We describe an outbreak of KPC producing Klebsiella pneumoniae ST258 that occurred in 2 institutions (a hospital and a nursing home) in The Netherlands between July and December 2013. In total 6 patients were found positive for KPC-producing K. pneumonia (KPC-KP). All isolates were resistant to colistin, and exhibited reduced susceptibility to gentamicin and tigecycline. In all settings, extensive environmental contamination was found. Whole genome sequencing revealed the presence of blaKPC-2 and blaSHV-12 genes, as well as the close relatedness of patient and environmental isolates. In the hospital setting, one transmission was detected despite contact precautions. After upgrading to strict isolation no further spread was found. After the transfer of the index patient to a nursing home in the same region, four further transmissions occurred. The outbreak in the nursing home was controlled by transferring all KPC-KP positive residents to a separate location outside the nursing home, where a dedicated nursing team cared for patients.

1. Outbreak of colistin-resistant Klebsiella
pneumonia Carbapenemase (KPC) -producing
Klebsiella pneumonia in the Netherlands, with
inter-institutional spread
Veronica Weterings1, Esther Weterings1, Erwin Verkade1, Desiree van Stenis2,
Elianne Thewessen2, Jan Kluytmans1,3
1 Amphia hospital, Breda
2 Riethorst Stromenlanden, Geertruidenberg
3 VU university medical center, Amsterdam
The Netherlands

2. Disclosure
no financial relationships exist

3. Occurrence of carbapenemase-producing
Enterobacteriaceae (CPE) in the Netherlands1
Overall situation CPE
1 Glasner C et al, the European Survey on Carbapenemase-Producing
Enterobacteriaceae (EuSCAPE) working group. Carbapenemase-producing
Enterobacteriaceae in Europe: a survey among national experts from 39 countries,
February 2013 . Euro Surveill. 2013;18(28):pii=20525.
National guideline for Highly Resistant Micro-
Organisms (HRMO):
• All patients who have been treated in
foreign hospitals are screened on admission
• Pre-emptive contact isolation:
o single patient room
o gown and gloves when direct contact
with patient

4. Nosocomial transmission
Transfer Index
patient Dutch
hospital
24/6/2013
Jun AugJul Sept - Nov
Contact isolation
1
hospital
Klebsiella pneumoniae, KPC-2, ST258
pan resistant, including colistin

5. Nosocomial transmission
Transfer Index
patient Dutch
hospital
24/6/2013
Jun AugJul Sept - Nov
Contact isolation
1
5/7/2013
Second patient;
pleural fluid
2
24/6/2013 - 5/7/2013
Outbreak Management Team (OMT)
Strict isolation
Contact tracing
hospital
Klebsiella pneumoniae, KPC-2, ST258
pan resistant, including colistin

6. Nosocomial transmission
Transfer Index
patient Dutch
hospital
24/6/2013
Jun AugJul Sept - Nov
Contact isolation
1
5/7/2013
Second patient;
pleural fluid
2
24/6/2013 - 5/7/2013
Outbreak Management Team (OMT)
Strict isolation
Contact tracing
Index patient: NH
Patient 2: home
5/8/2013
7/11/2013
Third patient;
Rectal swab
3
7/11/2013
6/7/2013 - 5/8/2013
hospital
• HRMO
• Transmission despite
contact isolationKlebsiella pneumoniae, KPC-2, ST258
pan resistant, including colistin

7. Site A: room 101 to 106Site B: room 107 to 113
Rehabilitation ward
Elevator
Shared area

8. 110
109
111 113
107108
112
Transmission nursing home
1
Transfer of index patient to nursing home
Elevator
Shared area
Jun AugJul Sept Oct Nov Dec
Contact isolation:
- Single patient room + private sanitary
- Contact precautions during care moments
- No restrictions

9. 110
109
111 113
107108
112
Transmission nursing home
1
3
Admission patient 3
‘use gowns of room 113’  shared storage of PPE
Elevator
Shared area
Jun AugJul Sept Oct Nov Dec

10. 110
109
111 113
107108
112
Transmission nursing home
1
Elevator
Jun AugJul Sept Oct Nov Dec
3
3
OMT NH
Shared area

11. 110
109
111 113
107108
112
Transmission nursing home
13
v
Elevator
Jun AugJul Sept Oct Nov Dec
3
Strict isolation:
- Single patient room + private sanitary
- Contact precautions and mask before entering the patient room
- Patients have to stay in the rooms
Shared area

