The First New Delhi Metallo-β-lactamase (NDM-1) Pseudomonas Aeruginosa Outbreak Identified in the United States in an Acute Care Hospital

Background: New Delhi metallo-β-lactamases impart resistance to carbapenems. Enterobacteriaceae carrying New Delhi metallo-β-lactamases have been reported before. However, only 7 cases of blaNDM-carrying Pseudomonas aeruginosa has been reported from 4 states in the United States as of January 1, 2018, according to the CDC. We describe an epidemiologic investigation of the first reported case of blaNDM-carrying Pseudomonas aeruginosa in Texas and the measures that controlled the spread of the organisms carrying this gene at a 30-bed spinal cord injury unit (SCI) and the acute-care hospital within the Veterans’ Affairs North Texas Health Care System. Methods: After identification of blaNDM-1–carrying P. aeruginosa from a urine culture in an SCI patient who received medical treatment in Thailand prior to transfer, we performed a rectal screen for the presence of blaNDM in the index patient’s hospital roommates. Based on the results, we expanded the investigation to other patient care units that had provided care to the patient. We initiated universal contact isolation precautions, 1:1 nursing care, restricted movement, phased point-prevalence testing, and intense environmental cleaning until the threat of blaNDM was mitigated. Whole-genome sequencing (WGS) was performed on clinical isolates from the index patient and the roommates by the CDC. Results: Of the 2 roommates of the index, 1 patient had a urine culture positive for blaNDM-5-carrying Escherichia coli. The second roommate has subsequently grown blaNDM-1-carrying P. aeruginosa from a clinical culture. A third patient who was in the same unit as the index patient but not in the same room in an acute-care unit tested positive for blaNDM in a rectal screen. Of the 54 patients who were hospitalized in the same unit as the index patient, 26 refused to get the test and 28 tested negative. In addition, point-prevalence rectal screening was conducted in the SCI in 3 phases that were 3 to 4 weeks apart. All of these screening tests were negative. WGS revealed that the index patient and roommate 2 had blaNDM-1–carrying P. aeruginosa, whereas the roommate 1 had blaNDM-5–carrying E. coli. No further spread occurred. Conclusions: Our aggressive efforts quickly mitigated further spread of blaNDM. Our epidemiologic investigation indicates that an intergenus transfer of blaNDM from P. aeruginosa to E. coli likely took place. In addition, it appears there was an evolution of NDM-1 to NDM-5, which differs from the former by 2 amino acid substitutions at positions 88 (Val→Leu) and 154 (Met→Leu). This type of evolution has been shown by prior studies to confer increased antibiotic resistance in certain resource limited settings.Funding: NoneDisclosures: None

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Sharp-Device Injuries to Hospital Staff Nurses in 4 Countries

Infection Control and Hospital Epidemiology ◽

10.1086/513445 ◽

2007 ◽

Vol 28 (4) ◽

pp. 473-478 ◽

Cited By ~ 24

Author(s):

Sean P. Clarke ◽

Maria Schubert ◽

Thorsten Körner

Keyword(s):

United States ◽

Acute Care ◽

Acute Care Hospital ◽

Hospital Staff ◽

The United States ◽

Staff Nurses ◽

Care Hospital ◽

Injury Rates ◽

The Past ◽

Hospital Staff Nurses

Objective.To compare sharp-device injury rates among hospital staff nurses in 4 Western countries.Design.Cross-sectional survey.Setting.Acute-care hospital nurses in the United States (Pennsylvania), Canada (Alberta, British Columbia, and Ontario), the United Kingdom (England and Scotland), and Germany.Participants.A total of 34,318 acute-care hospital staff nurses in 1998-1999.Results.Survey-based rates of retrospectively-reported needlestick injuries in the previous year for medical-surgical unit nurses ranged from 146 injuries per 1,000 full-time equivalent positions (FTEs) in the US sample to 488 injuries per 1,000 FTEs in Germany. In the United States and Canada, very high rates of sharp-device injury among nurses working in the operating room and/or perioperative care were observed (255 and 569 injuries per 1,000 FTEs per year, respectively). Reported use of safety-engineered sharp devices was considerably lower in Germany and Canada than it was in the United States. Some variation in injury rates was seen across nursing specialties among North American nurses, mostly in line with the frequency of risky procedures in the nurses' work.Conclusions.Studies conducted in the United States over the past 15 years suggest that the rates of sharp-device injuries to front-line nurses have fallen over the past decade, probably at least in part because of increased awareness and adoption of safer technologies, suggesting that regulatory strategies have improved nurse safety. The much higher injury rate in Germany may be due to slow adoption of safety devices. Wider diffusion of safer technologies, as well as introduction and stronger enforcement of occupational safety and health regulations, are likely to decrease sharp-device injury rates in various countries even further.

