Containing Multi-Drug-Resistant Organisms in a Long-Term Acute-Care Hospital


In response to a novel “superbug” discovered at a long-term acute-care hospital, the Florida Department of Health in Orange County responded rapidly to contain the outbreak and create tools for future use.

A close up of the word "superbug" in a dictionary

December 3, 2019

When a novel multi-drug-resistant organism (MDRO) was discovered in a patient at a long-term acute-care hospital in Orange County, Florida, the health department began a rapid response to investigate its source and contain its spread. The patient was colonized with a form Pseudomonas aeruginosa that was producing VIM (Verona integron-encoded metallo-beta-lactamase), an enzyme that makes it resistant to a class of antibiotics normally highly effective against antibiotic-resistant bacteria. This was Florida’s first reported case of this “superbug”—known as VIM-CRPA—and immediate containment was necessary.

The Florida Department of Health in Orange County (DOH-Orange) launched extensive screening throughout the facility, with support from CDC. Investigators performed direct observations of patient care, hand hygiene, personal protective equipment use, and environmental cleaning; conducted environmental sampling; and oversaw collection of rectal swabs from patients for screening. The Southeast Regional Antibiotic Resistance Laboratory Network performed antimicrobial resistance testing and genotyping on specimens. In the process, the investigators discovered that the facility had a concurrent outbreak of a different MDRO, Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacteriaceae (KPC-CRE).

To assess regional spread, DOH-Orange performed a social network analysis and extended the containment response to other high-risk healthcare facilities, where more cases were discovered. By the outbreak’s end, the investigation had uncovered 9 cases of VIM-CPRA, 44 cases of KPC-CRE, and 6 cases of co-infection. DOH-Orange’s containment efforts ultimately stopped the transmission of VIM-CRPA and the outbreak ended.

To support the regional investigation and partner effectively with patients, families, and facility staff, Orange-DOH developed multiple tools:

  • Facility laboratory collection guidance outlining a standardized process for specimen collection, personal protective equipment needed, and required supplies
  • A script and patient consent form for facility staff to increase patients’ comfort level and willingness to be screened
  • Patient and family education materials in English, Spanish, and Creole to help patients make informed decisions about screening and to help visitors protect themselves and others
  • Prominent precaution signs for special contact, droplet, contact, and airborne precautions
  • A discharge packet for long-term-care facilities with a transfer form for the front of the medical record, a letter explaining the outbreak, details about the patient’s specimen collection, contact precaution signs, enhanced standard precautions guidance, and contact information for health department staff
  • A one-pager and checklist about MDROs for the facilities’ environmental services managers to help them improve policies, staff training, and cleaning processes

DOH-Orange staff developed all tools with an eye to the future, knowing they could prove useful for responding to other emerging infectious diseases. To learn more about DOH-Orange’s efforts and access the tools, read an interviewexternal icon published by the National Association of County and City Health Officials.

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Disclaimer: Field Notes is designed to spotlight success and innovation in state, tribal, local, and territorial (STLT) health agencies. It is part of the Centers for Disease Control and Prevention’s (CDC’s) effort to highlight what is happening on the front lines of public health. The information in Field Notes is provided by STLT agencies external to CDC. Provision of this information is for informational purposes and does not necessarily constitute an endorsement, recommendation, and/or represent the views of CDC.

Page last reviewed: February 24, 2022