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BACKGROUND: MDR-Ab is challenging to control in healthcare settings due to its colonization potential, propensity for antimicrobial resistance, and extensive contamination of and prolonged survival in the environment. An increase in cases of MDR-Ab in a 5 county region of West Virginia was reported to public health in April 2012. Involved healthcare facilities included two large hospitals (A and B), an outpatient wound clinic, and 8 nursing homes. Investigations were launched to determine the extent of the outbreak and characterize risk factors.
METHODS: A case of MDR-Ab was defined as a patient with first positive culture between January 1 and August 31, 2012; the Association for Professionals in Infection Control and Epidemiology MDR-Ab definition was used. Retrospective lab review of MDR-Ab incidence from January 2006 to August 2012 was conducted by hospital A. Analysis of descriptive data was completed for all hospital cases, and site visits were conducted at both hospitals and the clinic. Standardized observations of wound care, respiratory therapy, and environmental cleaning were completed; environmental samples were taken and compared with clinical specimens by molecular typing. Periodic regional multidrug-resistant organism (MDRO) meetings between public health, hospitals, and nursing homes were initiated.
RESULTS: Cases of MDR-Ab at hospital A increased from 1 case in 2008 to 17 cases in 2011. Between January 1 and August 31, 2012, 23 cases were identified in hospital A, and 15 in hospital B. Of the 38 cases identified in 2012, median age was 61, 63% were female; risk factors included wounds (87%), prior healthcare exposure (hospital A 53%, nursing homes 53%, wound clinic 26%), and recorded infection/colonization with another MDRO (58%). Infection control deficiencies were identified in all 3 facilities. Molecular typing showed genetic diversity among clinical isolates. Following the investigation, hospital A started an MDRO task force with front-line staff; 3 facilities educated their staff using public health provided materials; and public health continued hosting regional meetings. The initial infection rate of 4.8 cases/month decreased to 3.7 cases/month in the subsequent year; the decrease, however, is not statistically significant (p=0.2).
CONCLUSIONS: A widespread, long-standing regional outbreak of MDR-Ab occurred with multiple strains circulating across multiple healthcare facilities. Cases continue to be identified despite public health intervention. MDR-Ab is extremely difficult to control in healthcare settings; limited public health resources make long-term follow-up challenging. Public health impact could be improved with resources to implement a prevention collaborative which would allow for sustained control of MDRO outbreaks.