Effective Public Health Response in Carbapenemase-Producing Carbapenem Resistant Enterobacteriaceae (CP-CRE) Outbreak in a Georgia Long Term Care Facility (LTCF), 2018

Abstract

BACKGROUND CP-CRE are an urgent public health threat in the United States because they are associated with high morbidity/mortality, limited treatment options, and high transmissibility. In addition to providing care to a high-risk population, LTCFs often lack a trained Infection Preventionist (IP). From August 15 to September 7, 2018, a 93-bed LTCF had 6 residents with clinical cultures positive for Klebsiella-Producing Carbapenamase (KPC) CRE; all 6 residents were located in their 13-bed ventilator unit. METHODS The Georgia Department of Public Health (DPH) and local Health District engaged executive leadership in containment efforts, visited the facility to observe and provide on-site recommendations, created a detailed infection control plan, conducted admission/readmission screenings to identify colonized residents upon admission, and held regular follow-up conference calls to facilitate remediation of infection control deficiencies. DPH facilitated monthly point prevalence surveys of known CP-CRE negative patients to assess facility transmission. Point prevalence rectal swabs were tested by the Antibiotic Resistance Laboratory Network in Tennessee for CP-CRE using real time Polymerase Chain Reaction testing. RESULTS The initial point prevalence screening conducted on 10/4/2018 included collection of 20 swabs and identified four additional KPC CRE (20%), suggesting inter-facility transmission. The second point prevalence screen conducted on 11/05/18 included 12 swabs and identified one Carbapenamase-Producing Pseudomonas aeruginosa (CPRA) (8.3%). The third swabbing on 12/05/18 included 13 swabs and identified no new transmission. Between 10/24-10/30/2018, five admission swabs were collected, and two were positive for KPC CRE, representing a 40% CP-CRE importation rate for that period. A follow-up visit conducted on 12/3-12/4/2018 validated compliance with the infection control plan. CONCLUSIONS The LTCF outbreak consisted of both inter-facility transmission and importation of CP-CRE, and Public Health's comprehensive response effectively contained this pathogen. Key response elements include executive leadership engagement, tailored infection control plans, and collaboration between Public Health and healthcare facilities to limit inter-facility transmission. CP-CRE are an urgent public health threat in the United States because they are associated with high morbidity/mortality, limited treatment options, and high transmissibility. In addition to providing care to a high-risk population, LTCFs often lack a trained Infection Preventionist (IP). From August 15 to September 7, 2018, a 93-bed LTCF had 6 residents with clinical cultures positive for Klebsiella-Producing Carbapenamase (KPC) CRE; all 6 residents were located in their 13-bed ventilator unit. The Georgia Department of Public Health (DPH) and local Health District engaged executive leadership in containment efforts, visited the facility to observe and provide on-site recommendations, created a detailed infection control plan, conducted admission/readmission screenings to identify colonized residents upon admission, and held regular follow-up conference calls to facilitate remediation of infection control deficiencies. DPH facilitated monthly point prevalence surveys of known CP-CRE negative patients to assess facility transmission. Point prevalence rectal swabs were tested by the Antibiotic Resistance Laboratory Network in Tennessee for CP-CRE using real time Polymerase Chain Reaction testing. The initial point prevalence screening conducted on 10/4/2018 included collection of 20 swabs and identified four additional KPC CRE (20%), suggesting inter-facility transmission. The second point prevalence screen conducted on 11/05/18 included 12 swabs and identified one Carbapenamase-Producing Pseudomonas aeruginosa (CPRA) (8.3%). The third swabbing on 12/05/18 included 13 swabs and identified no new transmission. Between 10/24-10/30/2018, five admission swabs were collected, and two were positive for KPC CRE, representing a 40% CP-CRE importation rate for that period. A follow-up visit conducted on 12/3-12/4/2018 validated compliance with the infection control plan. The LTCF outbreak consisted of both inter-facility transmission and importation of CP-CRE, and Public Health's comprehensive response effectively contained this pathogen. Key response elements include executive leadership engagement, tailored infection control plans, and collaboration between Public Health and healthcare facilities to limit inter-facility transmission.