Carbapenem-resistant Enterobacteriaceae (CRE) outbreak

Carbapenem-resistant Enterobacteriaceae (CRE) outbreak:  Tygerberg Hospital’s Neonatal Service

The Neonatal Service at Tygerberg Hospital (TBH) is currently in the midst of a significant Carbapenem-resistant Enterobacteriaceae (CRE) outbreak with a number of babies affected. The hospital has been dealing with this situation as per prescribed protocol, and since 2 January no new infections have been identified.

The following are important facts:

• Carpabenem-resistant infections are a challenge across the health system, both across RSA (public and private) and worldwide.
• This is part of an international trend where organisms are becoming more resistant to treatment with antibiotics. The “carbapenem” antibiotics are a relatively sophisticated treatment, and resistance to them poses a serious challenge.
• These infections are usually hospital-acquired, but exist throughout the community. They  particularly affect (low birthweight) neonates (babies in the first 28 days of life)
• Because Tygerberg Hospital has paediatric and neonatal specialised care services, it is the preferred facility and level of care where seriously ill infants will be treated.
• The consistently high number of neonates admitted at Tygerberg has led to crowded conditions. Four babies have been infected by CRE and sadly resulting in the death of one baby. Other babies who were exposed to but not infected with CRE have been cohorted (placed together) in specific neonatal wards, which now function solely as isolation wards.
• However, CRE infections can be associated with high mortality and the bacteria are easily transmitted by contaminated hands, medical equipment and surfaces. Hospitalized neonates and children are at higher risk of becoming infected with CRE and subsequently developing invasive (serious) CRE infection (though not all babies who are exposed to CRE will become ill).
• The outbreak has significantly impacted clinical services and the burden of care on the neonatal and paediatric services and there remains a high risk of CRE transmission despite the infection prevention measures in place.

Several contingency measures have been put in place to contain the outbreak:

1. Additional staff have been allocated to care for  affected babies and children who require isolation
2. Intensified infection control and cleaning of the hospital environment, clinical equipment and incubators to prevent further spread of CRE
3. Additional areas have been opened for additional neonatal beds 
4. Screening of all inpatient babies for the relevant micro – organisms
5. Visitor and student access to relevant areas has been severely restricted 
6. Selected babies are referred to other appropriate health facilities.

Babies who have been exposed to CRE (infected with actual sepsis) or babies that are CRE-colonized, (without actual sepsis) cannot be sent to any other health facility due to the risk of spreading. These babies will thus remain in the hospital’s CRE isolation wards until they are ready for discharge. It is likely that the new spaces that have been opened will need to remain open for this special purpose for at least 3 months

Caregivers of affected babies who have been discharged have received counselling (training/instructions). When discharged, they will also receive a letter/notification addressed to health care workers in the baby’s “Road to Health” booklet to take with them and to present it at the baby’s next visit to a health facility.