Not a failure, a lesson. The NIH KPC Outbreak

Mike posted about this yesterday and I'm sure we'll have more posts concerning the deadly KPC outbreak that occurred last year at the NIH Clinical Center. Since the whole report is behind a paywall (why is that??), I thought I'd describe the interventions taken to control the outbreak and also let you peruse the description of the 18 cases and 11 deaths (See table below).
The kitchen sink: the problem
and the current solution

Infection control measures used:
1) Index patient placed on enhanced contact isolation on admission.
2) All ICU patients during the outbreak were placed on universal enhanced contact precautions during their entire stay
3) A wall was built in the ICU, so that all KPC+ patients could be placed in a new six-bed unit
4) Infection control compliance monitors were hired (peak use was 9 monitors) who ensured that all healthcare workers entering the rooms practiced enhanced contact precautions and hand hygiene. Suboptimal monitors were fired
5) A private firm was hired to decontaminate the ICU and all KPC+ patient rooms using hydrogen peroxide vapor
6) Staff were cohorted so that staff did not care for both KPC+ and KPC negative patients
7) When the KPC was found in a sink, they tore out the plumbing
8) Active surveillance culturing using rectal and throat swabs was utilized

What an amazing effort by Tara Palmore and others at NIH. Why did it take so long to control the outbreak? It's not their fault. I was in a similar situation with an acinetobacter outbreak in 2002. What I faced in 2002 and what Dr. Palmore faced last year is that there is almost no science behind infection prevention interventions. We literally don't know what works or where in works. What this outbreak demonstrates is what happens when you make little investment in infection control science in decades. We don't know how to prevent these outbreaks, so we throw the kitchen sink (literally in this case) at them hoping something works.

Not every hospital can afford to undertake all of the expensive construction and staffing interventions that the NIH did, especially since it isn't clear what works and what doesn't. Unless we make serious efforts in understanding the science behind hand hygiene compliance improvement, optimal use of contact isolation, environmental cleaning and other "unstudied" areas, this scene will continue to be repeated over and over again. These outbreaks are happening every day in the US and patients are dying (see below). We need science in infection prevention just as much as we need novel antibiotics.  The lesson needs to be that we fund CDC and other agencies to direct the infection prevention studies necessary to prevent and terminate these terrible outbreaks.

The wrong lesson is to blame frontline infection prevention staff for fighting an outbreak with one hand behind their back and not being successful. We need to stop blaming clinicians and start funding the science to assist our infection prevention efforts.  If we won't have novel antibiotics for 10-20 years, we better start getting serious about infection prevention.


  1. The Aug 2012 issue of Emerging Infectious Diseases has a write-up of an outbreak of ESBL-producing K. oxytoca in a Toronto hospital likely involving colonization of handwashing sinks in ICU rooms. They also bent themselves into pretzels trying to control the outbreak, including some extreme efforts at chemical decontamination, before finally also altering the sink plumbing because the sinks were repeatedly found to be the source & were contaminating workers' hands during handwashing.

    In this situation, staff were disposing of body fluids down the handwashing sinks because the rooms had no bathrooms and the hopper was in an inconvenient place elsewhere in the unit. (I wonder: did this include poop? Were there chunks? What do you do with chunks in a sink? Squish them down the drain with a gloved hand?) These 2 stories and the plumbing similarity makes me think biofilm formation, which would be one of many potentially useful research areas to fund.

    Kudos to you for calling the NIH outbreak a lesson & not a failure. These outbreak reports are absolutely worth learning from.

  2. I was there (NIH) as a patient November 2011. This is the first I have heard!


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