Prevention of Colonization and Infection by Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae in Long-term Acute-Care Hospitals

Background. Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (hereafter "KPC") are an increasing threat to healthcare institutions. Long-term acute-care hospitals (LTACHs) have especially high prevalence of KPC. Methods. Using a stepped-wedge design, we tested whether a bundled intervention (screening patients for KPC rectal colonization upon admission and every other week; contact isolation and geographic separation of KPC-positive patients in ward cohorts or single rooms; bathing all patients daily with chlorhexidine gluconate; and healthcare-worker education and adherence monitoring) would reduce colonization and infection due to KPC in 4 LTACHs with high endemic KPC prevalence. The study was conducted between 1 February 2010 and 30 June 2013; 3894 patients were enrolled during the preintervention period (lasting from 16 to 29 months), and 2951 patients were enrolled during the intervention period (lasting from 12 to 19 months). Results. KPC colonization prevalence was stable during preintervention (average, 45.8%; 95% confidence interval [CI], 42.1%–49.5%), declined early during intervention, then reached a plateau (34.3%; 95% CI, 32.4%–36.2%; P < .001 for exponential decline). During intervention, KPC admission prevalence remained high (average, 20.6%, 95% CI, 19.1%–22.3%). The incidence rate of KPC colonization fell during intervention, from 4 to 2 acquisitions per 100 patient-weeks (P = .004 for linear decline). Compared to preintervention, average rates of clinical outcomes declined during intervention: KPC in any clinical culture (3.7 to 2.5/1000 patient-days; P = .001), KPC bacteremia (0.9 to 0.4/1000 patient-days; P = .008), all-cause bacteremia (11.2 to 7.6/1000 patient-days; P = .006) and blood culture contamination (4.9 to 2.3/1000 patient-days; P = .03). Conclusions. A bundled intervention was associated with clinically important and statistically significant reductions in KPC colonization, KPC infection, all-cause bacteremia, and blood culture contamination in a high-risk LTACH population.