Case of the Month

August 2019

Reshma Misra, Assistant Director, Provincial Infection Prevention and Control (Province of KwaZulu-Natal)

Case Presentation

A baby was born on the 26th June 2019 at 28 weeks gestation. Baby weighed 1500 grams, apgar was 5/10 and 6/10 with respiratory distress syndrome. Baby had a peripheral line, required ventilation and was transferred to a healthcare facility with intensive care. Baby was transferred without any IPC transfer form. Baby was placed in intensive care and on standard precautions. The intensive care unit is 6 bed unit and staffed by a professional nurse and an enrolled nurse. On the 27th June 2019, baby was noted to have brachycardia and pyrexial. Blood cultures and full blood count (FBC) was done. Blood culture was done as the baby had signs of sepsis. Rectal and axillae swabs were not done as baby already showed signs of sepsis. These are usually done to detect colonization. FBC was to determine the white cell count. Meropenem was commenced. Baby’s condition deteriorated. On the 28th June, Microbiologist informed of a gram negative organism in the blood culture. The baby was then put on standard and contact based precaution. On the 29th June carbapenem resistant Klebsiella pneumoniae was confirmed (CRKP), susceptible to Colistin. Colistin was added to the treatment regimen.

On 30th June, another baby became pyrexial and blood cultures were taken. Baby was not ventilated but had a peripheral line and commenced on meropenem. 2nd July, baby was confirmed with CRKP and commenced on Colistin. Baby was placed on standard and contract based precautions as CRKP is spread by contact transmission. Both CRKP babies were then placed on one side of the unit.

On 5th July, one ventilated baby became pyexial with temperature of 37.5 oC and apnoea and another ventilated baby had a temperature of 38.1 oC. Babies were on ampicillin and gentamycin and treatment was stepped up to meropenem. By 7th July, both babies were confirmed CRKP on blood culture and endotracheal aspirate. Colistin was added. Babies were placed on standard and contract based precautions. Both CRKP babies were also cohorted.

On isolation of four cases of CRKP, the unit manager then informed the IPC practitioner, on the 8th July, of a probable outbreak. Antibiograms, which are reports of the susceptibility pattern of an organism, were identical. Minimum inhibitory concentrations, which is a report that indicate the minimum antibiotic required to inhibit an organism , was also compared and found to be identical. It was then suspected that the organisms were related and acquired as a result of a breech in infection prevention practices.

An emergency meeting was called with the IPC Team on the 8th July. The IPC team comprising of, the IPC practitioner, Microbiologist, Pharmacist, Unit manager, IPC representative from NICU, Unit Manager, Quality Assurance, Medical Manager, Neonatologist, Infectious disease specialist and Nursing Manager. All facilities must have an IPC team in addition to an IPC committee. The purpose of the meeting was to discuss the cases, identify possible patient risk factors, possible underlying factors that contributed to disease transmission, develop a hypothesis, agree of control measures, agree on the manner in which the cases will be investigated and agree on lines on communication to media and higher authorities and the lead investigator.

Following discussion and careful considerations, non-compliance to hand hygiene was hypothesized to be the cause of transmission. There were no common factors that suggested a microbial source. The team then visited the unit to observe practice and identify risks. The unit did not conform to, the nursing norms of 2 professional nurses for every three beds; bed spacing of 1.5 m between incubators and 2 m between ICU cribs; alcohol handrub at every point of care, and contact precautions. Observation related to hand hygiene included poor compliance to the critical moments when hand hygiene should be practice, before contact with the patient, before aseptic procedure; after contact with the patient; after contact with blood and body fluids and after contact with the environment, allied staff wore long nails and nail polish, new staff did not receive hand hygiene training, and poor compliance to the hygienic rub technique. Staff reported workload as the underlying reason for hand hygiene non-compliance.

Based on observations, environmental swabbing was not done. This is usually done in line with the hypothesis or to prove/disprove microbial sources related to the environment, equipment or medications. In this case, it was not indicated.

