Infection Prevention Response to a Pediatric Patient with NDM-producing Enterobacter Colonization Without International Travel

Abstract

<h3>Background</h3> Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with high mortality worldwide, primarily due to delayed administration and limited availability of effective antibiotics. Some CRE produce carbapenemases, which confer increased resistance that can be transmitted horizontally to other Gram-negative bacteria. Although some carbapenemases, including Klebsiella pneumoniae carbapenemase, are now considered endemic in the United States, New Delhi metallo-β-lactamases (NDM) remain unusual in the U.S. and are typically associated with receipt of healthcare abroad. Here, we characterize the epidemiological investigation and infection prevention interventions implemented after an NDM-producing CRE was identified at a 490-bed academic pediatric hospital in Texas in a lymphoma patient admitted to the intensive care unit with no history of international travel. <h3>Methods</h3> Epidemiological investigation included a six-month retrospective review of CRE cases, point-prevalence survey for carriage of carbapenemase-producing isolates among inpatients admitted to the same unit as the index patient, and three-month prospective surveillance for carbapenem resistance. Infection prevention interventions were implemented to prevent hospital-based transmission of CRE. <h3>Results</h3> Six-month retrospective surveillance identified 11 CRE, but no high-level resistance or carbapenemase production. Carbapenemases were not detected in point-prevalence testing of 17 patients concurrently hospitalized in the same unit or in four additional CRE isolates identified during prospective surveillance. Infection prevention interventions included staff education; contact precautions and hand hygiene audits; additional cleaning measures in index patient rooms, including daily floor disinfection and ultraviolet light terminal disinfection; and continuation of contact precautions for the index patient during any subsequent admissions and outpatient visits. <h3>Conclusions</h3> Our investigation did not detect evidence of hospital-based transmission of NDM-CRE, suggesting the index isolate may have been acquired in the community and highlighting the potential for local transmission of NDM-producing isolates even in the absence of previously characterized risk factors. Ongoing surveillance and infection prevention strategies are necessary to detect CRE and prevent its transmission.