MANAGEMENT OF A CARBAPENEMASE-PRODUCING

ENTEROBACTERIACEAE OUTBREAK IN HOSPITAL :

COLLABORATION BETWEEN THE ‘CENTRE DE SANTE

DES FAGNES’ AND THE OUTBREAK SUPPORT TEAM

Anaïs Bothy – CSF ChimayElisabeth Miller – OST Siensano

INTRODUCTION

Declaration of an outbreakDeclaration of an outbreak

• Outbreak Support Team (OST) contacted in June 2018 by the hospital ‘Centre de Santé des Fagnes’ (Chimay – Belgium).

• Outbreak of 6 carbapenemase-producing Enterobacteriaceae (OXA-48) in 11 days.

• First in geriatric and surgery wards.

OST : MDRO Plan

Priorities• Antibiotic policy• Infection control• Improvement of epidemiological, microbiological surveillance• Improving coordination of MDRO – battle OST

• Federated Entities of infection control = point of contact• Brussels : Commission communautaire commune (COCOM) - Gemeenschappelijke

Gemeenschapscommissie (GGC)• Wallonia : Agence pour une Vie de Qualité (AVIQ)• Flanders : Agentschap Zorg en Gezondheid (ZG)

• Sciensano (Belgian Public Health Institute, ‘National Surveillance of Infections in Hospitals’ ward)

• National Reference Center (NRC)

• (External experts)

• Collaboration with infection team and management of the healthcaresetting

OST : composition

OST : operating procedure

• Hospital (team infection control) / nursing home (medicalcoordinator) / other healthcare setting

• Declaration of outbreak to the Federated Entities mandatory

• Asking help of OST not mandatory (voluntary) OST = supporting function (NOT inspection function)

• The final responsibility lies with the healthcare setting (even in case of intervention of the OST)

OST : intervention levels

• Preliminary analysis of the situation (checklist)

• Gathering data about MDRO characteristics and outbreaks

• Analysis of hospital’s indicators (hand hygiene, antibiotic use, MDRO surveillances)

• Contact (email, phone) with involved persons (infection control andprevention team, medical coordinator in nursing homes, etc)

• Contact with experts (Sciensano, NRC, others)

• Organisation and coordination of the discussions

OST : intervention levels

• Meetings on the field with all persons involved (ICP team, direction, nursing and medical team, cleaning and technical team, etc) :

• situation assessment

• visiting the concerned wards – observations

• detecting points of improvement, triggers and pitfalls of outbreak

• refining outbreak management - priorisation of measures

• mediation between different actors

• scientific advices

• sampling

OST : intervention levels

• Literature research on specific questions

• Interim and final reports

• Monitoring of the situation

• « Control » (only if necessary) : stopping specific actions, cohorting, closing of wards

• Mapping regional clusters

• Contain transmission between sectors of care (better coordination of MDRO-battle)

MANAGEMENT OF A MULTIFACTORIAL

OXA-48 CPE OUTBREAK IN A 144-BEDS ACUTE HOSPITAL

• 144-beds acute general hospital in South-East Belgium • Infection control team (ICT) : 1public health nurse + 1 infectious

disease specialist (since 2019) + 1 microbiologist / hygienist

Declaration of an outbreak Centre des Santé des FagnesChimay, Belgium

• Outbreak : occurrence of cases clearly in excess of the normal expectancy within a certain period of time

• Without surveillance data : index case + 2

• OXA-48 carbapenemase-producing enterobacteriaceae (CPE)

• Plasmidic gene conferring high-degree of resistance to temocillin (generally MIC ≥ 128 µg/mL) but variable for carbapenems (S/I/R)

SCREENING BREAKPOINT

• 75% of CPE in Belgium

Declaration of an outbreak Definitions

Declaration of an outbreakEpidemic curve

Declaration of an outbreakOutbreak description

Legend : Date H = date of hospitalization, Lenght H = length of stay; Noso = nosocomial; ATB : antibiotherapy ; M : Male; F : Female; C : Surgery; G : Geriatry; D3 : intern medecine;EXT : external; USI : intensive unit care; ESSCO : Escherichia coli; KPN : Klebsiella pneumoniae; KOX : Klebsiella oxytoca; CITFR : Citrobacter freundii; RORN : Raoultella ornithinolytica; ENCAN : Enterobacter cancerogenus; MMOR : Morganella morganii; Ind cath : indwelling catheter; RDC: residential disability center; Other H : other hospital; Rehab C : Rehabilitation centre; CSF : Centre de Santé des Fagnes;

