Instructions: Spend 10 minutes reviewing the case below and considering the questions that follow. Case Study 5: Containing an outbreak
In March 2007, the Ministry of Health of Israel set up a committee of infectious disease experts to contain a national outbreak of carbapenem- resistant Klebsiella pneumoniae (CRKP) around the country. In May 2007 a multifaceted strategy was devised to prevent dissemination of CRKP at Soroka University Medical Center, a 1000-bed acute care tertiary hospital. 89 The key elements of the strategy were an emergency department flagging system to identify high-risk patients, the building of a 12-bed cohort ward, the use of intensive active surveillances in high-risk wards, enforcement of compliance with hand hygiene, contact precautions, and disinfection protocols, and a carbapenem-restriction policy. The intervention produced an “enormous impact on patient location, surveillance cultures, and antibiotic policies and a massive investment in infection control resources.” A total of 10,680 rectal cultures were performed for 8,376 patients, which identified 433 (5.16%) patients who were CRKP-colonized and 370 (4.4%) who were CRKP-infected. 789 (98%) of 803 patients were admitted to the CRKP cohort ward. The CRKP infection density was reduced from 5.26 to 0.18 per 10,000 patient-days and no nosocomial CRKP infections were diagnosed. Carbapenem (meropenem) use was reduced from 283 to 118 defined daily doses per 1,000 patient-days.
1. Do you think such an aggressive multifaceted intervention strategy was necessary to contain this outbreak? Why or why not?
2. Which of the measures undertaken as part of this effort do you think was the most important? The least important?
3. If you have been a clinician involved in trying to contain an outbreak of an antibiotic-resistant strain of bacteria, what lessons did you learn? Do you think the lessons are applicable to other healthcare settings?
Efforts should be made to engage staff in infection prevention and to ensure that understaffing and disorganization are not hindering these efforts. Training, monitoring, compliance auditing, and feedback systems are also effective for improving compliance and appropriate use of contact precautions. The CDC recommends that healthcare facilities implement policies for important CRE prevention practices such as hand hygiene and antibiotic stewardship, and that policies be enforced through continuous monitoring, auditing, and feedback. Additionally, the CDC recommends that facilities strictly enforce CDC guidance for CRE detection, prevention, tracking, and reporting. Education must accompany any new policy to ensure effective implementation. Awareness about infection control policies is crucial to consistently and successfully implementing these procedures. Staff education has been part of several intervention efforts that have been successful in reducing CRE transmission. Conclusions Contact precautions are strongly recommended for patients infected with or colonized by CRE. There is little evidence to support universal active surveillance for CRE. However, active surveillance is recommended in outbreak scenarios, in highly endemic regions, and in healthcare facilities or units with ongoing transmission. In units already
using universal contact precautions, the evidence suggests that active surveillance does not have a significant impact on reducing transmission. There is little evidence to support preemptive contact precautions for high-risk patients, however, it is recommended that CDC guidelines be followed for this practice. In all settings, ongoing monitoring, staff feedback, and education on the implementation of contact precaution and infection control policies are highly recommended. They are often part of successful multi- faceted interventions. There is no strong support for discontinuation of contact precautions when an individual has been placed on contact precautions due to a positive CRE culture. Such patients should remain on contact precautions at each healthcare facility they are admitted to until they are discharged into the community. Harms due to anticoagulants Anticoagulants are a critical therapy in the prevention and treatment of various types of thromboembolic disorders. Key indications for anticoagulants include the prevention of stroke among patients with chronic atrial fibrillation, and prevention and treatment of venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism.
Anticoagulants include vitamin K antagonists (e.g., warfarin); heparin (unfractionated and low-molecular weight heparin); and novel oral anticoagulants (NOACs), such as direct thrombin inhibitors (e.g., argatroban and dabigatran) and factor Xa inhibitors (e.g., apixaban, rivaroxaban). Anticoagulants have been consistently identified as the most common cause of adverse drug events (ADEs) in health care settings. Bleeding is the primary ADE of concern for anticoagulants, but they require a careful balance between thrombotic and hemorrhagic risks. Anticoagulation management services An anticoagulation management service is a systematic and coordinated approach to anticoagulation care delivery by a single provider following a physician- approved protocol. For example, these may be pharmacist- or nurse- led “anticoagulant clinics,” in which patients are seen in an ambulatory setting on a regular basis to closely monitor bleeding and clotting laboratory values and adjust medications accordingly. A range of models for anticoagulation management services exist. Most are pharmacist led, but some are led by nurse practitioners, physician assistants, nurses, or pharmacy technicians.
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