Immediate control measures included, briefing if unit staff, careful evaluation of all cases with a view to down refer and decongest, placement of alcohol hand rub at every point of care and within arm’s reach, appointment of a hand hygiene champion to serve as a role model and monitor practice, re-training of all staff on hand hygiene and contact precautions, prohibition of staff who do not conform to IPC prescripts from entry to the unit, announced visits by IPC practitioner on a basis, laboratory was placed on high alert for gram negatives and daily reports from unit manager on the status in the unit in terms of HAIs and control measures. Then unit was not closed as the organism is not airborne and can be controlled with standard and contact precautions. The laboratory was requested to keep all isolates for Pulsed Filed gel Electrophoresis, which is a test used to produce a DNA fingerprint for each isolate. Quality Improvement Plan was developed by the IPC Team and monitored.

On 10th July, two other ventilated babies grew a CRKP in the endotracheal aspirate (ETA). The babies x-rays were clear, white cell count within range and no pus cells on the gram. Babies were suspected to be colonised. Babies were placed on standard precaution and contact precaution. Specimens were repeated with no growth in ETA.

Final Diagnosis

From the 27th June to the 10th July, in the NICU, 6 babies were identified with CRKP. Based on clinical signs and symptoms and laboratory results, 4 were diagnosed with HAI. The other two were not treated as these babies were well and repeat cultures yielded no growth. The unit did not have any cases of CRKP in the preceding month. The index case was identified as the baby that was transferred on the 26th June.


An outbreak of HAI is defined as the isolation of two or more cases of HAI, with the identical organism that is epidemiologically linked. It is critical to ensure that all units have a system in place to monitor and analyse microbiology results. Daily monitoring of microbiology results, with serve as an early warning system for outbreaks and also identify possible trends. Early detection allows for prompt outbreak response and contributes to preventing further transmission. In an outbreak introducing new measure serves only to cause confusion and frustration to staff that are already overworked. It makes sense to identify areas that have been compromised and correct those, in this case hand hygiene.

Whilst MICs are not a genotypic test, identical patterns, may be used as an indication of strain relatedness.

Summary and Outcome

Once the CRKP was positively identified, all babies colonised and infected were placed on standard precaution in addition to contact precaution. The antibiograms were carefully analysed and found to be identical. Outbreak protocol was initiated as per hospital procedure. PFGE showed strains were indistinguishable. Following investigations, it was determined that there was no environmental source or common vehicle. Non-compliance to hand hygiene was hypothesized to be the cause. Underlying factors related to understaffing and overcrowding contributed.

The focus for outbreak control was hand hygiene. Alcohol based hand rub in pump tops were placed at every point of care. Ward staff, allied staff and new staff were re-trained on hand hygiene. Hand hygiene champions were appointed to serve as role models and monitor practices.

Following the re-enforcement of hand hygiene, there were no further cases. The last two cases were thought to be colonised and not treated. All babies improved and were down referred. There were no deaths.

As part of any outbreak response is “lessons learnt.” The WHO multi modal strategy, to improve hand hygiene, was adopted, staffing needs were assessed, communication was submitted to referring facilities to utilise the patient transfer form and a standard operating procedure for outbreak response and surveillance was developed and implemented

Recommended Reading

  1. Moodley P, Coovadia YM, Sturm AW. Intravenous glucose preparation as the source of an outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae infections in the neonatal unit of a regional hospital in KwaZulu-Natal. S Afr Med J. 2005/12/14 ed. 2005;95(11):861–4.
  2. W.H van Nierop, A.G. Duse, R.G. Stewart. Y.R. Bilgeri HJ, Koornof. Molecular Epidemiology of an Outbreak of Enterobacter cloacae in the Neonatal Intensive Care Unit of a Provincial Hospital in Gauteng , South Africa Molecular Epidemiology of an Outbreak of Enterobacter cloacae in the Neonatal Intensive Care Unit of a Pro. J Clin Microbiol. 1998;36(10):3085–7.
  3. WorlD health organisation, Guidelines for the prevention and Control of carbapemend resisattnt Enbterobateriace, Acinteobacte bbaumanii and Psedufomona aeruginosa I health care facilities; 2017. https://www.who.int/infection-prevention/publictions/guidelines-cre/en/

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