• Step 1 : Detection (recognize the outbreak timely)• Step 2 : Confirm (or not) the existence of an outbreak• Step 3 : Crisis management cell & communication• Step 4 : First control measures & study the event

• Define & Identify cases (case definition, identify and count cases)

• Perform descriptive epidemiology • Review of literature • Develop hypotheses • Evaluate hypotheses & implement control measures• If necessary, reconsider/ refine hypotheses and execute

additional studies : epidemiologic, laboratory, environmental• Step 5 : Implement control & prevention measures and

communicate findings

Declaration of an outbreakStep-by-step approach

• Week 24 (June 2018) : DETECTION 6 cases : 4 cases in surgery (1 known + 1 unexpected clinical sample + 2 by screening) + 2 in ICU (1 known + 1 by screening)

• First control measures• Closing of the surgery unit to new admissions

• Week 25 : 1 additional case (surgery) + 1 possible (internal medicine)• Declaration (surveillance.sante@aviq.be) planification of OST meeting• Cohort unit • Creation of a cohort unit with dedicated staff• Intensive cleaning of the surgery unit (without patients) • Reopening to new patients with CPE screening on admission and D+4 (coexistence of

both units)

• Week 26 : No additional case • Discharge of patients from cohort unit • Intensive cleaning of the surgical day unit • Back to normal activity

• Weeks 27-28 : No additional case• Feedback to units and direction, CHH and GGA• Meeting with OST on site : revision of actions, analysis of hospital indicators, help to

perform in-depth literature

Declaration of an outbreakOutbreak : 1st part

• Reinforce standard hygienic measures, hand hygiene, cleaning + isolation precautions for positive patients

• Crisis management cell (head of nurse and medical service, hygienists, surgeons, pharmacist, qualitician)

• Communication +++ : • Flagging of CPE-positive cases and their contacts• Meeting healthcare workers to ensure good hygienic practices• Medical staff awareness : need to reduce impact of antibiotherapy, length of stay• General information sessions

• Revision of CPE screening program : recent hospitalization to CSF (< 3 months) as risk factor of CPE carriage

• Collecting of data about patients & strains descriptive epidemiology & mapping of the situation (Excel)

• Basal hypothesis : patient-to-patient cross-transmission via healthcare workers or (indirect) contact with human excreta local observations in the units

Declaration of an outbreakFirst control measures

Declaration of an outbreakMapping the situation (Excel)

Identification of critical points regarding hospital hygiene precautions

Declaration of an outbreakFirst local observations : Crit ical points

• General precautions • Insufficient hand hygiene• Insufficient medical device disinfection

or poor conception • Inadequate use of personal protective

equipment (PPE)

• Additional precautions • Poor communication between

services • Inadequate dressing sequence • Accumulation of material in isolation

room and inadequate disinfection • Poor education of patients and visitors

Hospital hygiene precautions

Declaration of an outbreakFirst local observations : Improvements

• Revision of procedures and users formation • Increasing of hydroalcoolic solution availability • Replacement of equipment • Isolation room : standardization of station, kit, check-list• Information access

Stool = huge reservoir of Enterobacteriaceae (1011 CFU/g selles)Risk of contamination of healthcare workers, environment and others patients

Declaration of an outbreakFirst local observations : Critical points

Critical points • No existing procedure • Misinformation about risks• Damaged material (cracked plastic)• Used bedpan : time to take over, emptying in patient toilets• Transport : no protections for transport of full bedpans,

juxtaposition of used bedpan• Bedpan cleaner

• Misloading• Unawareness of warning messages • Still dirty bedpans after cleaning manual cleaning with

inappropriate product• No traceability / tracking of recurrent faults or technical

maintenance• Inadequate number (FR : 1/12 beds)• Inadequate drying

• Utility room• Accumulation of dirty material on slop-hoppers • Use of water spray• Insufficient PPE• Poor separation between clean and contaminated

Excreta management

Declaration of an outbreakFirst local observations : Improvements

• Creation of procedures, encouraging to put directly full bedpan in the cleaner without emptying/flushing, covering of full bedpan for transport, correct use of PPE user formation

