Bathroom contamination by antibiotic-resistant Enterobacterales (ESBLPE and CPE): an experimental study

Cross-contamination of carbapenem-resistant Gram-negative bacteria between patients and the hospital environment in the first year of a newly built surgical ward

BACKGROUND

Transmission and outbreaks of carbapenem-resistant Gram-negative bacteria (CRGN) in hospitals are often associated with contamination of the wastewater environment. We performed a prospective observational study to investigate the colonization of the hospital wastewater environment during the first year of occupancy of the surgical intermediate and intensive care units of a newly constructed building at the University Hospital of Heidelberg, Germany.

METHODS

We performed monthly screening of the wastewater system (toilets and sinks) for 12 months, starting 1 month before opening (1st October 2020 to 30th October 2021). Admission and weekly rectal screening of patients for CRGN were also performed in parallel. Bacterial isolates were characterized by whole-genome sequencing.

RESULTS

Twenty-seven of 1978 (1.4%) admitted patients were colonized/infected with CRGN. A total of 29 CRGN isolates from 24 patients and 52 isolates were available for sequencing. Within the first month of occupancy, we identified seven patients colonized/infected with CRGN, while none were found in the environmental reservoirs. The first detection of CRGN isolates in the sewage system started five months after the first occupancy. Two previously non-colonized patients were colonized/infected with Pseudomonas aeruginosa strains colonizing the sewage system. The significant identity of plasmids carrying the carbapenemase gene suggests that long-term colonization of the sewage system facilitates the emergence of new carbapenem-resistant clones.

CONCLUSION

Cross-contamination between patients and the hospital environment is bidirectional. Our study demonstrated that contamination of the hospital wastewater environment may lead to persistent colonization and may serve as a reservoir for nosocomial acquisition of CRGN.

Sanitary installations and wastewater plumbing as reservoir for the long-term circulation and transmission of carbapenemase producing Citrobacter freundii clones in a hospital setting

BACKGROUND

Accumulating evidence shows a role of the hospital wastewater system in the spread of multidrug-resistant organisms, such as carbapenemase producing Enterobacterales (CPE). Several sequential outbreaks of CPE on the geriatric ward of the Ghent University hospital have led to an outbreak investigation. Focusing on OXA-48 producing Citrobacter freundii, the most prevalent species, we aimed to track clonal relatedness using whole genome sequencing (WGS). By exploring transmission routes we wanted to improve understanding and (re)introduce targeted preventive measures.

METHODS

Environmental screening (toilet water, sink and shower drains) was performed between 2017 and 2021. A retrospective selection was made of 53 Citrobacter freundii screening isolates (30 patients and 23 environmental samples). DNA from frozen bacterial isolates was extracted and prepped for shotgun WGS. Core genome multilocus sequence typing was performed with an in-house developed scheme using 3,004 loci.

RESULTS

The CPE positivity rate of environmental screening samples was 19.0% (73/385). Highest percentages were found in the shower drain samples (38.2%) and the toilet water samples (25.0%). Sink drain samples showed least CPE positivity (3.3%). The WGS data revealed long-term co-existence of three patient sample derived C. freundii clusters. The biggest cluster (ST22) connects 12 patients and 8 environmental isolates taken between 2018 and 2021 spread across the ward. In an overlapping period, another cluster (ST170) links eight patients and four toilet water isolates connected to the same room. The third C. freundii cluster (ST421) connects two patients hospitalised in the same room but over a period of one and a half year. Additional sampling in 2022 revealed clonal isolates linked to the two largest clusters (ST22, ST170) in the wastewater collection pipes connecting the rooms.

CONCLUSIONS

Our findings suggest long-term circulation and transmission of carbapenemase producing C. freundii clones in hospital sanitary installations despite surveillance, daily cleaning and intermittent disinfection protocols. We propose a role for the wastewater drainage system in the spread within and between rooms and for the sanitary installations in the indirect transmission via bioaerosol plumes. To tackle this problem, a multidisciplinary approach is necessary including careful design and maintenance of the plumbing system.

Visible-light photooxidation of ciprofloxacin utilizing metal oxide incorporated sol-gel processed La-doped NaTaO3 nanoparticles: A comparative study

The supper dissemination of antibiotic waste in water resources has exponentially progressed the vital water and soil pollution that affect human health and the environment. Consequently, there have been several types of research anticipated for the green mineralization of such pollutants. Herein, we intended a surfactant-aided sol-gel formation of lanthanum-doped sodium tantalate (LNTO) nanocrystals. The synthesized 13 nm averaged-size perovskite LNTO nanocrystals were responsive to visible-light irradiation by incorporation of 4.4-5.2 nm oxide nanoparticles, namely Bi₂O₃, CdO, Fe₂O₃, and CuO at 4.0 wt% through coprecipitation. The formed nanomaterials unveiled mesostructured surface textures with specific surface areas of 199-229 m² g^-1. The obtained nanoceramics were employed for the mineralization of 10 ppm of ciprofloxacin antibiotic (CPF) as an emerging antibiotic waste in water under visible light irradiation. The CuO-incorporated LNTO exhibited the best photocatalytic oxidation of CPF after 120 min compared with other oxides with an excellent photoreaction rate of 0.0343 min^-1 which is 49 times higher than the pure LNTO. The 2.0 gL^-1 CuO/LNTO-dose achieved the full photooxidation of CPF at an oxidation speed of 0.0738 min ^-1 within just 1.0 h of visible light irradiation and magnificent regeneration ability. This enhanced activity of CuO/LNTO is regarded as significant light absorption and a bandgap energy reduction to 2.12 eV. Besides that, the heterojunction between CuO and LNTO amended the photogenerated carrier mobility and separation as concluded from the photoluminescence and photocurrent exploration. This comparative work suggests the proper design of low bandgap oxide decoration of solution-based perovskite oxide photocatalysts for promoting the visible-light mineralization of antibiotics in water.

