BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE), particularly carbapenemase-producing CRE (CP-CRE), is an emerging threat to public health. CP-CRE is believed to be one of the primary reasons for the increasing spread of CRE in the United States. Although CRE did not officially become reportable in New Mexico until June 15, 2016, this case study demonstrates the first documented transmission of CP-CRE in New Mexico.
METHODS: On November 30, 2015, New Mexico Department of Health (NMDOH) was notified via electronic laboratory reporting (ELR) of a CRE urine specimen from patient A that tested positive by Modified Hodge Test. NMDOH notified the infection preventionist (IP) at the long-term acute care (LTAC) facility; CDC recommended CRE prevention methods were initiated immediately. The isolate was sent to CDC for confirmation. On December 29, 2015, NMDOH was notified by an IP at an acute care hospital of a second patient whose respiratory culture tested positive for CRE; CDC recommended CRE prevention methods were already implemented. Patient B’s isolate was shipped to CDC for confirmation. Interviews revealed patient A and patient B were roommates at the LTAC. Conference calls were held to open the lines of communication among all healthcare facilities as well as the local reference laboratory. Rectal swabs were collected from roommates at each of the healthcare facilities and sent to the local reference laboratory. An onsite visit was conducted at the LTAC and point prevalence culture surveillance was initiated.
RESULTS: CDC laboratory results confirmed that patient A and patient B were Klebsiella pneumoniae carbapenemase (KPC) positive for Enterobacter cloacae, which also had similar susceptibility reports. NMDOH screened 8 of the 10 roommates. The length of time each person roomed with either patient A or patient B varied from 2-13 days, however, all test results were negative. The original rectal swab for patient B was never tested due to an error in the paperwork submitted to the local reference laboratory; this was never communicated to the IP at the LTAC. When patient B was discharged to the skilled nursing facility, it was never communicated that patient B had pending results for CRE.
CONCLUSIONS: NMDOH identified transmission of a CP-CRE in the LTAC, which was compounded by subsequent miscommunication among healthcare facilities and the local reference laboratory. This case study illustrated the importance of communication among healthcare facilities to help prevent the spread of CRE in LTAC and other communities in New Mexico.