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

AbstractObjectives:To characterize risk factors associated with pneumococcal disease and asymptomatic colonization during an outbreak of multidrug-resistant Streptococcus 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.