Antimicrobial-Resistant Organism Outbreak in a Skilled Nursing Facility in Pennsylvania, 2019

Abstract

Background: In April 2019, the Montgomery County Office of Public Health (MCOPH) was notified by the Pennsylvania Department of Health (PADOH) of a tier 2 carbapenemase mechanism in a resident of a Pennsylvania skilled nursing facility that was detected through targeted surveillance. Production of the New Delhi metallo-β-lactamase (NDM) carbapenemase was detected using polymerase chain reaction (PCR). The initial follow-up revealed that the patient resided at a 148-bed skilled nursing facility that specializes in spinal cord injury, neurological diseases, ventilator dependence, and pulmonary diseases. MCOPH and PADOH initiated an investigation to identify additional cases and prevent transmission. Methods: Over a series of 9 point-prevalence surveys, we collected 518 specimens for colonization screening. Screening was conducted on the wing of the index case and was later expanded to include the entire unit (n = 90), after evidence of transmission was noted. Perirectal swabs were submitted to the regional antibiotic resistance laboratory for testing using the Cepheid GeneXpert Carba-R assay. Together with screening, MCOPH and PADOH conducted a series of on-site visits involving the completion of the CDC infection control assessment and response (ICAR) tool and direct care observations, including 409 hand hygiene observations. Results: In addition to NDM, Klebsiella pneumoniae carbapenemase (KPC) and Verona integron-encoded metallo-β-lactamase (VIM) were also detected. ICAR results and direct care observations revealed numerous deficiencies in the domains of hand hygiene, personal protective equipment, and environmental cleaning. In addition to 2 cases of carbapenemase-producing organisms (CPO) being detected through clinical specimens, an additional 27 CPO cases were identified through screening coordinated by public health. This large, multimechanism outbreak is attributed to a combination of intrafacility transmission and imported cases. Based on these findings, recommendations for infection prevention and control were provided on site and in writing. Our continued work with this facility lead to improvements in infection control, including a HH success rate improvement of 53%. Conclusions: Novel or targeted multidrug-resistant organisms are effectively contained when healthcare facilities and state and local public health work together to reduce transmission to baseline and to improve infection control practices.Funding: NoneDisclosures: None