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