Carbapenmase-producing Carbapenem-resistant Enterobacteriaceae (CP-CRE) Investigation and Containment in an Acute-Care Inpatient Physical Rehabilitation Hospital Mandates a Multi-Faceted Approach

BACKGROUND Patients admitted from an outside acute-care facility, to an acute-care inpatient rehabilitation facility (IRF), are considered at-risk-populations for undiagnosed Carbapenem-resistant Enterobacteriaceae (CRE). Potential intra-facility transmission could result in a facility-wide outbreak. Various diagnosed carbapenemase organisms challenged staff to prevent person-to-person transmission while providing optimal rehabilitative therapy. METHODS Over three months, point prevalent studies (PPS) were conducted by staff, county, and state representatives at an acute-care IRF. Input/consultation from a national health agency was provided. PPS were specific to the source patient's 41 bed unit. PPS consisted of increased hand hygiene audits (HH) and patient rectal swabbing. Prior to discontinuing PPS, two consecutive negative PPS were necessary. Patient's right-to-refusal to participate in any PPS was honored. Isolation precautions, personal protective equipment (PPE) and environmental services (EVS) procedures were observed and enhanced. RESULTS Five PPS were conducted. HH audits showed 78.7% compliance. Rectal swab results for census totaled 119 patients with 94 patients screened. Three various types of CRE were identified. Enhanced isolation precautions were instituted for CRE positive patients who were incontinent of bowel/bladder. IRF and EVS staffs were taught how to properly don/doff PPE, along with additional education around appropriate cleaning of shared equipment. Proper methods for isolation cleaning were reinforced with all EVS staff. CONCLUSIONS Prevention of intra-facility or person-to-person transmission of CRE is possible. Consistent reinforcement of HH in all disciplines is paramount. Adopting targeted interventions, including EVS cleaning to control transmission, instituting enhanced precautions to maintain optimal therapies and treatments, result in greatest patient outcomes. Screening incoming patients from other facilities, on admission, is a reserved option. Screening increases cost to patients, as well as debatably unnecessary testing. Administration, medical, nursing, therapeutic staff and EVS, must support one another to avert transmission of CRE.