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Carbapenem-resistant Enterobacteriaceae (CRE) infections are difficult to treat and
pose a significant threat to public health. In July 2018, an infection preventionist
(IP) notified Los Angeles County Department of Public Health (LACDPH) of eight cases
of healthcare-onset carbapenem-resistant Klebsiella pneumoniae (CRKP) among residents
of a 54-bed long term acute care facility (LTAC). LACDPH initiated an investigation
to identify risks for infection and disrupt transmission.
A case was defined as a LTAC patient with laboratory confirmation for CRKP or carbapenemase-producing
organism from June 28- August 7, 2018 and no previous CRE history. LACDPH conducted
two site visits of the facility to observe infection prevention practices. Medical
records, staff training records, and infection prevention audits were reviewed. Facility-wide
surveillance cultures were collected on three dates.
The first facility-wide screening yielded 13 additional cases; no further cases were
identified during subsequent screenings. Medical record review found one additional
case. A total of 22 cases were identified; overall prevalence was 39%. Site observations
revealed missed hand hygiene opportunities, unclear contact precaution signage, and
a knowledge deficit among staff regarding CRE and control measures. LACDPH recommended
enhanced environmental cleaning, infection control trainings for all staff, hand hygiene
and personal protective equipment audits, placing new admissions on contact precautions
pending CRE screening results, and the use of an interfacility transfer form upon
discharge of all known CRE patients.
We identified a high prevalence of CRE in an LTAC, a setting where patients generally
have higher invasive device and antibiotic utilization than other settings. However,
the implementation of evidence-based infection prevention practices enabled the facility
to stop the spread of infection. Identification and containment of a CRE outbreak
in a healthcare facility relies on several factors, including the collaboration of
a facility's IP with the local health department and continuing frontline staff education.
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© 2019 Published by Elsevier Inc.
