Abstract
BACKGROUND: In July 2004, four cases of ESBL+KP were diagnosed in two contiguous critical care units at a 700-bed university hospital. This represented a marked increase from an incidence of fewer than two cases per month. All were cefepime-resistant. No changes in the demographic characteristics of the patients were evident. An outbreak investigation was initiated. Twelve subsequent cases, including seven bacteremias, were identified. PROJECT: A multidisciplinary team was formed with representatives from infection control, medicine, surgery, nursing, housekeeping, respiratory therapy, and the microbiology laboratory. Efforts were directed toward early recognition of new cases and prevention of cross transmission. A list of patients with ESBL+KP was updated daily. Cases were placed on contact precautions with mandatory use of gloves and disposable gowns for any entry into the patient rooms. However, nonadherence to hand hygiene and contact precautions was observed among several staff members. Hand hygiene, including liberal use of alcohol-based hand rub, was reemphasized. Disinfection procedures for environmental surfaces and equipment were reinforced, and surface cleaning with 70% isopropyl alcohol was reinstituted. Environmental cultures were obtained. None of the cultures yielded ESBL+KP, with the exception of suctioning equipment in direct contact with body fluids from known cases. During the height of the outbreak, empiric use of contact precautions was implemented for all patients in the ICU. Nineteen isolates from 15 patients were submitted for molecular analysis. Pulsed-field gel electrophoresis (PFGE) analyses of DNA extract demonstrated that 18 of the isolates were indistinguishable. The remaining isolate was closely related to the others. CONCLUSION: The PFGE analysis confirmed our hypothesis that the transmission was related to cross contamination. Acquisition of ESBL+KP was likely multifactoral, due to horizontal transmission from infected and colonized patients and contaminated suction equipment. Control measures addressing these potential sources were successful in terminating the outbreak. Ongoing surveillance, hand hygiene, strict adherence to contact precautions and adequate environmental cleaning are essential elements to prevent recurrent outbreaks.
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