2 3

KPC positive

KPC negative

Not determined

Patient rooms

[3] Bedridden; faeces incontinence, urine catheter

Separate facility

1

3

2

Bed

Door handles wardrobe

Door handles bathroom

Index

1 2 3

5-12-2013

10-12-2013

20-12-2013

23-12-2013

01-01-2014

10-01-2014

21-01-2014

7-2-2014

12-2-2014

[3]

1 2 3

[5]

1 2 3

[4]

1 2 3

[6]

1 2 3

KPC positive

KPC negative

Not determined

Patient rooms

[3] Bedridden; faeces incontinence, urine catheter[5] servere unhygienic behavior, urine catheter

Separate facility

5-12-2013

10-12-2013

20-12-2013

23-12-2013

01-01-2014

10-01-2014

21-01-2014

7-2-2014

12-2-2014

[3 & 4]

KPC positive

KPC negative

Not determined

Patient Lift

[5]

KPC positive

KPC negative

Not determined

Kitchen Table + chairs Bedpan washer Office nurse DECT Glucose meter

5-12-2013

10-12-2013

20-12-2013

23-12-2013

01-01-2014

10-01-2014

21-01-2014

7-2-2014

12-2-2014

Communal area

Separate facility

Conclusion & Discussion

Conclusion

• Extensive environmental contamination was found in all settings

• KPC-KP was also detected outside the direct patient environment

• The environment can act as important reservoir for transmission during KPC-KP outbreaks

• VW: eigenlijk kunnen we niet hard maken dat door het onhygienisch gedrag ermeer omgevingscontaminatie is, omdat we vb. Niet gekeken hebben naar‘KPC-KP rectal concentration’ (CMI, lerner 2015). Daarom niet benoemd op deze slide

Discussion

• Contact isolation according to our national guideline, include wearing gloves when touching the patient and the patient’s immediate environment

• Our findings suggest contact isolation – as disclosed in the national guideline - is not sufficient to prevent transmission of KPC-producing Klebsiella pneumoniae ST258

• We advise to implement wearing a gown and gloves upon entry to a room of a patient/resident colonized or infected with KPC-KP as stated in the ESCMID guideline1

1 Tacconelli E, Cataldo MA, Dancer SJ, De Angelis G, Falcone M, Frank U, et al. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug- resistant gram-negative bacteria in hospitalized patients. Clin Microbiol Infect. 2014;20(Suppl 1):1–55. http://dx.doi. org/10.1111/1469-0691.12427

Acknowledgements

• My collegues of the Laboratoria Microbiology and Infection Control

Amphia Hospital Breda

• Staff of the nursing home

Riethorst Stromenlanden, Geertruidenberg