1. Brandon Merritt, MPH Regional Epidemiologist

2.  To discuss two recently identified CRKP outbreaks in separate Kanawha County long- term care facilities  To identify common challenges faced while investigating CRKP outbreaks  To recommend steps to build the collaborative effort required between local health and the LTCF during a CRKP outbreak 2

3.  On April 18, 2011, KCHD was notified by DIDE of an OHFLAC report indicating multiple positive lab results for CRKP dating back to November, 2010 in four different residents in Nursing Home “A” in Kanawha County. 3

4.  Two cases cohorted together on short-term rehab wing after positive labs  At least one resident expired while roommate of positive case 4

5.  DIDE/KCHD Site Visit – May 2, 2011  Recommendations: ◦ Review the prior 12 months of laboratory results to identify previously undetected cases ◦ Perform peri-rectal surveillance swabs on roommates of identified positives. ◦ Improve facility’s disease/infection tracking and include resistance status of organisms. ◦ Emphasize hand hygiene compliance with facility staff. 5

6.  After much discussion and convincing, surveillance cultures performed on June 28, 2011 ◦ Arranged with local lab for Modified Hodge Test ◦ No additional colonized or infected residents were identified of the 16 surveillance swabs  Implemented hand hygiene monitoring program 6

7.  “MDRO and Infection Control for Long Term Care Facilities”--June 21, 2011 ◦ Agenda included:  The ABCs of MDROs  Recognizing and Reporting Outbreaks  TB Control in LTCFs  Closed PODs in LTCFs (Emergency Preparedness) 7

8.  Nursing Home “B” informed KCHD of “possible KPC” the day of “MDRO and Infection Control for Long Term Care Facilities” ◦ CRKP confirmed on 6/23/2011  Resident had recently been in and out of hospital due to hip surgery  Previously had clear urine labs 8

9.  Recommendations for Nursing Home B were virtually the same as Nursing Home A ◦ 12 month lab look back ◦ Identify previous roommates and perform peri- rectal surveillance swabs ◦ Place colonized/infected residents under contact precautions and in single room if possible ◦ Emphasize hand hygiene compliance among staff and enhanced environmental cleaning 9

10.  Look back completed ◦ One additional case was identified, and… ◦ SURPRISE! New case was also an identified case from the outbreak at Nursing Home A  Surveillance Cultures performed on July 18 ◦ Eight residents tested  All negative for CRKP 10

11.  Lack of Reporting ◦ Neither facility was aware that a single case of CRKP should have been considered an outbreak and therefore reported to the health department immediately  Physician Resistance ◦ Inattention to susceptibility profiles ◦ Treating with end line antibiotics  Corporate Resistance ◦ IC manuals generally treat CRE/CRKP same as MRSA 11

12.  Importance of Collaboration with LTCF ◦ Relationship building ◦ Emphasizing local health as supporting agency  Provide Resources  Education, Education, Education ◦ IC staff, administration, physicians, corporate Nevertheless, there’s a long way to go. 12

13. 108 LEE STREET EAST CHARLESTON, WV 25301 304-344-KCHD(5243) 13

14. 1 Carbapenem Resistant Klebsiella Pneumoniae (CRKP) Somu Chatterjee MPH., M.B.B.S. Regional Epidemiologist, Wheeling-Ohio County Health Department Email: somu.k.chatterjee@wv.govsomu.k.chatterjee@wv.gov Ph: 304-234-3682 Cell: 304-830-3710

15. 2 Carbapenem Resistant Klebsiella Pneumoniae (CRKP) Case background Challenges faced Public Health Action

16. 3 Case Background Friday the 13 th, 4:30 pm 2 cases of CRKP reported by Hospital X

17. 4 Case Background cont.. Ms A. 67 yrs. F, had surgery in Hospital Y (04/19)  transferred to Hospital Z (04/23)  Life - flighted to Hospital X (04/23)  Expired on 05/10 Reported to LHD on 05/13 Status on admission: Septicemia, Hypotension Acute Renal Failure Cardiogenic Shock Fever etc. } +ve Blood Cx

18. 5 Case Background cont.. Ms B. 79 yrs F Inpatient in Hospital X from 04/16 – 05/12 2 beds away, in the same Unit Past History: Was at home for 2 months before admission. LTCF resident Skilled unit of Hospital X Myasthenia Gravis Current admission: Dysphasia, Low grade temp. Bronchial Washing  CRKP

19. 6 Challenges Faced Confirm if 2 cases meet CRKP definition Culture reports Lab methods used Location in Hospital X, where exposure occurred

20. 7 Challenges Faced cont.. Protocols in place to prevent infection If other patients in the Hospital X were infected with CRKP Where, When and How was the infection acquired

21. 8 Public Health Action Lab methods used; Sensitive CRKP, Elevated MIC (Minimum Inhibitory Conc.) Modified Hodge Test Automated indicators of elevated MIC Lab upgraded to CLSI and CDC guidelines Location: SICU, MICU

22. 9 Public Health Action cont.. Infection Control Protocols: Automated alert on EMR System Suggested to: Observe / Monitor environmental cleaning Use FDA approved disinfectants

23. 10 Public Health Action cont.. Exposed Patients: Epi linked Active surveillance  Rectal swabs & Culture  7 patients; all negative for CRKP 6 Month review of CRKP in Hospital X: Microbiological review Frequency of CRKP cases

24. 11 Public Health Action cont.. 6 month review results: 6 patients with CRKP Conf call DIDE, LHD, Hospital X 2 patients. Not CRKP 4 patients with CRKP 3 in-patients in SICU/MICU 1 outpatient. Diagnostic aspiration from body cavity in radiology ¾ patients came from Ohio & 2 had been in a particular LTCF X

25. 12 Public Health Action cont.. Suggestions for screening: Pre-emptive isolation of ptns from LTCF X Active surveillance on Epi linked patients. Periodic point prevalence If negative, be selective: -- Susceptible -- High risk areas.

26. 13 CONCLUSIONS Team Work !! Depending on number of cases reported: None or rarely detected (≤ 1 / month) Periodically detected (2-3 cases /month) Options: 6-12 months of Micro reports Repeat Surveillance Point prevalence study Monitor cleaning performance.