• If enteric pathogen : patient-use plastic bedpan + single-use superabsorbent cover

• Bedpan cleaner • Cycle optimization • Technical interventions• procedure + log-book

Other potential solutions • Replacement of material (polypropylene >>

metal, Bryce E 2014)• Hand-free bedpan cleaner (Bryce E 2014)• Disposable pulp-receptacle seems to be less of

a risk in spreading infectious disease (Phua2016)

• Better separation between clean and contaminated (Van Knippenberg 2015)

Afterwards…

Geriatry : 1 probable (urine) + 2

C (screening)

Surgery : + 3C

D1 : 2 acquisitions

29

31

37

Contact

Environnement

- Close to new admissions- 2nd crisis meeting

- Shared material : negativesamples

?? Contact

?

43-

46

- Screening sensitivity ? - Critical points in cleaning :

organization, task division, … - Multiple sampling of the

rooms (dry and moistsurfaces)

R. ornithinolytica

M. MorganiiK. pneumoniaeC. Freundii

C. Freundii (2)Staff training

Same rooms, same strains …

C : + 2C + 1 Po Contact/Environnement

49Geriatry :1Po + 1 C (roomate)

Contact

- Environnemental sampling (water-related environment)

Staff training

No more until now…ACTIVE SURVEILLANCE : screening admission in high-risk units + once a week for all if ≥1 CPE/unit

FEEDBACK TO UNITS, CHH et GGA

34

36

C. Freundii M. morganiiE. coli

K . pneumoniae

• Environment could be a reservoir for MDROs (Advised report, SHC 2017)• Could persist at sufficient concentrations to contamine hands of healthworkers

(Siani 2015)• Risk of MDRO acquisition from prior occupants is as important for Gram-negative

as for Gram-positive organisms (Mitchell 2015)

CSF :

• Several different species of OXA-48 CPE: environmental plasmid accumulation ?• Some acquisitions with the same strain as prior occupant of a same room• Local observations :inadequate organization, gray zone

Revision of cleaning procedures for daily and terminal cleaning of the rooms, clear distribution of work

Environmental sampling :o Dry surfaces : high-touched surfaces (bed, crib bars, bed control unit,

doors, handles, divider curtain, nightstand, IV stand, shared material) : ALL NEGATIVE

o Water-related environment : toilets (water, edge of the bowl, toilet brush), sink taps and traps

o Toilet brush and water of the toilet bowl: M. morganii OXA-48o Sink traps + for OXA-48 strains : Cit. freundii (2) + K. pneumoniae

(2) + M. morganii (1)

Declaration of an outbreakEnvironmental considerations

Contamined sinks trap • Direction of contamination questionable

Literature • Increasing number of reports about enterobacteriaceae outbreaks with sinks as a source of

transmission (De Geyter 2017, Morange 2015, Leitner 2015, Wolf 2014, Lowe 2012, Starlander2012)

• Moist environment, particularly if difficult access to disinfection (waterpipes, toilets) are reservoirs of enterobacteriaceae with resistance genes to disinfectant and antibiotics (Taconnelli 2014)

• Aerosols and splashing containing bacteria from the trap could reach 1 meter around the tap when water is running (Hota 2009)

• Perpendicular flow and tap distance (< 20 cm) foster splashing

• Transmission to patient possible via direct splashing on patient, onto healthcare profesionnals’ hands or via contaminated environment (including patient belongings)

CSF• Toilet basin flushed into patient’s room sink• Clogged sinks in surgery ward• Sink plugs no available for patients room, some of them are using their washcloth !

Declaration of an outbreakEnvironmental considerations

Contaminated sinks trap : How to handle it ?

Literature • Meta-analysis (Gordon 2017) : hospital water environment as reservoir for carba-R

organisms causing hospital outbreaks • Enterobacteriaceae : tap disinfection possible with bleach, hydrogen peroxide and UV light

but no total eradication of colonization if chemical disinfection only• Eradication of MDRO from the environment requires bundled measures : reinforcing

general IC measures, chemical disinfection and reservoir replacement• Other useful measures : drainage or sink redesign

• UZ Brussel 2015 : sinks remained CPE-positive after gluprotamine disinfection, but no more after replacement of reservoir with newly engineered ones with an open inlet

• CHU Tours 2015 : OXA-48 CPE outbreak terminates only after replacement of sinks with ball siphon, allowing sufficient contact with chlorine solution 2,6%

Declaration of an outbreakEnvironmental considerations

CSF• Replacement of contaminated siphons with new ones

with closing valve + daily chlorination protocol • Emission of “good sink practices” • Pre-moistered wash gloves (no rinsing – no drying)

Declaration of an outbreakEnvironmental considerations

.

