BACKGROUND: Multidrug-resistant organisms (MDRO) in healthcare facilities create challenges for infection control. In July, 2016, a long term care (LTC) facility reported four tracheal residents tested positive for Acinetobacter baumannii based on admission surveillance cultures. After reviewing other residents’ charts, prior MDRO infection within the last year was identified among 13 residents.
METHODS: The LTC facility’s screening protocol for newly admitted/readmitted tracheal residents required collecting a tracheal aspirate for culture. The attending physician then determined if positive results were attributable to colonization or infection. If residents were infected, the physician prescribed appropriate treatment. A point prevalence survey was conducted on all trach residents to determine the status of patient infection and whether transmission was occurring within the facility or being imported. The survey required the collection of trach aspirates/sputum cultures for Pseudomonas/Acinetobacter and stool samples/rectal swabs for carbapenem-resistant Enterobacteriaceae (CRE). Isolates were sent to the Indiana State Department of Health (ISDH) Laboratory and Centers for Disease Control and Prevention (CDC) for testing.
RESULTS: Based on pulsed-field gel electrophoresis (PFGE) results from the point prevalence survey, two main clusters of Klebsiella were identified, cluster A and cluster B, each containing two isolates. Two other Klebsiella isolates were closely related to cluster A and four others were related to cluster B. In addition, two clusters of Acinetobacter were identified, cluster A had four isolates and cluster B had two isolates. Additionally, two other Acinetobacter isolates were found to be related to cluster A and B, respectively. Finally, one cluster of Pseudomonas was identified with two indistinguishable isolates, which were the rectum and the sputum sample from the same resident. The remaining eight Pseudomonas isolates were unrelated.
CONCLUSIONS: Since all Klebsiella and Acinetobacter isolates were indistinguishable or closely related, transmission of those organisms likely occurred within the facility. Most of the Pseudomonas isolates were unrelated, suggesting importation. The ISDH and the CDC recommended that the LTC facility continue surveillance screening for newly admittance/readmitted trach residents; however, the screening protocol should be expanded to include rectal screening for CRE. Staff education is crucial in implementing tiered transmission-based precautions which includes appropriate hand hygiene, personal protective equipment, and contact precautions. Diligent environmental cleaning of frequently touched surfaces and equipment is also recommended.