Cobalt ferrite-modified sol-gel synthesized ZnO nanoplatelets for fast and bearable visible light remediation of ciprofloxacin in water

Currently, metal oxide photocatalysts is a green and facile tool for the elimination of emerging pollutants utilizing light illumination. Though, the wide bandgap energy (E_g), rapid recombination of photogenerated carriers, and photostability of these oxides represent critical issues before the actual application. Herein, we familiarise a sol-gel based synthesis of ZnO hexagonal nanoplatelets modified with CoFe₂O₄ (CFO) nanoparticles at minor loading (1.0-4.0 wt %) to yield CFO/ZnO nanoheterojunctions. The CFO/ZnO unveiled mesostructured surfaces at surface areas of 102-120 m² g^-1 and photoactive in the visible region with high. The CFO addition to ZnO reduced its E_g from 3.14 to 2.66 eV. The formed nanoheterojunctions were applied to remediate ciprofloxacin (CPF), as an antibiotic pollutant in wastewater. The 2.4 g L^-1 3.0 wt % CFO-added ZnO exhibited a 100% removal of 10-ppm CPF within 45 min of visible-light irradiation and sustainable recycling ability for five consecutive runs at 97%. The sustainable performance of CFO/ZnO is ascribed to the suppression of photogenerated carriers and reduction of E by p-n nanoheterojunction formation. This study broadens the way for nanoheterojunction oxides for the destruction of pharmaceutical wastes under visible-light illumination.

Genomic Investigation and Successful Containment of an Intermittent Common Source Outbreak of OXA-48-Producing Enterobacter cloacae Related to Hospital Shower Drains

The hospital environment has been reported as a source of transmission events and outbreaks of carbapenemase-producing Enterobacterales. Interconnected plumbing systems and the microbial diversity in these reservoirs pose a challenge for outbreak investigation and control. A total of 133 clinical and environmental OXA-48-producing Enterobacter cloacae isolates collected between 2015 and 2021 were characterized by whole-genome sequencing (WGS) to investigate a prolonged intermittent outbreak involving 41 patients in the hematological unit. A mock-shower experiment was performed to investigate the possible acquisition route. WGS indicated the hospital water environmental reservoir as the most likely source of the outbreak. The lack of diversity of the blaOXA-48-like harbouring plasmids was a challenge for data interpretation. The detection of blaOXA-48-like-harboring E. cloacae strains in the shower area after the mock-shower experiment provided strong evidence that showering is the most likely route of acquisition. Initially, in 20 out of 38 patient rooms, wastewater traps and drains were contaminated with OXA-48-positive E. cloacae. Continuous decontamination using 25% acetic acid three times weekly was effective in reducing the trap/drain positivity in monthly environmental screening but not in reducing new acquisitions. However, the installation of removable custom-made shower tubs did prevent new acquisitions over a subsequent 12-month observation period. In the present study, continuous decontamination was effective in reducing the bacterial burden in the nosocomial reservoirs but was not sufficient to prevent environment-to-patient transmission in the long term. Construction interventions may be necessary for successful infection prevention and control. IMPORTANCE The hospital water environment can be a reservoir for a multiward outbreak, leading to acquisitions or transmissions of multidrug-resistant organisms in a hospital setting. The majority of Gram-negative bacteria are able to build biofilms and persist in the hospital plumbing system over a long period of time. The elimination of the reservoir is essential to prevent further transmission and spread, but proposed decontamination regimens, e.g., using acetic acid, can only suppress but not fully eliminate the environmental reservoir. In this study, we demonstrated that colonization with multidrug-resistant organisms can be acquired by showering in showers with contaminated water traps and drains. A construction intervention by installing removable and autoclavable shower inserts to avoid sink contact during showering was effective in containing this outbreak and may be a viable alternative infection prevention and control measure in outbreak situations involving contaminated shower drains and water traps.

Transmission of extended-spectrum β-lactamase-producing Klebsiella pneumoniae associated with sinks in a surgical hospital ward, confirmed by single-nucleotide polymorphism analysis

BACKGROUND

Although sink- and drain-related carbapenemase-producing Enterobacterales transmission has been reported previously, there is limited research regarding the transmission of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales.

AIM

To investigate nosocomial ESBL-producing Klebsiella pneumoniae transmission via patient sinks and drains on a general surgical hospital ward.

METHODS

ESBL-producing K. pneumoniae transmission on a surgical ward at Tokyo Medical University Hospital (built in July 2019) from July 2019 to February 2020 was investigated. Information regarding the relatedness of the isolates from the patients and the environment was provided by whole-genome sequence analysis.

FINDINGS

Four clinical isolates of K. pneumoniae (TUM19831, TUM19832, TUM19833 and TUM19834) were detected during the study. TUM19831 was identified prior to moving to the new building and was detected again in the new building. TUM19832 and TUM19833 were detected in July 2019, and TUM19834 was detected in December 2019. TUM19835 and TUM19836 were detected in two different sinks and drains in July 2019, while a further two sinks and drains tested positive for TUM19837 and TUM19838 in February 2020. Whole-genome analysis revealed that all strains were ST307 and CTXM15 sequence types, and the isolates were indistinguishable by genetic analysis. Due to inadequate removal of the slime biofilm coating, the sinks needed to be cleaned again before TUM19837 and TUM19838 could be detected.

CONCLUSIONS

This study demonstrated the transmission of indistinguishable ESBL-producing K. pneumoniae strains from sinks and drains in the patient area of a general surgical hospital ward. There is a need to recognize this risk and develop optimal management strategies for plumbing systems in hospitals and other healthcare settings.