 a response to a single patient colonized with vim crpa and kpc cre identified concurrent outbreaks at a long term acute care hospital epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of vim crpa and kpc cre and to the transfer of carbapenemase genes across different bacteria species and strains improved infection control including interventions that minimized potential spread from wastewater premise plumbing stopped transmission 