Dutch microbiologists are disciplined for delays during pneumonia outbreak

The Dutch Healthcare Inspectorate has filed a rare medical disciplinary complaint against a group of three medical microbiologists, aimed at reaffirming standards of hospital care when tackling outbreaks of infection involving multiple antibiotic resistant bacteria.

The action comes after a highly critical report by the inspectorate into an outbreak of Klebsiella pneumoniae Oxa-48 at Maasstad Hospital, Rotterdam.

The outbreak continued without proper action for more than a year, infecting more than 100 patients and causing very probably three and possibly a further 10 deaths. Up to 4000 patients risked exposure, having shared a room with an infected patient.

The inspectorate concludes that the “seriousness, extent, and duration” of the outbreak were caused by “inadequate treatment” and “lack of effective cooperation” by many staff. In particular, medical microbiologists and advisers on infection prevention, though aware of many cases of K pneumoniae infection, failed to take the necessary measures.

However, the inspectorate held the whole hospital “culpable,” concluding “from observations, conversations, and documents” that it was perfectly plain that failures on many levels played a role and that patients were exposed to great risks.

The outbreak began in the middle of 2009. By June 2010 several cases of the infection were found among intensive care patients. But it was not until next May, after other hospitals identified Klebsiella among patients transferred from Maasstad, that microbiologists carried out further laboratory tests to confirm K pneumoniae Oxa-48. Only then did they inform management and launch a crisis team.

The inspector general, Gerrit van der Wal, said that infection control is generally well managed in the Netherlands so it was “almost inconceivable” that in the course of nearly a year measures such as setting up an outbreak team, informing local hospital and nursing homes, and informing the management board did not happen. The complaints were being brought not just because of the seriousness of the case but also to confirm standards as an example to the whole country.

The inspectorate’s report argues that the microbiologists did not satisfactorily fulfil their responsibilities for implementing guidelines for controlling an outbreak of a highly resistant micro-organism. They did not react to the increasing number of patients infected with K pneumoniae, and their failure to cooperate with infection control advisers made the “seriousness of the calamity greater.”

The hospital’s director and supervisory board also failed to “keep an eye” on the quality and safety of care; action from care managers and the board of directors was late and insufficient; and consultants and nurses failed to take responsibility or work together to limit the outbreak or prevent new infections.

Johan Legemaate, professor of health law at Amsterdam University, said it was the first time since 1995 that such an action against a group, rather than an individual doctor, had been taken. A decision by the disciplinary board could now provide standards for future cases to clarify a doctor’s responsibilities in a particular circumstance.

In a statement the hospital apologised and said that it was continuing to implement the inspectorate’s recommendations to improve safety throughout the organisation.