By Carol A. Kemper, MD, FACP
Dr. Kemper reports no financial relationships relevant to this field of study.
Providers Facilitate Transmission of Resistant Organisms
SOURCE: Grabowski ME, Kang H, Wells KM, et al. Provider role in transmission of carbapenem-resistant Enterobacteriaceae. Infect Control Hosp Epidemiol 2017;38:1329-1334.
Researchers investigated the provider role in patient-to-patient transmission of carbapenem-resistant Enterobacteriaceae (CRE) in a hospital facility with a robust CRE surveillance program. Between 2011 and 2015, researchers conducted a case-controlled study of patients who acquired CRE during their hospitalization and those who did not. Cases had negative stool CRE surveillance within 48 hours of admission, with a subsequent positive CRE culture, and a hospital stay of at least nine days.
Controls had two or more negative stool surveillance studies with a similar length of hospital stay (LOS). Patient-provider interactions were documented per day. CRE status was documented in the electronic record, and any patient with a history of CRE was placed in contact isolation with use of gowns and gloves. Hand hygiene was actively monitored, and compliance with hand hygiene was 81%.
A total of 121 patients acquired CRE during their hospital stay during the six-year study period. Cases were admitted more commonly to the general surgery/transplant unit, intensive care unit, or burn unit. The median LOS for cases was 49 days compared with 20.5 days for controls. Cases had an average of 43 ± 8 unique documented provider interactions in one week (an average of 10.5 ± 3 per day) compared with 41 ± 8.7 for controls (an average of 9.5 ± 3 per day).
Case patients were statistically significantly more likely to be cared for by a CRE-shared provider, meaning providers caring for another patient with CRE, than controls. Case patients had an average of four more shared providers per week than controls. Controlling for age and intensive care unit stay, the odds of a case being exposed to a shared-source provider was 2.27 higher than for controls. Providers caring for a known CRE patient appear to have an active role in patient-to-patient transmission.
The Time Is Now — Stop CRKP
SOURCE: Centers for Disease Control and Prevention. Carbapenem-resistant Klebsiella pneumoniae associated with a long-term care facility – West Virginia, 2009-2011. MMWR Morb Mortal Wkly Rep 2011;60:1418-1420.
The first recognized outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in a West Virginia acute care facility occurred in January 2011, involving 19 patients, and prompting public health involvement and field investigation. Sixteen of 19 hospitalized cases were admitted from long-term care facilities, with 14 from facility A. Cultures from 10 of these patients were obtained within less than two days of admission, suggesting patients presented to the hospital with existing CRKP infection and/or colonization.
Investigators conducted a case control study comparing the 19 cases with 38 non-CRKP-infected controls, demonstrating that, in fact, prior stay at long-term care facility A was a significant risk for CRKP. Case patients also were significantly more likely to be non-ambulatory, and to have not spent much time at home during the previous year.
Field investigation at the acute care hospital found no significant infection control deficiencies. In contrast, investigation of long-term care facility A revealed numerous deficiencies: They had no available infection control expertise, cultures were not identified as multidrug-resistant, and the laboratory used for cultures did not stipulate whether isolates were carbapenem resistant. Patients with resistant organisms were not isolated, gowns and gloves were not conveniently available, and isolation and environmental cleaning practices were generally deficient.
Point surveillance at long-term care facility A found 11/118 (9%) residents were positive for CRKP, including eight previously recognized patients.
Long-term care facilities are increasingly serving as a reservoir — to the community and to their locally serving hospitals — for increasingly drug-resistant organisms and Clostridium difficile. For more than two years, our local hospital has been dealing with the presence of NDM carbapenemase-producing CRE (CP-CRE), both in patients coming from India, but also with documented inter-facility transmission between the hospital and a local skilled nursing facility (SNF). As a result, the hospital staff now screen all admissions from this facility for stool colonization with CP-CRE — and every patient admitted from this facility is placed in contact isolation until their CRE stool surveillance comes back negative (much to the patients’ and their families’ consternation). Further, 11% of all SNF admissions to our facility are colonized with toxigenic strains of C. difficile, and 17% are colonized with ESBL.
Such surveillance is expensive and not reimbursed by Medicare or third parties, and is conducted solely at hospital expense in an effort to prevent inter-facility and in-hospital transmission of these pathogens. And yet, we know that stool surveillance is not sufficiently sensitive. Some patients have had active urine or bloodstream infections with negative stool surveillance. Patients with negative stool surveillance on presentation later demonstrate emergence of a resistant organism under the selective pressure of broad-spectrum antibiotics.
I chose to review this 2011 MMWR article simply to make a point. There needs to be a coordinated, regional approach to the emergence of these multidrug-resistant organisms in our communities and in long-term care facilities across the United States, facilitated by state and federal governments. Resources must be made available to long-term care facilities to improve their infection-control practices and to provide active surveillance of admissions to their facility so they can protect their long-term elderly residents and their local community hospitals.
Guidelines for isolation and cohorting of patients in long-term care facilities need to be developed. Many elderly patients essentially live in care facilities the last years of their lives, and permanent contact isolation is a depressing prospect; however, no systems have been developed to provide an alternative. Electronic alerts should be triggered when patients are transferred between facilities. (We’ve even had two CP-CRE patients and their families intentionally lie about their culture status when moving between different hospitals, even though they had been counseled and educated appropriately, because they didn’t wish to be placed in isolation, much to their own risk, as well as that of others.)
Forget Zika — this will be the emerging infection of the decade in the United States, with anticipated high rates of mortality. If the federal government is serious about controlling hospital-associated infections, resources and expertise need to be extended in this direction to long-term care facilities, as well as hospitals.