Declaration of an outbreakOutbreak management : summary

Major improvements :

• Revue of standard and additional precautions procedures, including increase of hydroalcoolic solution availability

• Excreta management • Revue of patient room disinfection protocol (daily and terminal), including replacement of

reservoirs and daily chlorination of toilets and sinks• Revue of screening program on admission• Systematic weekly screening of all patients in same ward if ≥ 1 CPE+• Revue of internal and external communication

• Customized transfer document for nursing homes and homecare + systematic oral communication

• Systematic family doctors communication• Awareness meeting with Dr C Shirvel (april 2019)

Ongoing projects • Presentation of outbreak procedure management to hospital hygiene committee• Audit practices and feed-back to the teams : Hand hygiene (post-campaign

observances), MDRO screening, contact precautions, excreta management, antibiotics prescription

• Hand-free bedpan cleaner and utility room reorganization

Declaration of an outbreakConclusions

• Key elements

• Cross-transmission remains privileged hypothesis but think to consider environmental reservoirs as a potential source of CPE transmission

• Bundled and methodic approaches based on descriptive analysis, field observations, literature …and experience sharing ! Thi(a)nk to OST !

• Active, structured communication and collaboration +++ between all implicated actors

• Multiple opportunities of practice improvement, ICT visibility

• Crucial need to develop further collaborations in the MDRO battle with other potential reservoirs (i.e. nursing homes)

1. OMS. Global priority list of antibiotic-resistant bacteria to guide research, discovery and development of new antibiotics. 2017. 2. CSS. Avis n°9344 Recommandations en matière d'hyigène des mains durant les soins. 2018. 3. Dirty bedpans and MDRO: partners in crime. Van Knippenberg-Gordebeke, G. 2, 2013, Antimicrob Resist Infect Control, p. 3764. PIDAC. Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices. 2013. 3rd edition.5. The Faecal Quandary - Bedpan Management in a modern age. Van Knippenberg-Gordebeke, G. 2014. XXVe Congrès National de la

Société Française d’Hygiène Hospitalière. 6. Worldwide improper bedpan-management: risk for spreading (multi drug) resistant organisms. Van Knippenberg-Gordebeke, G. 48 (2),

2015, Journ of Microbiol Immunol and Infection , p. 537.7. GREPHH. Gestion des excréta : documents et outils français existants au 1er décembre 2016. [En ligne] 2016.

http://www.grephh.fr/PDF/Excreta/Excreta_Outils_Liens_V1.pdf. 8. Bedpan washer disinfectors: An in-use evaluation of cleaning and disinfection. Bryce, E. 39, 2011, pp. 566-70. 9. Disposable single-use receptacles in a tertiary hospital: A large survey of staff after a hospital-wide implementation. Phua, MY. 44,

2016, American Journal of Infection Control, pp. 1041-43. 10. CSS. Avis n°9277 - Recommandations en matière de prévention, maîtrise et prise en charge des patients porteurs de bactéries multi-

résistantes aux antibiotiques (MDRO) dans les institutions de soins . 2017. 11. Best practice in healthcare environment decontamination. Siani, H et Maillard, JY. 34 (1), 2015, Eur J Clin Microbiol Infect Dis, pp. 1-

11. 12. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Dancer, SJ. 27

(4), 2014, Clin Microbiol Rev, pp. 665-90. 13. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative

bacteria in hospitalized patients. Tacconelli, E et al., et. 20, 2014, Clinical Microbiology and Infection, pp. 1-55.14. The sink as a potential source of transmission of CPE in intensive car unit. De Geyter, D. 6, 2017, Antimicrobial Resistance and

Infection Control. 15. Epidémie à BHRe : attention aux points d’eau ! Morange, V. 2015. XXVIème congrès national de la Société Française d'Hygiène

Hospitalière. 16. Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room

design. Hota, S. 30, 2009, Infect Control Hosp Epidemiol, pp. 25-33. 17. 17. The Hospital Water Environment as a Reservoir for Carbapenem-resistant organisms causing Hospital-Acquired infections - A

systemactic Review of the Literature. Gordon, A Kizny. 64, 2017, Clinical Infectious Diseases, pp. 1435-44.18. 18. Duration of carriage of carbapenem-resistant Enterobacteriaceae following hospital discharge. Zimmerman, FS. 41 (3), 2013, Am J

Infect Control, pp. 190-4.

