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Inkster T. A narrative review and update on drain related outbreaks. J Hosp Infect 2024:S0195-6701(24)00201-9. [PMID: 38830539 DOI: 10.1016/j.jhin.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Outbreaks linked to hospital drainage systems are well reported and continue to present challenges to incident management teams. Such outbreaks can be protracted and complex, with multi-modal strategies being required for remediation. AIM The aim was to summarise recent drain related outbreaks, investigate whether multimodal control measures are being implemented and determine any antecedent factors. METHODS Databases were searched for drain related outbreaks over a five-year period. Search terms employed included healthcare drainage outbreaks; drain outbreaks;drainage system outbreaks; sink outbreaks; shower outbreaks . Information was collected on country of origin, pathogens involved, unit affected, drain types, patient numbers, drainage system interventions, type of drain disinfectant, infection control interventions, typing method, outcomes and any antecedent factors. FINDINGS Nineteen drain related outbreak papers were reviewed. The majority of incidents were due to Carbapenemase producing Enterobacterales (CPE) and were from critical care settings. Most (16/19) recognised the need for a multi-modal approach. Information on the success of interventions was not documented for all but 13/19 reported no further cases after control measures. Variation in the choice of agent and frequency of application exists with regards to drain disinfection. Seven studies discussed antecedent factors. CONCLUSION Despite drain related outbreaks being reported for the last 24 years and review articles on the subject, outbreaks continue to pose significant challenges. There is currently no UK guidance on the management of drain related outbreaks or the design of new buildings to mitigate the risk. Addressing the challenges from hospital drainage systems should be considered a priority by agencies and guidance developers.
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Affiliation(s)
- Teresa Inkster
- Antimicrobial Resistance and Healthcare Associated Infection, Delta House, Glasgow, Scotland,UK.
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Inkster T, Caldwell I, Aird H, Willis C, Lai S, Mallon J. Development and evaluation of test methods for the detection and enumeration of opportunistic waterborne pathogens from the hospital environment. J Hosp Infect 2024; 149:98-103. [PMID: 38685413 DOI: 10.1016/j.jhin.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/01/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Many Gram-negative bacteria other than Pseudomonas aeruginosa have been implicated in waterborne outbreaks, but standardized laboratory detection methods for these organisms have not been established. AIM This study aimed to establish laboratory testing methodologies for six waterborne pathogens: Acinetobacter spp., Burkholderia spp., Cupriavidus spp., Delftia acidovorans, Elizabethkingia spp. and Stenotrophomonas maltophilia. METHODS Water samples were spiked by UK Health Security Agency laboratories and sent to the Glasgow Royal Infirmary laboratory for analysis. Water samples were spiked with either a pure culture of target organism or the target organism in water containing normal background flora, to ensure that the methodology could identify organisms from a mixed culture. Volumes of 100 mL were filtered under negative pressure on to culture media and incubated at 30 °C and 37 °C. The incubation time was 7 days, with plates read on days 2, 5 and 7. Further identification of colonies was undertaken using matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS). FINDINGS Optimal recovery of organisms was obtained by culturing water samples on tryptic soy agar, chocolate bacitracin agar and pseudomonas selective agar. The optimal temperature for isolation was 30 °C. The optimal incubation time was 5 days, and MALDI-TOF MS identified all test species reliably. CONCLUSION The methodology described was able to detect the six tested waterborne pathogens reliably, and can be utilized by laboratories involved in testing water samples during outbreak investigations.
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Affiliation(s)
- T Inkster
- Antimicrobial Resistance and Healthcare Associated Infection, Glasgow, UK.
| | - I Caldwell
- Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
| | - H Aird
- Food Water and Environmental Microbiology Laboratory York, UK Health Security Agency, York, UK
| | - C Willis
- Food Water and Environmental Microbiology Laboratory Porton, UK Health Security Agency, Salisbury, UK
| | - S Lai
- Food Water and Environmental Microbiology Services, Colindale, UK Health Security Agency London, UK
| | - J Mallon
- Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
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Inkster T, Walker J, Weinbren M. Waterborne infections in haemato-oncology units - a narrative review. J Hosp Infect 2023:S0195-6701(23)00165-2. [PMID: 37290689 DOI: 10.1016/j.jhin.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/10/2023]
Abstract
Bone marrow transplant and haemato-oncology patients are at risk of healthcare associated infections due to waterborne pathogens. We undertook a narrative review of waterborne outbreaks in haemato-oncology patients from 2000-2022. Databases searched included Pubmed, DARE and CDSR and were undertaken by two authors. We analysed the organisms implicated, sources identified and infection prevention and control strategies implemented. The most commonly implicated pathogens were Pseudomonas aeruginosa, non-tuberculous mycobacteria and Legionella pneumophila. Bloodstream infection was the most common clinical presentation. The majority of incidents employed multimodal strategies to achieve control, addressing both the water source and routes of transmission. This review highlights the risk to haemato-oncology patients from waterborne pathogens and discusses future preventative strategies and the requirement for new UK guidance for haemato-oncology units.