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Admission Surveillance for Carbapenamase-Producing Enterobacteriaceae at a Long-Term Acute Care Hospital

Infection Control and Hospital Epidemiology ◽

10.1086/671263 ◽

2013 ◽

Vol 34 (8) ◽

pp. 832-834 ◽

Cited By ~ 12

Author(s):

Jessica D. Lewis ◽

Matthew Bishop ◽

Brenda Heon ◽

Amy J. Mathers ◽

Kyle B. Enfield ◽

...

Keyword(s):

United States ◽

Prospective Study ◽

Acute Care ◽

Acute Care Hospital ◽

Acute Care Hospitals ◽

The United States ◽

Routine Screening ◽

Care Hospital ◽

High Prevalence

Carbapenemase-producing Enterobacteriaceae (CPE) are of increasing prevalence worldwide, and long-term acute care hospitals (LTACHs) have been implicated in several outbreaks in the United States. This prospective study of routine screening for CPE on admission to a LTACH demonstrates a high prevalence of CPE colonization in central Virginia.

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Estimated number of N95 respirators needed for healthcare workers in acute-care hospitals during the coronavirus disease 2019 (COVID-19) pandemic

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1418 ◽

2021 ◽

pp. 1-9

Author(s):

Patrick T. Wedlock ◽

Kelly J. O’Shea ◽

Madellena Conte ◽

Sarah M. Bartsch ◽

Samuel L. Randall ◽

...

Keyword(s):

United States ◽

Resource Allocation ◽

Acute Care ◽

Healthcare Workers ◽

Acute Care Hospital ◽

The United States ◽

Care Hospital ◽

Single Use ◽

N95 Respirators ◽

Admission Prevalence

Abstract Objective: Due to shortages of N95 respirators during the coronavirus disease 2019 (COVID-19) pandemic, it is necessary to estimate the number of N95s required for healthcare workers (HCWs) to inform manufacturing targets and resource allocation. Methods: We developed a model to determine the number of N95 respirators needed for HCWs both in a single acute-care hospital and the United States. Results: For an acute-care hospital with 400 all-cause monthly admissions, the number of N95 respirators needed to manage COVID-19 patients admitted during a month ranges from 113 (95% interpercentile range [IPR], 50–229) if 0.5% of admissions are COVID-19 patients to 22,101 (95% IPR, 5,904–25,881) if 100% of admissions are COVID-19 patients (assuming single use per respirator, and 10 encounters between HCWs and each COVID-19 patient per day). The number of N95s needed decreases to a range of 22 (95% IPR, 10–43) to 4,445 (95% IPR, 1,975–8,684) if each N95 is used for 5 patient encounters. Varying monthly all-cause admissions to 2,000 requires 6,645–13,404 respirators with a 60% COVID-19 admission prevalence, 10 HCW–patient encounters, and reusing N95s 5–10 times. Nationally, the number of N95 respirators needed over the course of the pandemic ranges from 86 million (95% IPR, 37.1–200.6 million) to 1.6 billion (95% IPR, 0.7–3.6 billion) as 5%–90% of the population is exposed (single-use). This number ranges from 17.4 million (95% IPR, 7.3–41 million) to 312.3 million (95% IPR, 131.5–737.3 million) using each respirator for 5 encounters. Conclusions: We quantified the number of N95 respirators needed for a given acute-care hospital and nationally during the COVID-19 pandemic under varying conditions.

