ECCMID 2014: Outbreak of colistin-resistant Klebsiella pneumonia Carbapenemase (KPC) -producing...

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

Disclosure

no financial relationships exist

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



24/6/2013


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



24/6/2013


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

Site A: room 101 to 106Site B: room 107 to 113

Rehabilitation ward

Elevator

Shared area

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


1

3

Admission patient 3

‘use gowns of room 113’ shared storage of PPE

Elevator

Shared area


110

109

111 113

107108

112


1Elevator


3

3

OMT NH

Shared area

110

109

111 113

107108

112


13

v

Elevator


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


13

v

Elevator


3

1st Contact tracing (n=23) No new KPC findings

Shared area

110

109

111 113

107108

112


13P

Elevator


3

Shared area

110

109

111 113

107108

112


1 3 P

Elevator


3

Shared area

110

109

111 113

107108

112


1 3

P

Elevator


3

Shared area

110

109

111 113

107108

112


1 3

P

Elevator


3

2nd Contact tracing (n=21) TWO new KPC findings

Shared area

c

110

109

111 113

107108

112


1 3

Elevator

4


3

2nd Contact tracing (n=21) TWO new KPC findings

Shared area

Site A

101 102 103

106 105

104

kitchen

office

5

Elevator

c

110

109

111 113

107108

112


1 3

4

5 Elevator

c


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


1 3

4

5 Elevator

c


3

3rd Contact tracing (n=18) ONE new KPC finding

Site A

101 102 103

106 105

104

kitchen

office

Elevator

c

6

c



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

Huisvesting KPC-KP positieve cliëntenSeparate location

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

ECCMID 2014: Outbreak of colistin-resistant Klebsiella pneumonia Carbapenemase (KPC) -producing...

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Transcript of ECCMID 2014: Outbreak of colistin-resistant Klebsiella pneumonia Carbapenemase (KPC) -producing...