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Affiliation(s)
- T Inkster
- Department of Microbiology, Queen Elizabeth University Hospital, Glasgow, UK.
| | - J Walker
- Walker on Water, 23 Anderson Road, Bishopdown, Salisbury, UK
| | - M Weinbren
- Department of Microbiology, Kings Mill Hospital, Sutton-in -Ashfield, UK
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Walker J, Inkster T, Weinbren M. Aspects and problems associated with the water services to be considered in intensive care units. J Infect Prev 2023; 24:60-64. [PMID: 36815062 PMCID: PMC9940243 DOI: 10.1177/17571774231152716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023] Open
Abstract
Background Water is a product taken for granted and assumed to be a safe commodity in intensive care units (ICU). Biofilm readily becomes established in complex water services presenting a risk to vulnerable patients. Harboured within biofilms are opportunistic pathogens which can be transmitted via hand contact, splashing, aerosol and indirect contact through medical equipment. Evidence linking the role of water services in transmission of infection to patients in ICUs has increased in recent years. Aims This research based commentary set out to identify current problems with water and wastewater systems in ICU settings. Methods Databases and open source information was used to obtain data on current water and wastewater-related issues in ICU settings. This and the authors experiences have been used to describe current challenges. Findings the authors found a number of problems with water systems in ICU to which there has not been a cohesive response in terms of guidance to support users and designers. The resultant void permits new projects to proceed with suboptimal and designs which place patients and staff at risk. Discussion Hand hygiene stations are frequently misused or close enough to patients such that splashing poses a transmission risk. The wastewater system (drain) also presents a risk, from where Gram-negative antibiotic resistant organisms may be dispersed resulting in untreatable patient infections. The water and wastewater system provide a superhighway for the movement of pathogenic microorganisms and these risks need to be addressed if we are to safeguard vulnerable users in ICU.
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Affiliation(s)
| | - Teresa Inkster
- Department of Microbiology, Queen Elizabeth University Hospital Campus, Glasgow, UK
| | - Michael Weinbren
- Department of Microbiology, King’s Mill Hospital, Sutton-in-Ashfield, UK
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Liu S, Zhou Y, Ma D, Zhang S, Dong Y, Zhang X, Mao J. Environment microorganism and mature daqu powder shaped microbial community formation in mechanically strong-flavor daqu. FOOD BIOSCI 2023. [DOI: 10.1016/j.fbio.2023.102467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Rice W, Martin J, Hodgkin M, Carter J, Barrasa A, Sweeting K, Johnson R, Best E, Nahl J, Denton M, Hughes GJ. A protracted outbreak of difficult-to-treat resistant Pseudomonas aeruginosa in a haematology unit: a matched case-control study demonstrating increased risk with use of fluoroquinolone. J Hosp Infect 2023; 132:52-61. [PMID: 36563938 DOI: 10.1016/j.jhin.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Between September 2016 and November 2020, 17 cases of difficult-to-treat resistant Pseudomonas aeruginosa (DTR-PA) were reported in haematology patients at a tertiary referral hospital in the North of England. AIM A retrospective case-control study was conducted to investigate the association between DTR-PA infection and clinical interventions, patient movement, antimicrobial use and comorbidities. METHODS Cases were patients colonized or infected with the outbreak strain of DTR-PA who had been admitted to hospital prior to their positive specimen. Exposures were extracted from medical records, and cases were compared with controls using conditional logistic regression. Environmental and microbiological investigations were also conducted. FINDINGS Seventeen cases and 51 controls were included. The final model included age [>65 years, adjusted OR (aOR) 6.85, P=0.232], sex (aOR 0.60, P=0.688), admission under the transplant team (aOR 14.27, P=0.43) and use of ciprofloxacin (aOR 102.13, P=0.030). Investigations did not indicate case-to-case transmission or a point source, although a common environmental source was highly likely. CONCLUSION This study found that the use of fluoroquinolones is an independent risk factor for DTR-PA in haematology patients. Antimicrobial stewardship and review of fluoroquinolone prophylaxis should be considered as part of PA outbreak investigations in addition to standard infection control interventions.
