Volume 7 | Issue 24 | June 10, 2014 “Heroes” award from APIC Infection Control Honored for Closing the Door on Drug-Resistant Bugs By Tyler Smith About a year and a half ago, members of University of Colorado Hospital’s Infection Control team detected a lab culture of a UCH patient infected with carbapenem-resistant Enterobacteriaceae (CRE), bacteria that can cause often untreatable infections whose global rise has been stoked by the inappropriate use of antibiotics. Two weeks later, another CRE-infected hospital patient was identified, raising the brightest red flag possible. Hunt begins. A massive, hospital-wide effort to contain the highly contagious bug ensued after the Infection Control team flagged the second case. The work included tight patient surveillance, broad-scale testing, intensive cleaning, provider education, close work with state and federal agencies, and a thorough review of procedures aimed at sealing the gaps through which the potentially deadly organisms might slip. “Two cases of CRE is an outbreak,” Michelle Barron, MD, the hospital’s infectious disease medical director said. The stakes were high. In 2011, an outbreak of carbapenemresistant Klebsiella pneumoniae – a type of CRE – at the National Institutes of Health Clinical Center killed 11 patients and sickened another seven. The two patients initially identified at UCH were infected by CRE containing a gene called NDM-1. Like the organism that wreaked havoc at the NIH, NDM-1 CRE produces an enzyme that breaks down carbapenems, a powerful group of antibiotics generally considered a last resort in fighting infections. Members of the Infection Control team at UCH will be honored by the Association for Professionals in Infection Control and Epidemiology (APIC) in June for their work in containing an outbreak of a drug-resistant organism. Left to right: Linda “B” Burton; Tara Janosz; Susan West; Chris Olson; Teri Hulett; Larissa Pisney, MD; Michelle Barron, MD; Teresa Ruiz. Early next month, the UCH Infection Control team will be in Anaheim, Calif., to receive a “Heroes of Infection Prevention” award at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). The team’s extraordinary efforts in the face of the CRE outbreak led to the honor. Quelling the outbreak required an initial investigation to determine if the first patient transmitted the infection to the second – and if it had spread. That meant working with hospital administration and nursing staff to screen all patients who had been on units where the original patient was admitted. Hundreds of patients required rectal swabs and testing for infection. Into the lab. That effort, in turn, spurred a quick gear-up by the Microbiology team in the Clinical Laboratory. Led by Technical Specialist Elizabeth Kassner, MT(ASCP), Microbiology instituted a screening protocol for CRE established by the Centers for Disease Control and Prevention (CDC) within days. Kassner downloaded the CDC protocol, wrote a procedure for testing, validated it, made sure the testing supplies were in-house, Subscribe: The Insider is delivered free via email every other Wednesday. To subscribe: [email protected] Comment: We want your input, feedback, notices of stories we’ve missed. To comment: [email protected] Continued Volume 7 | Issue 24 | June 10, 2014 | Page 2 and helped train staff to run the protocol and identify the rogue organisms if they colonized in cultures. The hospital notified the Colorado Department of Public Health and Environment (CDPHE) and the CDC of any samples that tested positively for CREs. which sent staff who set up shop in the hospital for several weeks, walking units, clinics, and hallways with Barron as anxious staff looked on. The scrutiny and precautions were intense. Environmental Services conducted deep terminal cleans of surfaces, curtains, furniture, and equipment. The work revealed previously overlooked gateways, including equipment and mats in the Inpatient Rehabilitation Unit gym and patient ventilators, neither of which had logs to document terminal cleans. Those oversights were corrected as a result of the work. Elizabeth Kassner, technical specialist in the Microbiology Lab at UCH, led a massive screening effort to identify patients infected with NDM-1 CRE. The volume of additional work was significant – as many as 30 cultures and three or four extra hours of work each day without additional staff, Kassner said. The work was also “brand-new territory,” she said. In addition, the Infection Control team used the Epic electronic health record to find every patient who had been on units with the originally colonized patients between May and September 2012. The hospital identified roughly 1,400 patients in that group and flagged their charts so that when they were readmitted to the hospital they could be tested for the microbe. Seven more patients tested positive for CRE, but none of those had the NDM-1 enzyme. As for the patients with NDM-1 CRE, Barron treated them with a combination of antibiotics she readily admits she made up. “There was no data to support it,” she said, “but it cleared the infections.” The hospital has had no new cases in more than a year. “It was my life for a couple of months,” said Kassner, a 34-year Clinical Lab veteran who said she’d never encountered a microbial threat of this magnitude. “I’ve seen drug-resistant organisms a few times, but nothing like this,” she said. “The need for screening was huge.” The screenings identified six additional patients infected with NDM-1 CRE. Using pulsed field gel electrophoresis, the lab genetically typed each sample and found they were clones of one another. The first patient had been in the hospital several times, Barron said, and had been the original source of the infection. But a mystery emerged that remains unsolved: The first patient had never been in proximity with the others, meaning a “ghost” carrier had at some point entered the picture and provided the link from the first patient to the others. Closing the door. Regardless, the Clinical Lab results confronted Barron and the Infection Control team with the frightening possibility of a large CRE outbreak in the hospital – and a large population of unknowingly infected patients being discharged to the community. They notified the CDPHE and the CDC, both of Hard lessons. As stressful as the episode was, the hospital benefited from it, Barron said. In reporting the cases to the CDPHE, she and her team alerted other hospitals in the state to the increasing danger of difficult to treat hospital-acquired infections. “It opened eyes,” Barron said. “We helped to make other facilities aware that even if you haven’t seen CRE, it’s there.” Continued Volume 7 | Issue 24 | June 10, 2014 | Page 3 The outbreak also helped the hospital shore up its infection defenses and improved its ability to respond early if CRE cases crop up again. Susan Dolan, RN, CIC, an epidemiologist with Children’s Hospital Colorado, summed up the change in a letter nominating the Infection Control team for the APIC award. “Through an epidemiologic investigation and education, the [Infection Prevention and Control] team put into place a sustainable model to detect patients potentially colonized with CRE as a result of an outbreak of NDM-1 CRE at the hospital,” Dolan wrote. For her part, Barron also sees the drama as an illustration of the hospital’s ability to respond to crises. “There was a lot of extraordinary work beyond what we all normally do,” she said. “It shows that being under duress brings out the best in people.”