By the end, 18 people harbored the dangerous germ, and six died of bloodstream infections from it. Another five made it through the outbreak only to die from the diseases that brought them to NIH's world-famous campus in the first place.
It took gene detectives teasing apart the bacteria's DNA to solve the germ's wily spread, a CSI-like saga with lessons for hospitals everywhere as they struggle to contain the growing threat of
It all stemmed from a single patient carrying a fairly new superbug known as KPC -- Klebsiella pneumoniae that resists treatment by one of the last lines of defense, antibiotics called carbapenems.
"We never want this to happen again," said Dr. Tara Palmore, deputy hospital epidemiologist at the NIH Clinical Center.
Infections at health care facilities are one of the nation's leading causes of preventable death, claiming an estimated 99,000 lives a year. They're something of a silent killer, as hospitals fearful of lawsuits don't like to publicly reveal when they outfox infection control -- yet no hospital is immune.
Wednesday, government researchers published an unusually candid account of last year's outbreak, with some advice: Fast sequencing of a germ's genome, its full DNA, may be essential. It can reveal how drug-resistant bacteria are spreading so that doctors can protect other patients.
"This is not an easy story to tell," said Dr. Julie Segre, a senior investigator at NIH's National Human Genome Research Institute. She led the genetic sleuthing that found the bug hiding in sink drains and, most chilling, even in a ventilator that had been cleaned with bleach.