dcasip.medicine.duke.edu

CP-CRE Transmission Related to ICU Room SinksSARAH LEWIS, MD MPH

GoalShare our experience with CP-CRE in sinksCompare/contrast management strategies Novel mechanism of resistance and isolated sink colonization Endemic mechanism of resistant and widespread sink colonization

Reiterate importance of hospital design and basic infection prevention strategies to reduce transmission of CP-CRE

BackgroundInfection Prevention noted an increase in CRE clinical isolates in July 2017 Mass education (HCWs, EVS, patient/families) Enhanced communication regarding CRE patient locations and transfer Increased hand hygiene/PPE compliance observations rooms of CRE patients Enhanced environmental cleaning in rooms of CRE patients (whole house) and high-risk units

(4 adult ICUs) – bleach and TruD Tracked CRE acquisitions in space/time to determine possible modes of transmission Began weekly point prevalence screening of patients in 4 adult ICUs mid-October 2017

3/2/2017 3/30/2017 4/27/2017 5/25/2017 6/22/2017 7/20/2017 8/17/2017 9/14/2017

Patient A Unit 1Patient B Unit 1Patient C Unit 1Patient E Unit 1Patient F Unit 1Patient G Unit 2Patient H Unit 2Patient J Unit 2Patient K Unit 3Pateint L Unit 3Patient M Unit 3Patient N Unit 3Patient N Unit 3Patient N Unit 4Patient N Unit 4Patient O Unit 4Patient K Unit 4Patient P Unit 5Patient B Unit 5

3/2/2017 3/30/2017 4/27/2017 5/25/2017 6/22/2017 7/20/2017 8/17/2017 9/14/2017

Patient A Unit 1Patient B Unit 1Patient C Unit 1Patient E Unit 1Patient F Unit 1Patient G Unit 2Patient H Unit 2Patient J Unit 2Patient K Unit 3Pateint L Unit 3Patient M Unit 3Patient N Unit 3Patient N Unit 3Patient N Unit 4Patient N Unit 4Patient O Unit 4Patient K Unit 4Patient P Unit 5Patient B Unit 5

Silent colonization?Persistent environmental source?

Sink Cultures Round 1 3 patients developed KPC+ Klebsiella pneumoniae

clinical cultures soon after admission to the same ICU room over a 3 month span In-room sink drains of the ICU room in common were

cultured and colonized with KPC+ Klebsiella pneumoniae Relatedness of patients and environmental isolates

confirmed by whole genome sequencing

Many questions….What do we do with colonized sinks? Removal? Disinfection? Room Closure?

Do we look for other colonized sinks?Expert advice:Mitigate epidemiologically-linked sinksFocus on evidence-based CRE prevention measuresCautioned against going looking……

Sink Cultures: Round 23/2018: Notified by reference laboratory of positive rectal surveillance screen for KPC Citrobacter and NDM-1 K. pneumoWhere did the NDM-1 come from? Current patient admitted <1 week prior to positive culture but no healthcare contacts, foreign travel A second patient had been admitted to DUH 9 months previously who developed

clinical infection with NDM-1 K. pneumoniae No typical risk factors for NDM-1 Had been discharged from our facility for several weeks by the time the result returned from the state

lab On review of location history, the patient from 9 months prior had spent a significant

amount of time in the same ICU room as the current patient

Documenting the chain of infection Cultures from the drain and P trap of

the ICU room sink also grew KPC-Citrobacter and NDM-1 K. pneumo

We performed this experiment anddocumented transmission of KPC-Citrobacter to sink edge during use

We removed the sink drain and P trap

Patient Age Admitting Diagnosis Date of Isolation

Site of Isolation

Status

1 48Liver transplant (in 

India) complicated by liver abscesses

2/2015Liver 

abscess Infected

2 67Hospital transfer for respiratory failure due 

to thyroid mass7/2017 Bacteremia Infected

3 77Hospital transfer for massive pulmonary 

embolism3/2018 Rectal swab Colonized

Clinical and Epidemiological Characteristics of Patients Infected or Colonized with NDM-1 K. pneumoniae

Whole Genome Sequencing Results of Patient and Environmental NDM-1 K. pneumoniae Isolates

Whole Genome Sequencing

<20 SNV

• No additional cases of NDM-1 colonization or clinical cultures have occurred since 3/2018

Sink Point Prevalence Study: April-May 2018All patient room sink drains and P traps were swabbed and sampled and cultures processed by UVA labs for carbapenemase-producing bacteria

Results: ICU 1: 92% of patient room sinks contaminated with KPC+ organisms ICU 2: 88% of patient room sinks contaminated with KPC+ organisms ICU 3: 69% of patient room sinks contaminated with KPC+ organisms (No sinks positive for NDM-1)

Opportunities for Improvement

Mitigation Strategies at DukeRelocation of hooks away from sinks in DMPModifications of sinks to restrict water flow, discharge away from drain, and minimize splashingNew solutions for storage of linens, pillows, supplies away from sinkSink Safety Education Separation of clean and dirty tasks Do not prime IV tubing into sink Do not place patient care items on/around sink prior to their use Use appropriate waste receptacles

Hospital-acquired KPC CRE Colonization

0

2

4

6

8

10

12

14

Total Clinical Isolates Total Rectal Screens

Hook relocation/faucet change begun

Hook relocation completed

Implemented rectal surveillance programCompleted sink prevalence study and shared initial results and recommendations

Sink guidance document shared

ConclusionsWe identified widespread colonization of our ICU room sinks with KPC-CRE (despite a historically low prevalence of clinical cultures positive for KPC)Implementation of a comprehensive CPO prevention bundle including weekly rectal point prevalence screens in high risk units significantly decreased transmission of CP-CRE (despite widespread environmental contamination)Low-cost interventions (education, sink modification, hook removal) further reduced transmission of CP-CRE in our hospitalRemoval of plumbing may be considered when the is evidence of isolated sink colonization/novel mechanism of resistance