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Concurrent transmission of multiple carbapenemases in a long-term acute-care hospital
Danielle A Rankin1,2,3, Maroya Spalding Walters3, Luz Caicedo1
1Florida Department of Health in Orange County, Orlando, Florida.
Objective:
We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying blaVIM (VIM-CRPA) and Enterobacterales carrying blaKPC (KPC-CRE) at a long-term acute-care hospital (LTACH A).
Methods:
We defined an incident case as the first detection of blaKPC or blaVIM from a patient's clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing.
Results:
From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had blaKPC, 11 had blaVIM, and 7 had blaVIM and blaKPC. Also, blaKPC were identified from 7 Enterobacterales, and all blaVIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates.
Conclusions:
Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. Epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of VIM-CRPA and KPC-CRE and to the transfer of carbapenemase genes across different bacteria species and strains. Improved infection control, including interventions that minimized potential spread from wastewater premise plumbing, stopped transmission.
Insights
Concurrent outbreaks of carbapenemase-producing organisms (CPO) were identified at a long-term acute-care hospital. Improved infection control measures, including addressing wastewater contamination, successfully halted the spread of these resistant bacteria.
Area of Science:
- Infectious Diseases
- Microbiology
- Hospital Epidemiology
Background:
- Long-term acute-care hospitals (LTACHs) are vulnerable settings for healthcare-associated infections.
- Carbapenemase-producing organisms (CPO), including VIM-CRPA and KPC-CRE, pose significant treatment challenges.
- Concurrent outbreaks of different CPO strains can complicate infection control efforts.
Purpose of the Study:
- To investigate concurrent outbreaks of VIM-CRPA and KPC-CRE at a specific LTACH.
- To identify the sources and transmission routes of these carbapenemase-producing organisms.
- To evaluate the effectiveness of infection control interventions.
Main Methods:
- Defined incident cases based on the first detection of blaVIM or blaKPC.
- Conducted medical record reviews, infection control assessments, and colonization screening.
- Utilized pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing for molecular characterization of clinical and environmental isolates.
Main Results:
- Identified 76 incident cases of VIM-CRPA and KPC-CRE between July 2017 and December 2018.
- Detected CPO in clinical cultures, colonization screening, drains, and toilets, indicating environmental contamination.
- Found evidence of carbapenemase gene transfer across different bacterial species and strains, alongside multiple introductions.
Conclusions:
- Concurrent CPO outbreaks were identified and linked to a single colonized patient.
- Multiple introductions and horizontal gene transfer contributed to the observed diversity of CPO.
- Enhanced infection control, particularly interventions targeting wastewater, effectively stopped transmission.
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