Download (cre) in a neonatal intensive care unit (nicu)

OUTBREAK OF
CARBAPENEM-RESISTANT
ENTEROBACTERIACEAE (CRE)
IN A
NEONATAL INTENSIVE CARE
UNIT (NICU)
Soichiro Kawata1, Manami Ishibashi1, Kaori Ishikawa1, Fumiko Kinoshita1,
Katsunori Yanagihara2, Koichi Izumikawa3, Hiroyuki Moriuchi1
1: Department of Pediatrics, Nagasaki University Hospital, Nagasaki, Japan
2: Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
3: Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
Disclosure of Conflict of Interest
Name of the speaker： Soichiro Kawata
We have no COI
with regard to our presentation.
Introduction
• Neonates, especially those born by C-section, are
born sterile.
• Neonates in NICU receive antibiotic treatment and
undergo various manipulations and procedures.
∴Neonates are vulnerable to colonization and
infection with multidrug-resistant bacteria.
• Carbapenem-resistant Enterobacteriaceae (CRE),
one of the most topical drug-resistant organisms
recently, is a great threat especially for children
with underlying disease.
Dr. Frieden, director of the CDC, said…
CRE is
“Nightmare
bacteria.”
CRE outbreak at the NICU
in Nagasaki Univ. Hospital
CRE outbreak at the NICU
in Nagasaki Univ. Hospital
Press Reporting
Background of our NICU
6 beds in NICU, 9 beds in GCU.
Our patients are
• Infants who undergo surgical procedure (excluding
heart surgeries) or have some underlying disease.
• low-birth-weight infants (excluding very-low-birthweight infants) born in-hospital.
Layout of beds
GCU: 9beds, 72m2
NICU:6beds, 70m2
Onset of Outbreak
Oct.
28
29
30
Nov.
31
1
2
3
1
On 3rd November, 2014…
CRE colonization was detected
in the index case.
MIC
MIC
Ampicillin
≧32
R
Cefoperazone/Sulbactam
≧64
R
Ampicillin/Sulbactam
≧32
R
Latamoxef
≧64
R
4
S
Cefmetazole
≧64
R
≦4
S
Imipenem/Cilastatin
2
I
Cefazolin
≧32
R
Meropenem
2
I
Cefotiam
≧32
R
Aztreonam
≦0.5
S
Cefotaxime
≧64
R
Gentamicin
8
I
Ceftriaxone
≧64
R
Amikacin
≦4
S
Cefditoren-Pivoxil
≧4
R
Minocycline
1
I
Cefpodoxime
≧8
R
Ciprofloxacin
≦0.5
S
Ceftazidime
≧64
R
Levofloxacin
≦0.5
S
Cefpirome
16
R
ST
≦19
S
Cefepime
16
R
Piperacillin
Piperacillin/Tazobactam
Enterobacter
Cloacae
complex
(IMP type)
CRE was isolated from 16 patients
through active surveillance culture.
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
=
negative
=
Enterobacter spp.
=
Enterobacter spp.
(CRE, metallo)
=
Klebsiella oxytoca
(CRE, metallo)
Cooperation with Infection
Control and Education Center
• Active surveillance culture once a week
• Behavior monitoring and re-education of staffs
• Strict management of medical devices
(ex: ultrasound, bronchoscope)
• Cleaning of the NICU/GCU, by the NICU/GCU staffs
• Consultation to the external expert institutions
Infection Control Committee of
National and Public University Hospital
Field Epidemiology Training Program of
National Institute of Infections Disease
Major Interventions
Hand hygiene practice per 1 patient-day at NICU/GCU
(National University Hospitals in Kyushu area in 2014)
Total: 145.9 cycles
66%
Efficacy of alcohol-based hand rubs on
hydrophilic GNR, such as Enterobacter spp.
No
MRSA hand hygiene strategy
→Changed
colonization
from hand washing to hand rubbing
34%
Changing Layout of the NICU/GCU
before
Started recording of bed positions
AFTER
“Zoning of patient areas”
Each zone includes all tools for daily patient care, such as a
hazardous waste box and personal protective equipment (PPE)
→stopped sharing tools and using a dirt disposing room.
“Cohorting”
GCU: 9 beds
CRE carriers
NICU: 6 beds
CRE colonized patients were cared by nurses
exclusively in charge of them.