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Affiliation(s)
- W Rice
- Field Epidemiology Training Programme, United Kingdom Heath Security Agency, London, UK; Field Service, United Kingdom Health Security Agency, Leeds, UK
| | - J Martin
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - M Hodgkin
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J Carter
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Barrasa
- Field Epidemiology Training Programme, United Kingdom Heath Security Agency, London, UK
| | - K Sweeting
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - R Johnson
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E Best
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J Nahl
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M Denton
- Field Service, United Kingdom Health Security Agency, Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - G J Hughes
- Field Service, United Kingdom Health Security Agency, Leeds, UK.
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Inkster T, Wilson G, Black J, Mallon J, Connor M, Weinbren M. Cupriavidus spp and other waterborne organisms in healthcare water systems across the United Kingdom. J Hosp Infect 2022; 123:80-86. [PMID: 35181399 DOI: 10.1016/j.jhin.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cupriavidus pauculus is a rare clinical pathogen with cases having been linked to contaminated hospital water systems. An outbreak of three cases of C. pauculus and other waterborne organisms was reported in a Glasgow hospital in 2018. AIMS The aim of this study was to determine whether Cupriavidus spp are present in hospital water systems elsewhere in Scotland and the UK and to ascertain the optimal laboratory methodology for detection. We also sought to establish where in the water system these organisms are detected and whether a selective media could be developed for isolation. In addition, we tested water samples for the presence of other Gram negative waterborne organisms. METHODS Water samples were received from ten UK NHS hospitals and from various parts of the water system. Isolates were plated on to TSA and Pseudomonas Isolation Agar and further identified using MALDI-TOF and 16S PCR FINDINGS: Cupriavidus spp. were detected in four of ten hospitals tested and all five isolates were from the periphery of the water system. All hospitals had evidence of other OPPPs. Cupriavidus spp. were identified using TSA, with some isolates growing on Pseudomonas isolation agar; as such they may be inadvertently be detected when testing water specifically for Pseudomonas aeruginosa. CONCLUSION This study demonstrates that isolation of Cupriavidus spp. was not unique to the Glasgow incident, these bacteria being present in hospital water systems elsewhere in the UK. We therefore recommend water testing in response to clinical cases. Consideration should also be given to water testing following bacteraemias due to other rare and unusual water borne pathogens.
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Affiliation(s)
- T Inkster
- Department of Microbiology, Queen Elizabeth University Hospital, Glasgow, UK; NHS Assure, National Services Scotland, Edinburgh, UK.
| | - G Wilson
- Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
| | - J Black
- Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
| | - J Mallon
- Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
| | - M Connor
- Department of Microbiology, Dumfries and Galloway Hospital, UK
| | - M Weinbren
- NHS Assure, National Services Scotland, Edinburgh, UK
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Butler J, Kelly SD, Muddiman KJ, Besinis A, Upton M. Hospital sink traps as a potential source of the emerging multidrug-resistant pathogen Cupriavidus pauculus: characterization and draft genome sequence of strain MF1. J Med Microbiol 2022; 71. [PMID: 35113779 PMCID: PMC8941954 DOI: 10.1099/jmm.0.001501] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction.Cupriavidus pauculus is historically found in soil and water but has more recently been reported to cause human infection and death. Hospital sink traps can serve as a niche for bacterial persistence and a platform for horizontal gene transfer, with evidence of dissemination of pathogens in hospital plumbing systems driving nosocomial infection. Gap Statement. This paper presents the first C. pauculus strain isolated from a hospital sink trap. There are only six genome assemblies available on NCBI for C. pauculus; two of these are PacBio/Illumina hybrids. This paper presents the first ONT/Illumina hybrid assembly, with five contigs. The other assemblies available consist of 37, 38, 111 and 227 contigs. This paper also presents data on biofilm formation and lethal dose in Galleria mellonella; there is little published information describing these aspects of virulence. Aim. The aims were to identify the isolate found in a hospital sink trap, characterize its genome, and assess whether it could pose a risk to human