Failure to Control an Outbreak of Multidrug-ResistantStreptococcus pneumoniaein a Long-Term–Care Facility Emergence and Ongoing Transmission of a Fluoroquinolone-Resistant Strain

Abstract

Objectives:To characterize risk factors associated with pneumococcal disease and asymptomatic colonization during an outbreak of multidrug-resistantStreptococcus pneumoniae(MDRSP) among AIDS patients in a long-term–care facility (LTCF), evaluate the efficacy of antimicrobial prophylaxis in eliminating MDRSP colonization, and describe the emergence of fluoroquinolone resistance in the MDRSP outbreak strain.Design:Epidemiologic investigation based on chart review and characterization of SP strains by antimicrobial susceptibility testing and PFGE and prospective MDRSP surveillance.Setting:An 80-bed AIDS-care unit in an LTCF.Participants:Staff and residents on the unit.Results:From April 1995 through January 1996, 7 cases of MDRSP occurred. A nasopharyngeal (NP) swab survey of all residents (n = 65) and staff (n = 70) detected asymptomatic colonization among 6 residents (9%), but no staff. Isolates were sensitive only to rifampin, ofloxacin, and vancomycin. A 7-day course of rifampin and ofloxacin was given to eliminate colonization among residents: NP swab surveys at 1, 4, and 10 weeks after prophylaxis identified 1 or more colonized residents at each follow-up with isolates showing resistance to one or both treatment drugs. Between 1996 and 1999, an additional 6 patients were diagnosed with fluoroquinolone-resistant (FQ-R) MDRSP infection, with PFGE results demonstrating that the outbreak strain had persisted 3 years after the initial outbreak was recognized.Conclusions:Chemoprophylaxis likely contributed to the development of a FQ-R outbreak strain that continued to be transmitted in the facility through 1999. Long-term control of future MDRSP outbreaks should rely primarily on vaccination and strict infection control measures.

Outbreaks of serious pneumococcal disease in closed settings in the post-antibiotic era: A systematic review

“…This trend appears to have subsequently declined to one outbreak per year. Of the 42 outbreaks reported, 24 occurred in the USA, 10,11,13,14,25,26,38,39,42,44 10 in the UK, 9,12,15,17,20,21,24,33,36 three in Canada, 30 two in France 28,35 and one each in Israel, 34 the Netherlands 32 and Spain. 27 The majority of outbreaks 14 occurred in hospital settings 12,13,15,20e22,31e34,36,43,45 followed by long term care facilities (LTCF) in which 12 were reported.…”

“…25,38,44,47 Carter et al, reported an outbreak of 10 cases with serotype information available for seven; five with serotype 23F and two with serotype 2. 14 We could calculate an attack rate in 11 of the outbreaks; median: 11.7 (range 7.4e14.9), and a case fatality ratio for all the outbreaks, median: 24% (range 0e44).…”

“…Nasopharyngeal swabbing of residents and staff was undertaken in five of the 12 reported outbreaks 14,27,38,39,42 leading to the identification of carriers of the same strain among patients in three of these outbreaks 14,38,39 and among staff in two of them. 27,38 In eight of the 12 outbreaks pneumococcal polysaccharide vaccine (PPV) coverage was reported among the population living in the facility 14,25,38,39,42,44,48 ; coverage was less than 10% in six.…”

“…27,38 In eight of the 12 outbreaks pneumococcal polysaccharide vaccine (PPV) coverage was reported among the population living in the facility 14,25,38,39,42,44,48 ; coverage was less than 10% in six. 11,25,38,39,42 In the other two outbreaks 14,44 PPV coverage was 58% and 49%, respectively.…”

Antimicrobial Susceptibility and Genetic Characteristics of Streptococcus pneumoniae Isolates Indicating Possible Nosocomial Transmission Routes in a Community Hospital in Japan

“…Age, previous hospitalization, and previous antimicrobial therapy have been thought to contribute to penicillin-resistant pneumococcal infection in nosocomial outbreaks (18,27). Previous studies conducted to determine the antimicrobial susceptibilities of isolates from NPI found that a high percentage of pneumococcal pathogens had multidrug resistance, including resistance to new quinolones (4,5,28,39). Masaki et al reported a possible relationship between the pulsed-field gel electrophoresis (PFGE) patterns of Moraxella catarrhalis isolates from hospital-and community-acquired respiratory infections in a community hospital (20).…”