19
Assessment of risk factors
significant
Risk Factors
Cases
n=16
Controls
(%)
n=24
Total
(%)
n=40
Odds
Ratio
P
value
95%CI
upper
lower
Birth Weight <2,500g
12
80
7
28
40
10.29 <0.005
1.85
Inborn
14
93
11
44
40
17.82 <0.005
1.96 805.86
stayed at only NICU
9
56
3
13
12
9
<0.01
1.55
62.5
Born with C-section
14
88
9
38
23
11.7
<0.01
1.86
121
Tube Feeding
16
100
16
67
32
0.01
1.89
-
6
85.7
1
12.5
7
42
<0.01
2.1
825.7
Mechanical Ventilation
9
56
6
25
15
3.86
0.05
0.83
18.5
CV catheter
16
0.14
0.75
-
Surgical Procedure
1
1
0.06
5.86
Antibiotics Usage
12
0.05
0.88
22.6
-
69.57
2014/1/20～3/9
Tube Feeding
not significant
20
83
36
Tube
feeding
6
4
17
6
0.71
Odds
42.0 4.2
75
10 ratio
42
22
100
• The source of outbreak thought to be based on daily
medical procedures.
About milk formulae
Milk preparation room
Dissolving
breast milk
by warm
water
• Both new and used feeding
bottles are collected to here.
• washing, sterilizing and
forming of bottles are
performed at same place.
• formed by nurse during
caring patients.
Requested nutritionists for
milk preparation
Major Interventions
• Hand hygiene
“Washing  Rubbing”
• Zoning
Completion of patient care within each zone
• Cohorting
Isolation of colonized patients
• Counterapproaches based on risk assessment
Outsourcing of milk formulae
New colonization : 0
Major Interventions
• Hand hygiene
“Washing  Rubbing”
• Zoning
Completion of patient care within each zone
• Cohorting
Isolation of colonized patients
• Counterapproaches based on risk assessment
Outsourcing of milk formulae
At the beginning of Feb., Recurrence
New
colonization
:
0
th
―From 14 , Feb. : Ward Closure―
After ward closure…
Emptying the NICU/GCU
• Discharge or Transfer to other institutes
• Moved to a Room at Pediatric ward: “Satellite NICU”
→on 28th March : No patients in the NICU/GCU
• Further interventions
130 points of Environmental Surveillance
CRE genes Positive
Incubators
Patient monitors
Dirt disposing room
Requested their
management to
Medical Equipment
Center
Negative after cleaning
th
“Cleaning” of NICU/GCU on 7 April 2015
26
130 points of Environmental Surveillance
Culture Positive
faucets
All 4 faucets were renewed.
Culture turned to be negative.
Re-opened the NICU/GCU
• All CRE positive points were confirmed to be
negative after the major cleaning.
• Restarted partial NICU activity with 2 patients
• Had attained full operation on May, 2015
• No relapse of CRE colonization until today.
Discussion
Looking back at this outbreak
• CRE-positive culture of the wash stand: cause or effect?
→ Whichever the case, thoroughgoing hand rubbing practice
decreased the exposure to water in wash stands and improved
decontamination of hydrophilic bacteria.
• Two patients developed CRE-associated diseases that were
successfully treated with tazobactam/piperacillin.
→It is noteworthy that beta-lactam antibiotics can induce AmpC,
making Enterobacter more powerful resistant bacteria.
• Fortunately, spreading of CRE to the other wards was successfully
prevented.
About interventions
• Zoning and Cohorting : It is important to visualize the respective
patient zone in an unpartitioned room like our NICU/GCU.
• Outsourcing : Understaffing is a risk of outbreak (Andersen et al, 2002).
Involvement of other professionals will improve the management.
On the other hand, efficacy of the following remains unclear:
• Cleaning : Efficacy has been proven for Streptococci and
Staphylococci (Bokulich, et al. 2013), but not for GNRs.
• Surveillance culture and environmental screening : Efficacy is
evident, but cost-effectiveness remains unclear (Williams, el at. 2014).
No studies have demonstrated
what will be the most effective approach.
Conclusion
• Once the outbreak has occurred, we cannot help
trying all possible interventions.
• Apart from cost-effectiveness, the following
procedures should be beneficial for early and
successful control of the outbreak.
Take home message
Risk Assessments, Hand Hygiene,
Zoning and Active Surveillance Culture
must be effective for control.
Economically… calculated by Infection Control and Education Center
* $ 1 = \ 1 2 0 .8 0 at M ay, 2 0 1 5
Fall in income
(Mar.-May, 2015 : compared with 1year before)
Replacing faucets
$497,004
$8,238
Drain cleaning with high pressure
$932
creating "satellite NICU"
$287
the other constructions
$13,518
Purchasing goods
(Defrosting instruments for breast milk etc.)
$17,897
PPEs for colonized patients
Surveillance culture, cost for LAMP etc.
total
$8,300
?
$546,175+α
The costs for outsourcing (cleaning incubator and washing bottles)
$12,550/month from now on!!