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Carbapenem-Resistant Enterobacteriaceae Rectal Screening during an Outbreak of New Delhi Metallo-β-Lactamase–Producing Klebsiella pneumoniae at an Acute Care Hospital

Infection Control and Hospital Epidemiology ◽

10.1086/675597 ◽

2014 ◽

Vol 35 (4) ◽

pp. 434-436 ◽

Cited By ~ 14

Author(s):

Larissa M. Pisney ◽

M. A. Barron ◽

E. Kassner ◽

D. Havens ◽

N. E. Madinger

Keyword(s):

Klebsiella Pneumoniae ◽

Acute Care ◽

Teaching Hospital ◽

Tertiary Care ◽

Acute Care Hospital ◽

University Teaching ◽

New Delhi ◽

Care Hospital ◽

Carbapenem Resistant ◽

Carbapenem Resistant Enterobacteriaceae

We describe the results of carbapenem-resistant Enterobacteriaceae (CRE) screening as part of an outbreak investigation of New Delhi metallo-β-lactamase–producing CRE at a tertiary care university teaching hospital. The manual method for CRE screening was useful for detecting patients with asymptomatic CRE carriage but was time-consuming and costly.

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Medicaid Threats on the Horizon

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.145 ◽

2020 ◽

Vol 35 (3) ◽

pp. 145-145

Author(s):

Paul Baldwin

Keyword(s):

United States ◽

Long Term Care ◽

Acute Care Hospital ◽

The United States ◽

Care Hospital ◽

Short Term ◽

Term Care ◽

Episodes Of Care ◽

Primary Payer

Those of you who have been around for a while understand that Medicaid is the primary payer for long-term care in the United States. While Medicare pays for the short-term episodes of care associated with rehabilitation following a three-day stay in an acute-care hospital, it?s Medicaid that foots the bill for live-in residents who are unable to afford it themselves.

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Epidemiology of Clostridium difficile Infection

Journal of Pharmacy Practice ◽

10.1177/0897190013499521 ◽

2013 ◽

Vol 26 (5) ◽

pp. 464-475 ◽

Cited By ~ 108

Author(s):

Daryl D. DePestel ◽

David M. Aronoff

Keyword(s):

Clostridium Difficile ◽

Acute Care ◽

Clostridium Difficile Infection ◽

Hospital Setting ◽

Acute Care Hospital ◽

Disease Recurrence ◽

The United States ◽

Care Hospital ◽

Term Care ◽

Populations At Risk

There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.

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Outbreak of New Delhi metallo-β-lactamase-1–producing Enterobacter cloacae in an acute care hospital general ward in Singapore

American Journal of Infection Control ◽

10.1016/j.ajic.2015.08.028 ◽

2016 ◽

Vol 44 (2) ◽

pp. 177-182 ◽

Cited By ~ 3

Author(s):

Hanley J. Ho ◽

Cheng Yen Toh ◽

Brenda Ang ◽

Prabha Krishnan ◽

Raymond T.P. Lin ◽

...

Keyword(s):

Acute Care ◽

Acute Care Hospital ◽

Enterobacter Cloacae ◽

General Ward ◽

New Delhi ◽

Care Hospital ◽

Hospital General

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Impact of an antimicrobial stewardship programme on antimicrobial utilization and the prevalence of MDR Pseudomonas aeruginosa in an acute care hospital in Qatar

JAC-Antimicrobial Resistance ◽

10.1093/jacamr/dlaa050 ◽

2020 ◽

Vol 2 (3) ◽

Author(s):

Mazen A Sid Ahmed ◽

Hamad Abdel Hadi ◽

Sulieman Abu Jarir ◽

Abdul Latif Al Khal ◽

Muna A Al-Maslamani ◽

...

