CP-CRE Transmission Related to ICU Room...
Transcript of CP-CRE Transmission Related to ICU Room...
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CP-CRE Transmission Related to ICU Room SinksSARAH LEWIS, MD MPH
GoalShare our experience with CP-CRE in sinksCompare/contrast management strategies Novel mechanism of resistance and isolated sink colonization Endemic mechanism of resistant and widespread sink colonization
Reiterate importance of hospital design and basic infection prevention strategies to reduce transmission of CP-CRE
BackgroundInfection Prevention noted an increase in CRE clinical isolates in July 2017 Mass education (HCWs, EVS, patient/families) Enhanced communication regarding CRE patient locations and transfer Increased hand hygiene/PPE compliance observations rooms of CRE patients Enhanced environmental cleaning in rooms of CRE patients (whole house) and high-risk units
(4 adult ICUs) – bleach and TruD Tracked CRE acquisitions in space/time to determine possible modes of transmission Began weekly point prevalence screening of patients in 4 adult ICUs mid-October 2017
3/2/2017 3/30/2017 4/27/2017 5/25/2017 6/22/2017 7/20/2017 8/17/2017 9/14/2017
Patient A Unit 1Patient B Unit 1Patient C Unit 1Patient E Unit 1Patient F Unit 1Patient G Unit 2Patient H Unit 2Patient J Unit 2Patient K Unit 3Pateint L Unit 3Patient M Unit 3Patient N Unit 3Patient N Unit 3Patient N Unit 4Patient N Unit 4Patient O Unit 4Patient K Unit 4Patient P Unit 5Patient B Unit 5
3/2/2017 3/30/2017 4/27/2017 5/25/2017 6/22/2017 7/20/2017 8/17/2017 9/14/2017
Patient A Unit 1Patient B Unit 1Patient C Unit 1Patient E Unit 1Patient F Unit 1Patient G Unit 2Patient H Unit 2Patient J Unit 2Patient K Unit 3Pateint L Unit 3Patient M Unit 3Patient N Unit 3Patient N Unit 3Patient N Unit 4Patient N Unit 4Patient O Unit 4Patient K Unit 4Patient P Unit 5Patient B Unit 5
Silent colonization?Persistent environmental source?
Sink Cultures Round 1 3 patients developed KPC+ Klebsiella pneumoniae
clinical cultures soon after admission to the same ICU room over a 3 month span In-room sink drains of the ICU room in common were
cultured and colonized with KPC+ Klebsiella pneumoniae Relatedness of patients and environmental isolates
confirmed by whole genome sequencing
Many questions….What do we do with colonized sinks? Removal? Disinfection? Room Closure?
Do we look for other colonized sinks?Expert advice:Mitigate epidemiologically-linked sinksFocus on evidence-based CRE prevention measuresCautioned against going looking……
Sink Cultures: Round 23/2018: Notified by reference laboratory of positive rectal surveillance screen for KPC Citrobacter and NDM-1 K. pneumoWhere did the NDM-1 come from? Current patient admitted <1 week prior to positive culture but no healthcare contacts, foreign travel A second patient had been admitted to DUH 9 months previously who developed
clinical infection with NDM-1 K. pneumoniae No typical risk factors for NDM-1 Had been discharged from our facility for several weeks by the time the result returned from the state
lab On review of location history, the patient from 9 months prior had spent a significant
amount of time in the same ICU room as the current patient
Documenting the chain of infection Cultures from the drain and P trap of
the ICU room sink also grew KPC-Citrobacter and NDM-1 K. pneumo
We performed this experiment anddocumented transmission of KPC-Citrobacter to sink edge during use
We removed the sink drain and P trap
Patient Age Admitting Diagnosis Date of Isolation
Site of Isolation
Status
1 48Liver transplant (in
India) complicated by liver abscesses
2/2015Liver
abscess Infected
2 67Hospital transfer for respiratory failure due
to thyroid mass7/2017 Bacteremia Infected
3 77Hospital transfer for massive pulmonary
embolism3/2018 Rectal swab Colonized
Clinical and Epidemiological Characteristics of Patients Infected or Colonized with NDM-1 K. pneumoniae
Whole Genome Sequencing Results of Patient and Environmental NDM-1 K. pneumoniae Isolates
Whole Genome Sequencing
<20 SNV
• No additional cases of NDM-1 colonization or clinical cultures have occurred since 3/2018
Sink Point Prevalence Study: April-May 2018All patient room sink drains and P traps were swabbed and sampled and cultures processed by UVA labs for carbapenemase-producing bacteria
Results: ICU 1: 92% of patient room sinks contaminated with KPC+ organisms ICU 2: 88% of patient room sinks contaminated with KPC+ organisms ICU 3: 69% of patient room sinks contaminated with KPC+ organisms (No sinks positive for NDM-1)
Opportunities for Improvement
Mitigation Strategies at DukeRelocation of hooks away from sinks in DMPModifications of sinks to restrict water flow, discharge away from drain, and minimize splashingNew solutions for storage of linens, pillows, supplies away from sinkSink Safety Education Separation of clean and dirty tasks Do not prime IV tubing into sink Do not place patient care items on/around sink prior to their use Use appropriate waste receptacles
Hospital-acquired KPC CRE Colonization
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Total Clinical Isolates Total Rectal Screens
Hook relocation/faucet change begun
Hook relocation completed
Implemented rectal surveillance programCompleted sink prevalence study and shared initial results and recommendations
Sink guidance document shared
ConclusionsWe identified widespread colonization of our ICU room sinks with KPC-CRE (despite a historically low prevalence of clinical cultures positive for KPC)Implementation of a comprehensive CPO prevention bundle including weekly rectal point prevalence screens in high risk units significantly decreased transmission of CP-CRE (despite widespread environmental contamination)Low-cost interventions (education, sink modification, hook removal) further reduced transmission of CP-CRE in our hospitalRemoval of plumbing may be considered when the is evidence of isolated sink colonization/novel mechanism of resistance