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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