Keyword(s):

Pseudomonas Aeruginosa ◽

Acute Care ◽

Antimicrobial Stewardship ◽

Acute Care Hospital ◽

Antibiotic Use ◽

Significant Rise ◽

Successful Implementation ◽

Care Hospital ◽

Antimicrobial Consumption ◽

Healthcare Facilities

Abstract Background The excessive and inappropriate use of antibiotics is universal across all healthcare facilities. In Qatar there has been a substantial increase in antimicrobial consumption coupled with a significant rise in antimicrobial resistance (AMR). Antimicrobial stewardship programmes (ASPs) have become a standard intervention for effective optimization of antimicrobial prescribing. Methods A before–after study was conducted in Hamad General Hospital (603 bed acute care hospital): 1 year before implementation of a comprehensive ASP compared with the following 2 years. The ASP included a hospital-wide pre-authorization requirement by infectious diseases physicians for all broad-spectrum antibiotics. Prevalence of MDR Pseudomonas aeruginosa was compared with antimicrobial consumption, calculated as DDD per 1000 patient-days (DDD/1000 PD). Susceptibility was determined using broth microdilution, as per CLSI guidelines. Antibiotic use was restricted through the ASP, as defined in the hospital’s antibiotic policy. Results A total of 6501 clinical isolates of P. aeruginosa were collected prospectively over 3 years (2014–17). Susceptibility to certain antimicrobials improved after the ASP was implemented in August 2015. The prevalence of MDR P. aeruginosa showed a sustained decrease from 2014 (9%) to 2017 (5.46%) (P = 0.019). There was a significant 23.9% reduction in studied antimicrobial consumption following ASP implementation (P = 0.008). The yearly consumption of meropenem significantly decreased from 47.32 to 31.90 DDD/1000 PD (P = 0.012), piperacillin/tazobactam from 45.35 to 32.67 DDD/1000 PD (P < 0.001) and ciprofloxacin from 9.71 to 5.63 DDD/1000 PD (P = 0.015) (from 2014 to 2017). Conclusions The successful implementation of the ASP led to a significant reduction in rates of MDR P. aeruginosa, pointing towards the efficacy of the ASP in reducing AMR.

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Carbapenem-Resistant Klebsiella pneumoniae Producing New Delhi Metallo-β-Lactamase at an Acute Care Hospital, Colorado, 2012

Infection Control and Hospital Epidemiology ◽

10.1086/675607 ◽

2014 ◽

Vol 35 (4) ◽

pp. 390-397 ◽

Cited By ~ 29

Author(s):

Erin E. Epson ◽

Larissa M. Pisney ◽

Joyanna M. Wendt ◽

Duncan R. MacCannell ◽

Sarah J. Janelle ◽

...

Keyword(s):

Acute Care ◽

Medical Records ◽

Acute Care Hospital ◽

New Delhi ◽

Care Hospital ◽

Hospital Units ◽

Direct Observations ◽

Carbapenem Resistant ◽

Polymerase Chain ◽

Carbapenem Resistant Enterobacteriaceae

Objective.To investigate an outbreak of New Delhi metallo-β-lactamase (NDM)–producing carbapenem-resistant Enterobacteriaceae (CRE) and determine interventions to interrupt transmission.Design, Setting, and Patients.Epidemiologic investigation of an outbreak of NDM-producing CRE among patients at a Colorado acute care hospital.Methods.Case patients had NDM-producing CRE isolated from clinical or rectal surveillance cultures (SCs) collected during the period January 1, 2012, through October 20, 2012. Case patients were identified through microbiology records and 6 rounds of SCs in hospital units where they had resided. CRE isolates were tested by real-time polymerase chain reaction for blaNDM. Medical records were reviewed for epidemiologic links; relatedness of isolates was evaluated by pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). Infection control (IC) was assessed through staff interviews and direct observations.Results.Two patients were initially identified with NDM-producing CRE during July–August 2012. A third case patient, admitted in May, was identified through microbiology records review. SC identified 5 additional case patients. Patients had resided in 11 different units before identification. All isolates were highly related by PFGE. WGS suggested 3 clusters of CRE. Combining WGS with epidemiology identified 4 units as likely transmission sites. NDM-producing CRE positivity in certain patients was not explained by direct epidemiologic overlap, which suggests that undetected colonized patients were involved in transmission.Conclusions.A 4-month outbreak of NDM-producing CRE occurred at a single hospital, highlighting the risk for spread of these organisms. Combined WGS and epidemiologic data suggested transmission primarily occurred on 4 units. Timely SC, combined with targeted IC measures, were likely responsible for controlling transmission.

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