Declaration of an outbreakBibliographic references

Declaration of an outbreakSpeakers contact

Phn Biol Anaïs BothyMicrobiology Lab/ InfectioncontrolCentre de Santé des Fagnes+32 (0) 60 218 816a.bothy@csf.be

Dr Elisabeth MillerScientist / OST member

Sciensano+32 (0)2 642 53 28elisabeth.miller@sciensano.be

Additionnal slides

Caractéristiques des patients -24 patients entre août 2017 et septembre 2018 = 17 patients après semaine 24-18 (alerte)+ 7 patients avant -1 acquisition dans une autre structure hospitalière = 23 patients 5 noso CSF possibles, 11 probables et 7 certaines

-Ratio ho/fe : 2,43-Age : 72+/- 14 ans -Unités au diagnostic : chirurgie (10), gériatrie (6), médecine interne (3), onco-pneumologie (2), ambulatoire avec histoire récente d’hospitalisation au CSF (2)-3 infections (urinaires) + 26 colonisations-Durée hospitalisation : 32+/- 28 jours-Antibiothérapie endéans le mois chez tous les patients (sauf un: données non disponibles)-Comorbidités : insuffisance rénale (9), diabète type II (6), BPCO (5), insuffisance cardiaque (5), néoplasie solide (4), artériopathie oblitérante (2). 8 n’en présentaient aucune, certains en présentaient plusieurs.

Caractéristiques des souches CPE OXA-48-Klebsiella pneumoniae (13), Escherichia coli (9), Citrobacter freundii (7), Raoultella ornithinolytica (4), Klebsiella oxytoca (2), Morganella morganii (2), Enterobacter cancerogenus(1). -13 patients : une seule souche, plusieurs pour les autres patients (maximum 3)-Sites de détection : frottis rectal (17), urines (6), frottis de plaie chirurgicale (1)

Declaration of an outbreakPatients and strains characteristics

Prélèvements-Prélèvements cliniques (urines, expectorations, sang …)-Prélèvement de dépistage : frottis intrarectal visiblement souillé, à l’aide de frottis avec milieu de conservation gélosé de type Amies (Copan, Italie) ensemencement sur milieu chromogène chromID Smart (CARB/OXA) (Biomérieux, France)-Prélèvements environnementaux : frottis gel pour surfaces sèches, siphons (15 cm de profondeur). Eau de toilette récoltée à l’aide de seringue 50mL (BD Plastipack, USA), pulvérisée à travers un filtre à membrane Millipore MicropreSure 0,45 μm (Merck Millipore, USA), lui-même ensemencé sur milieu chromogène.

Identification des entérobactéries par galeries d’identification biochimique API 32 E (Biomérieux, France)

Réalisation d’antibiogrammes sur les colonies d’intérêt par la méthode de diffusion sur milieu Mueller-Hinton selon les directives de l’EUCAST

Confirmation des souches suspectes de produire des CPE OXA-48 par test immunochromatographique K-SeT OXA-48 (Coris Bioconcept, Belgique)

Comparaison phénotypique des souches collectées et congélation systématique pour analyses ultérieures

• Microbiological limitations • Culture + biochemical identification = delay ++• Insufficient sensitivity ? (+ Mc Conkey with mero/temo disks)• No genotyping • Molecular biology?

– Outbreaks– Contact patients– Re-admission of previously colonized patients

Declaration of an outbreakMicrobiological investigations

• Small-sized structure with limited (human) resources

• Coordination of actions between all healthcare workers need for a descriptive procedure of outbreak management

• Access and knowledge of hygiene procedures need to develop new approaches for formation

• Need of actions to reduce length of stay, re-admission rates and impact of antibiotherapy : strategic lever for general direction

• Microbiological limitations • Culture + biochemical identification = delay ++• Insufficient sensitivity ? (+ Mc Conkey with mero/temo disks)• No genotyping • Molecular biology?

– Outbreaks– Contact patients– Re-admission of previously colonized patients

Declaration of an outbreakLimitations and difficulties