Fatal MDR Klebsiella in ICU — How was it Dealt with?

Abstract

How to cite this article: Khandelwal V, Sharma S. Fatal MDR Klebsiella in ICU — How was it Dealt with? Indian J Crit Care Med 2019;23(9):411–413.

INTRODUCTION

Multidrug resistant (MDR) infections in any ICU are troublesome and undesirable. Moreover the management of such infections in any critical care setting is a challenge for the physician as well as the infection control team. Klebsiella pneumoniae, resistant to carbapenam infection is one of the most threatening GNB,¹ and spreading rapidly all over.² The risk of nosocomial infection in ICU is 5–10 times greater than those acquired in general medicine and surgical wards.³ We present here a report of an outbreak of MDR Klebsiella infection in our ICU and how it was dealt with.

MATERIALS AND METHODS

During the months of September and October 2018, we observed a significant surge of MDR Klebsiella pneumonia in our ICU. Multiple patients had this organism grown in their endotreacheal cultures. These were nosocomial infections including hospital acquired pneumonia (HAP) and ventilatory acquired pneumonia (VAP). More than five patients in less than four weeks had a similar culture sensitivity report. (Fig. 1). Further it was sensitive to only a few drugs like colistin, polymyxin B and tigecycline. Majority of them were resistant to carbapenams.

Fig. 1.

Culture and sensitivity report

The mortality ratio of ICU increased due to this MDR bug. Also the cost of treatment escalated due to use of drugs like colistin. The duration of stay of such patient who had acquired nosocomial infections in the ICU prolonged.

To our surprise, when we did an environmental sampling of our ICU, the same MDR Klebsiella was grown on culture, taken from bed rails, switches, etc. (Fig. 2)

Fig. 2A.

Klebsiella

It was not difficult to understand that we were facing an outbreak of MDR Klebsiella in our hospital, which was increasing the morbidity and mortality rate of ICU. The actual fear was that this infection if not curtailed would spread to the entire hospital and would be detrimental to the health of even those patients who were admitted outside the critical care areas.

Immediately an outbreak control team was formulated. It consisted of members from the hospital management, infection control team, housekeeping staff, intensive care team, laboratory staff and the nursing staff.

First and foremost, this team reviewed the video recording of critical care areas. To their surprise, it was observed that there was a sharp decline in hand-hygiene practices which were observed under video surveillance. Direct observation and video surveillance was done for last two months for critical care areas to monitor hand-hygiene practices which were being followed (Fig. 3).

Fig. 3.

Direct observation and video surveillance of hand-hygiene practices in critical care areas

Following this, efforts were started to train the entire staff and doctors for 5 key moments of hand hygiene.

WHO 5 key moments of hand hygiene (Fig. 4):

Fig. 4.

Five key moments of hand hygiene

1. Before touching the patient

2. After touching the patient

3. Before aseptic technique

4. After aseptic technique

5. Patient surrounding (bed side looker, medicine trolley, monitors, IV stand, bed, bed railing)

Apart from repeated training and observation, hand swabs were taken for culture and sensitivity. Staff and doctors were shown their video recording and informed about the moments when they missed out on hand hygiene practices. Positive reinforcement was done, in the form of rewarding the staff and also the areas which were showing best practices of hand hygiene. Similarly chronic defaulters were punished.

Apart from this, deep cleaning of beds and surrounding was started in the ICU with bacilli.

Further patients, who had their culture positive, were isolated and kept away from other patients. Care was taken to prevent cross infections. For these patients, entry of staff and relatives was restricted in the isolation areas

OBSERVATIONS

To, our surprise, after 15 days, environmental sampling was done again which showed that the deadly multidrug resistant Klebsiella was eradicated from most sources (Fig. 5).

Fig. 5A.

 

On the same lines, we also found that klebsiella infection among patient had declined after following strict infection control practices.

Fig. 2B.

Environmental sampling report of critical care areas (Prereports)

CONCLUSION

A multidisciplinary team approach of infection control practices helps in combating any multidrug resistant organism spread, like Klebsiella in our study;⁴ a special emphasis on hand hygiene practices should be laid as a single most important prevention strategy to prevent health care infections⁵ and ultimately decreases the hospital stay of critical patients.⁶

Figs 5A and B.

Environmental sampling reports after hand-hygiene practices implemented