12. 110
109
111 113
107108
112
Transmission nursing home
13
v
Elevator
Jun AugJul Sept Oct Nov Dec
3
1st Contact tracing (n=23) No new KPC findings
Shared area

13. 110
109
111 113
107108
112
Transmission nursing home
13P
Elevator
Jun AugJul Sept Oct Nov Dec
3
Shared area

14. 110
109
111 113
107108
112
Transmission nursing home
1 3 P
Elevator
Jun AugJul Sept Oct Nov Dec
3
Shared area

15. 110
109
111 113
107108
112
Transmission nursing home
1 3
P
Elevator
Jun AugJul Sept Oct Nov Dec
3
Shared area

16. 110
109
111 113
107108
112
Transmission nursing home
1 3
P
Elevator
Jun AugJul Sept Oct Nov Dec
3
2nd Contact tracing (n=21) TWO new KPC findings
Shared area

17. c
110
109
111 113
107108
112
Transmission nursing home
1 3
Elevator
4
Jun AugJul Sept Oct Nov Dec
3
2nd Contact tracing (n=21) TWO new KPC findings
Shared area

18. Site A
101 102 103
106 105
104
kitchen
office
5
Elevator
c

19. 110
109
111 113
107108
112
Transmission nursing home
1 3
4
5 Elevator
c
Jun AugJul Sept Oct Nov Dec
3
Shared area
Cohort isolation:
- Single patient room + private sanitary
- Contact precautions and mask before entering the patient room
- Patients may not leave the room
- Dedicated team

20. 110
109
111 113
107108
112
Transmission nursing home
1 3
4
5 Elevator
c
Jun AugJul Sept Oct Nov Dec
3
3rd Contact tracing (n=18) ONE new KPC finding

21. Site A
101 102 103
106 105
104
kitchen
office
Elevator
c
6

22. c
Jun AugJul Sept Oct Nov Dec
Transmission nursing home
Environmental cultures
• Sterile gauze moistened with sterile saline
18-24h
Colorex KPC1 EbSA 2
TSB-VC2
1 bioTrading Benelux
2 Cepheid
• 25 samples; ‘clean’ and ‘dirty’ site
– Glucose meter
– Door handle - KPC room
– Bedside table (2x) - KPC room
Index patient
+ patient 5

23. Transmission nursing home
27-11-2013
 Separate, empty location
• Nursing home:
– Cleaning of rehabilitation ward by H2O2
– Environmental cultures (2x)  no KPC
– Contact tracing; n=146 (2x)  no KPC
Patient Cultures sites KPC positive
Index patient Rectal
[3] Rectal, urine (catheter)
[4] Rectal, urine (catheter), wound
[5] Rectal
[6] Rectal

24. Huisvesting KPC-KP positieve cliënten
Separate location

25. Separate location
• Dedicated and skilled staff
• Contact precautions during care moments, no further restrictions
• Weekly active surveillance culturing for patients
No surveillance cultering for healthcare workers
• Environmental cultures:
 Highly contaminated patient rooms
 Low or no contamination in shared areas

26. Current state KPC positive patients
Patient status
Index patient KPC negative
Patient 2 KPC positive (+ 10 months)
Patient 3 KPC negative
Patient 4 Died
Patient 5 Died
Patient 6 KPC negative

27. Conclusion
General
The environment served as a reservoir of transmission;
• frequent detection of Klebsiella in the environment in all locations
• all secondary cases in the nursing home have a link to room 113 or
shared devices (glucose meter)
Hospital
• Despite contact precautions transmission to one patient occurred.
• Strict isolation, active screening cultures and education prevented further
transmission

28. Conclusion
Nursing home
• Infection control measures designed for hospitals cannot be transposed to the
setting of nursing homes easily, due to:
‒ long length of stay
‒ residential setting
‒ no or poor isolation possibilities
‒ education level of staff
• Nursing homes can become important reservoir for KPCs
• Nursing home was notified upon patient transfer, but without ‘active support’
by experts  possible this has contributed to the outbreak.

29. Future question
Is it possible to control the spread of KPC in nursing homes?
Possible solutions:
 Define regional location(s) voor KPC positive patients (and
other HRMO)
 Adequate decolonisation stategy

30. Acknowledgements
• Jacobien Veenenmans
Amphia Hospital Breda
• My collegues of the Laboratoria Microbiology and Infection Control
Amphia Hospital Breda
• Staff of the nursing home
Riethorst Stromenlanden, Geertruidenberg
• Staff of the Molecular and Sequence Unit for Clinical Bacteriology
University Medical Center Groningen