Tiny Patients, Big Threat: Navigating a Carbapenemase-Producing-Organism Outbreak in the Neonatal-Intensive-Care-Unit

Session Description: On June 26, 2025, the Infection Prevention team was alerted to a case of carbapenemase-producing Klebsiella pneumoniae identified in an infant in the Neonatal Intensive Care Unit. Per protocol, unit-wide point prevalence screening was conducted, ultimately revealing eight additional cases of colonization, both secondary and tertiary, identified to have the same resistance gene, OXA-48. The situation escalated rapidly, prompting a comprehensive, multidisciplinary response involving hospital senior leadership, Infection Prevention, Facilities, Environmental Services, Clinical Laboratory, bedside staff, and providers, all mobilized to prevent further transmission. Collaboration with the state public health department confirmed genetic relatedness among the isolates, and provided valuable oversight and guidance throughout the remediation process.

Notably, the index patient's twin tested negative for colonization, effectively ruling out maternal transmission and prompting further investigation. Through detailed bed tracing and case review, an alternate index case was identified: an infant whose maternal history presented plausible risk factors for introduction. Cohorting strategies were implemented, with colonized infants relocated to one side of the unit. Staff and equipment were designated to individual infants, and infection prevention compliance - particularly hand hygiene, isolation practices, and environmental cleanliness - was reinforced and closely monitored. Following multiple rounds of surveillance, transmission was deemed mitigated and the outbreak contained.

Outbreaks involving carbapenemase-producing organisms are exceedingly rare in neonatal populations, making this case an invaluable learning opportunity. By sharing this experience, Infection Preventionists across settings can better prepare for and respond to similarly complex and high-consequence events.

This session will lead participants through the nuances of outbreak response in a uniquely vulnerable patient population. It will emphasize the critical importance of rapid containment, sustained infection prevention practices, and coordinated, multidisciplinary action - including cohorting, strict adherence to hand hygiene and isolation precautions, separation of clean and dirty workflows, and environmental hygiene, in restoring safety and preventing recurrence.

Katrina Foakes

Infection Preventionist, University of Colorado Hospital

Katrina Espiritu Foakes, MPH, CIC, is an experienced Infection Preventionist with a background spanning public health departments, pediatric hospitals, and large academic medical centers. She’s passionate about turning surveillance data into real-world strategies that improve patient safety and outcomes, especially when it comes to outbreak response and hospital-acquired infection reduction. When she’s not deep in a spreadsheet or on unit rounds, you’ll likely find her geeking out over Clostridium difficile rates, or exploring new snacks.