Brandon Merritt, MPHRegional Epidemiologist

To discuss two recently identified CRKP outbreaks in separate Kanawha County long-term care facilities

To identify common challenges faced while investigating CRKP outbreaks

To recommend steps to build the collaborative effort required between local health and the LTCF during a CRKP outbreak

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On April 18, 2011, KCHD was notified by DIDE of an OHFLAC report indicating multiple positive lab results for CRKP dating back to November, 2010 in four different residents in Nursing Home “A” in Kanawha County.

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Two cases cohorted together on short-term rehab wing after positive labs

At least one resident expired while roommate of positive case

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DIDE/KCHD Site Visit – May 2, 2011 Recommendations:

◦ Review the prior 12 months of laboratory results to identify previously undetected cases

◦ Perform peri-rectal surveillance swabs on roommates of identified positives.

◦ Improve facility’s disease/infection tracking and include resistance status of organisms.

◦ Emphasize hand hygiene compliance with facility staff.

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After much discussion and convincing, surveillance cultures performed on June 28, 2011◦ Arranged with local lab for Modified Hodge Test◦ No additional colonized or infected residents were

identified of the 16 surveillance swabs

Implemented hand hygiene monitoring program

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“MDRO and Infection Control for Long Term Care Facilities”--June 21, 2011◦ Agenda included:

The ABCs of MDROs Recognizing and Reporting Outbreaks TB Control in LTCFs Closed PODs in LTCFs (Emergency Preparedness)

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Nursing Home “B” informed KCHD of “possible KPC” the day of “MDRO and Infection Control for Long Term Care Facilities”◦ CRKP confirmed on 6/23/2011

Resident had recently been in and out of hospital due to hip surgery

Previously had clear urine labs

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Recommendations for Nursing Home B were virtually the same as Nursing Home A◦ 12 month lab look back◦ Identify previous roommates and perform peri-

rectal surveillance swabs◦ Place colonized/infected residents under contact

precautions and in single room if possible◦ Emphasize hand hygiene compliance among staff

and enhanced environmental cleaning

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Look back completed◦ One additional case was identified, and…◦ SURPRISE! New case was also an identified case

from the outbreak at Nursing Home A Surveillance Cultures performed on July 18

◦ Eight residents tested All negative for CRKP

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Lack of Reporting◦ Neither facility was aware that a single case of

CRKP should have been considered an outbreak and therefore reported to the health department immediately

Physician Resistance◦ Inattention to susceptibility profiles◦ Treating with end line antibiotics

Corporate Resistance◦ IC manuals generally treat CRE/CRKP same as

MRSA

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Importance of Collaboration with LTCF◦ Relationship building◦ Emphasizing local health as supporting agency

Provide Resources Education, Education, Education

◦ IC staff, administration, physicians, corporate

Nevertheless, there’s a long way to go.

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108 LEE STREET EASTCHARLESTON, WV

25301304-344-KCHD(5243)

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Carbapenem Resistant Klebsiella Pneumoniae (CRKP)

Somu Chatterjee MPH., M.B.B.S.Regional Epidemiologist,

Wheeling-Ohio County Health Department

Email: somu.k.chatterjee@wv.gov

Ph: 304-234-3682

Cell: 304-830-3710

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Carbapenem Resistant Klebsiella Pneumoniae (CRKP)

Case background

Challenges faced

Public Health Action

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Case Background

Friday the 13th, 4:30 pm

2 cases of CRKP reported by Hospital X

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Case Background cont..

Ms A. 67 yrs. F, had surgery in Hospital Y (04/19) transferred to Hospital Z (04/23) Life - flighted to Hospital X (04/23) Expired on 05/10

Reported to LHD on 05/13 Status on admission:

Septicemia, Hypotension Acute Renal Failure Cardiogenic Shock Fever etc.

} +ve Blood Cx

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Case Background cont..

Ms B. 79 yrs F Inpatient in Hospital X from 04/16 – 05/12 2 beds away, in the same Unit Past History:

Was at home for 2 months before admission. LTCF resident Skilled unit of Hospital X Myasthenia Gravis

Current admission: Dysphasia, Low grade temp. Bronchial Washing CRKP

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Challenges Faced

Confirm if 2 cases meet CRKP definitionCulture reportsLab methods used

Location in Hospital X, where exposure occurred

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Challenges Faced cont..

Protocols in place to prevent infection

If other patients in the Hospital X were infected with CRKP

Where, When and How was the infection acquired

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Public Health Action

Lab methods used; Sensitive CRKP, Elevated MIC (Minimum

Inhibitory Conc.) Modified Hodge TestAutomated indicators of elevated MICLab upgraded to CLSI and CDC guidelines

Location:SICU, MICU

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Public Health Action cont..

Infection Control Protocols:Automated alert on EMR System

Suggested to:Observe / Monitor environmental cleaningUse FDA approved disinfectants

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Public Health Action cont..

Exposed Patients: Epi linkedActive surveillance Rectal swabs &

Culture 7 patients; all negative for CRKP

6 Month review of CRKP in Hospital X:Microbiological reviewFrequency of CRKP cases

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Public Health Action cont..

6 month review results: 6 patients with CRKP

Conf call DIDE, LHD, Hospital X 2 patients. Not CRKP

4 patients with CRKP

3 in-patients in SICU/MICU

1 outpatient. Diagnostic aspiration from body cavity in radiology

¾ patients came from Ohio & 2 had been in a particular

LTCF X

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Public Health Action cont..

Suggestions for screening:Pre-emptive isolation of ptns from LTCF XActive surveillance on Epi linked patients.Periodic point prevalence

If negative, be selective:

-- Susceptible

-- High risk areas.

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CONCLUSIONS

Team Work !! Depending on number of cases reported:

None or rarely detected (≤ 1 / month) Periodically detected (2-3 cases /month)

Options: 6-12 months of Micro reports Repeat Surveillance Point prevalence study Monitor cleaning performance.