BACKGROUND: Klebsiella pneumoniae Carbapenemase (KPC)-Producing Carbapenem Resistant Enterobacteriaceae (CRE) have a resistance mechanism that can spread rapidly, making prevention crucial. In October 2016 a 120-bed skilled nursing facility voluntarily notified the Pennsylvania Department of Health of 6 cases of CP-CRE among residents since January 2016. We gave recommendations following CDC guidelines for CRE. We investigated to identify risk factors and prevent further cases.
METHODS: On October 26, we completed a site visit to review prevention measures and observe infection control practices. We performed case finding by reviewing medical records. A case was defined as a specimen positive for CRE from any site during 2016 in a facility resident. Rectal surveillance cultures were collected during November 7–15 from 4 residents who were known to be positive for CRE and 7 residents who had a CRE-positive roommate in the past 2 years. Specimens were sent to CDC for culture, mechanism testing, and PFGE. In December, we conducted a point prevalence survey. Rectal screening of 77/88 (88%) residents was completed and specimens were tested for KPC by polymerase chain reaction. We performed a cohort analysis to examine risk factors for colonization using Fisher’s Exact Test.
RESULTS: Suboptimal infection control practices were observed including poor technique with personal protective equipment and urinary catheter care, and inadequate environmental cleaning; we provided recommendations accordingly. We confirmed 7 cases of clinically-diagnosed CRE. All were urine specimens from patients with indwelling urinary catheters. Surveillance specimens revealed one colonized roommate for a total of 8 cases. All available surveillance (n=5) and clinical (n=3) specimens were identified as KPC-CRE. PFGE revealed two clusters of closely related patterns and several unrelated patterns. Our point prevalence survey revealed 13 additional cases of KPC-CRE for a total of 21 cases. The only independent risk factors for colonization were a history of another multidrug-resistant organism (17% among non-colonized residents vs. 46% among colonized residents; p=0.03) and room location on wing A (41% vs. 85%; p=0.01). Indwelling urinary catheters were common in clinically-diagnosed residents but were not a risk factor for colonization. In addition to recommendations for CRE control according to CDC guidelines, we recommended rectal screening for CP-CRE of new admissions to the facility.
CONCLUSIONS: KPC-CRE cases likely occurred in this facility due to multiple importations and intra-facility transmission, particularly on wing A. Although recommendations were made to reduce transmission within the facility, regional prevention efforts are needed to reduce the likelihood of reintroduction of KPC-CRE.