T Delory1, E Seringe2, G Antoniotti3, I Novakova1, C Goulenok3, I Paysant3, S Boyer4, A Carbonne5, T Naas6, P Astagneau7. 1. Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France. 2. Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France. Electronic address: elise.seringe@aphp.fr. 3. Groupe Générale de Santé, Paris, France. 4. Groupe Générale de Santé, Paris, France; Laboratoire Bactériologie Novescia, Paris, France. 5. Office of Quality and Safety in Care, Direction Générale de l'Offre de Soins-Bureau PF2-Ministère de la Santé, des affaires sociales et du droit des femmes, Paris, France. 6. Department of Bacteriology, APHP, Laboratoire de Bactériologie-Virologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France; Centre National de Référence de la résistance aux antibiotiques, Le Kremlin Bicêtre, France; EA7361, Faculté de Médecine, Université Paris Sud, France. 7. Regional Centre for Nosocomial Infection Control, CClin Nord, Paris, France; Department of Epidemiology, Ecole des Hautes Etudes en Santé Publique/Universités Sorbonne Paris Cité, Paris, France.
Abstract
BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak. METHODS: An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method. RESULTS: The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members. CONCLUSION: Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.
BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak. METHODS: An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method. RESULTS: The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members. CONCLUSION: Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.
Authors: Vincent C C Cheng; Shuk-Ching Wong; Vivien W M Chuang; Simon Y C So; Jonathan H K Chen; Siddharth Sridhar; Kelvin K W To; Jasper F W Chan; Ivan F N Hung; Pak-Leung Ho; Kwok-Yung Yuen Journal: Am J Infect Control Date: 2020-05-24 Impact factor: 2.918