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Antibiotics are frequently prescribed inappropriately for acute respiratory infections in the outpatient setting. We report the implementation of a multifaceted outpatient antimicrobial stewardship initiative resulting in a 12.3% absolute reduction of antibiotic prescribing for acute bronchitis in primary care clinics receiving active interventions.
Background: In April 2019, Nebraska Public Health Laboratory identified an NDM-producing Enterobacter cloacae from a urine sample from a rehabilitation inpatient who had recently received care in a specialized unit (unit A) of an acute-care hospital (ACH-A). After additional infections occurred at ACH-A, we conducted a public health investigation to contain spread. Methods: A case was defined as isolation of NDM-producing carbapenem-resistant Enterobacteriaceae (CRE) from a patient with history of admission to ACH-A in 2019. We conducted clinical culture surveillance, and we offered colonization screening for carbapenemase-producing organisms to all patients admitted to unit A since February 2019. We assessed healthcare facility infection control practices in ACH-A and epidemiologically linked facilities by visits from the ICAP (Infection Control Assessment and Promotion) Program. The recent medical histories of case patients were reviewed. Isolates were evaluated by whole-genome sequencing (WGS). Results: Through June 2019, 7 cases were identified from 6 case patients: 4 from clinical cultures and 3 from 258 colonization screens including 1 prior unit A patient detected as an outpatient (Fig. 1). Organisms isolated were Klebsiella pneumoniae (n = 5), E. cloacae (n = 1), and Citrobacter freundii (n = 1); 1 patient had both NDM-producing K. pneumoniae and C. freundii. Also, 5 case patients had overlapping stays in unit A during February–May 2019 (Fig. 2); common exposures in unit A included rooms in close proximity, inhabiting the same room at different times and shared caregivers. One case-patient was not admitted to unit A but shared caregivers, equipment, and devices (including a colonoscope) with other case patients while admitted to other ACH-A units. No case patients reported travel outside the United States. Screening at epidemiologically linked facilities and clinical culture surveillance showed no evidence of transmission beyond ACH-A. Infection control assessments at ACH-A revealed deficiencies in hand hygiene, contact precautions adherence, and incomplete cleaning of shared equipment within and used to transport to/from a treatment room in unit A. Following implementation of recommended infection control interventions, no further cases were identified. Finally, 5 K. pneumoniae of ST-273 were related by WGS including carriage of NDM-5 and IncX3 plasmid supporting transmission of this strain. Further analysis is required to relate IncX3 plasmid carriage and potential transmission to other organisms and sequence types identified in this study. Conclusions: We identified a multiorganism outbreak of NDM-5–producing CRE in an ACH specialty care unit. Transmission was controlled through improved infection control practices and extensive colonization screening to identify asymptomatic case-patients. Multiple species with NDM-5 were identified, highlighting the potential role of genotype-based surveillance.
Disclosures: Muhammad Salman Ashraf reports that he is the principal investigator for a study funded by an investigator-initiated research grant.
Outbreaks of infections in healthcare negatively impact patient outcomes and experience. Transparency is critical to engendering trust and optimizing health. Consistent guidance is not available regarding when to report a possible outbreak of healthcare-associated infections (HAIs) to public health and when to notify a limited population or to publicly disclose the occurrence of HAI. Recent analyses of state public health policies revealed that most states address reporting of outbreaks using terms such as clusters, unusual occurrences, or incidences over baseline. Specific wording about healthcare outbreaks or guidance for notifying patients or public is often absent. Thus, HAI outbreak notification and disclosure guidance and practices vary significantly around the country. A best-practice guidance document will provide clarity for when such reporting should occur. Methods: The Council for Outbreak Response: HAI and Antimicrobial-Resistant Pathogens (CORHA) has undertaken the task of developing this guidance by forming a multidiscipline policy work group with representation from its partner organizations. This work group has been tasked with creating a general framework that will guide notification and disclosure in the context of a possible HAI outbreak. The draft guidance document has been developed over several months of telephone and in-person conferences among work group members. Results: The standardized actions stemming from the guiding principles and recommended practices for conducting step 1 (immediate notification, initial and critical communications that occur when an outbreak is first suspected), were arranged in a table format with rows representing stakeholders and constituents to be notified and columns demonstrating the actions to be taken (Fig. 1). As an investigation progresses, notification should be revisited, especially if an investigation’s scope expands. The principles and practices for step 2 (expanded notification) have also been drafted in a table format. Next, the draft guidance addresses step 3 (public disclosure), outlining indications, practical guidance, and considerations in an outline and/or summary format. Real-world examples demonstrating application of the framework are being developed as supplementary resources to the framework. Current work group activities include engaging bioethicists, media reporters and patient advocates to review and comment on the guidance to ensure that it is clear, consistent and practical. Discussion: The draft guidance provides a framework for standardized actions for HAI outbreak notification and disclosure in a stepwise fashion, modeling public health practices and grounded in bioethical principles. The final product will provide valuable, practical advice for effectively sharing information with affected or potentially affected individuals and their caregivers in a timely manner.
Dawn Terashita reports that her spouse has received honoraria rom the speaker’s bureaus of Novo Nordisk and Abbott.
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