METHODS: Beginning in February 2015, weekly rounds of CRE surveillance cultures were collected from patients on affected units. CRE isolates were assessed for KPC production by polymerase chain reaction. Infection control measures to prevent transmission of CRE included: CRE screening of all newly admitted patients; placing all patients in contact precautions; physical cohorting and assignment of dedicated nursing, respiratory therapy, and hospitalist physician staffing for CRE patients; chlorhexidine bathing of all patients; rigorous environmental cleaning; and notifying facilities receiving CRE patients upon transfer.
RESULTS: From January to April, 2015, CRE surveillance cultures identified 23 patients with KPC-CRE (Figure 1). Patients had a median of length of stay at the LTAC hospital of 31 days (range 11- 431) before KPC-CRE identification. Public health investigators found many appropriate prevention strategies in place, although hand hygiene adherence was incomplete at 77% (33 of 43 observed opportunities), personal protective equipment was not consistently donned and doffed correctly when entering and exiting patient rooms, and shared cabinets for medications and wound care supplies were not sufficiently separated. After seven rounds of surveillance cultures, no further KPC-CRE was identified in 10 rounds of surveillance cultures from May to August 2015.
CONCLUSIONS: A substantial KPC-CRE outbreak at a single LTAC hospital in a low CRE prevalence region was contained following prompt recognition of two patients with CRE. Implementation of multiple rounds of CRE surveillance cultures allowed for targeted infection control measures including physical cohorting and use of dedicated staff for CRE patients. Public health must be prepared to assist healthcare facilities to rapidly respond to clusters or outbreaks of CRE by implementing surveillance cultures and adopting prevention measures, even in regions with low CRE prevalence.