health. Methodology. The genome was sequenced, and a hybrid assembly of short and long reads produced. Antimicrobial susceptibility was determined by the broth microdilution method. Virulence was assessed by measuring in vitro biofilm formation compared to Pseudomonas aeruginosa and in vivo lethality in Galleria mellonella larvae. Results. The isolate was confirmed to be a strain of C. pauculus, with a 6.8 Mb genome consisting of 6468 coding sequences and an overall G+C content of 63.9 mol%. The genome was found to contain 12 antibiotic resistance genes, 8 virulence factor genes and 33 metal resistance genes. The isolate can be categorized as resistant to meropenem, amoxicillin, amikacin, gentamicin and colistin, but susceptible to cefotaxime, cefepime, imipenem and ciprofloxacin. Clear biofilm formation was seen in all conditions over 72 h and exceeded that of P. aeruginosa when measured at 37 °C in R2A broth. Lethality in G. mellonella larvae over 48 h was relatively low. Conclusion. The appearance of a multidrug-resistant strain of C. pauculus in a known pathogen reservoir within a clinical setting should be considered concerning. Further work should be completed to compare biofilm formation and in vivo virulence between clinical and environmental strains, to determine how easily environmental strains may establish human infection. Infection control teams and clinicians should be aware of the emerging nature of this pathogen and further work is needed to minimize the impact of contaminated hospital plumbing systems on patient outcomes.
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Affiliation(s)
- James Butler
- School of Engineering, Computing and Mathematics, Faculty of Science and Engineering, University of Plymouth, Plymouth PL4 8AA, UK
| | - Sean D Kelly
- School of Biomedical Sciences, Faculty of Health, University of Plymouth, Plymouth PL4 8AA, UK
| | - Katie J Muddiman
- School of Biomedical Sciences, Faculty of Health, University of Plymouth, Plymouth PL4 8AA, UK
| | - Alexandros Besinis
- School of Engineering, Computing and Mathematics, Faculty of Science and Engineering, University of Plymouth, Plymouth PL4 8AA, UK.,Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth PL4 8AA, UK
| | - Mathew Upton
- School of Biomedical Sciences, Faculty of Health, University of Plymouth, Plymouth PL4 8AA, UK
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Weinbren M, Inkster T, Lafferty F. Drains and the periphery of the water system - what do you do when the guidance is outdated? Infect Prev Pract 2022; 3:100179. [PMID: 34988421 PMCID: PMC8696270 DOI: 10.1016/j.infpip.2021.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
The periphery of the water system (defined as the last 2 m of pipework from an outlet and ensuing devices including drainage), is the juncture of multiple inherent risks: the necessity to use materials with higher risk of biofilm formation, difficulty in maintaining safe water temperatures, a human interface with drainage systems, poor design, poor layout and use by staff. Add to this risk a large new healthcare facility capital build programme in England, outdated guidance and bacteria emanating from drainage systems containing highly mobile genetic elements (threatening the end of the antibiotic era), and the scene is set for the perfect storm. There is an urgent need for the re-evaluation of the periphery of the water system and drainage systems. Consequently, in this article we examine the requirement and placement of hand wash stations (HWSs), design of showers, kitchens and the dirty utility with respect to water services. Lastly, we discuss the provision of safe water to high-risk patient groups. The purpose of this article is to stimulate debate and provide infection control and design teams with support in deviating from the outdated existing guidance and to challenge conventional thinking until new advice is forthcoming.
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Affiliation(s)
- M Weinbren
- Department of Microbiology, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - T Inkster
- Department of Microbiology, Queen Elizabeth University Hospital, Glasgow, UK
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Weinbren M, Inkster T. Role of the kitchen environment. Infect Prev Pract 2021; 3:100155. [PMID: 34647009 PMCID: PMC8498711 DOI: 10.1016/j.infpip.2021.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- M Weinbren
- Department of Microbiology, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - T Inkster
- Department of Microbiology, Queen Elizabeth University Hospital, Glasgow, UK
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Inkster T, Weinbren M. Is it time for water and drainage standards to be part of the accreditation process for haemato-oncology units? Clin Microbiol Infect 2021; 27:1721-1723. [PMID: 34400342 DOI: 10.1016/j.cmi.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/21/2021] [Accepted: 08/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Teresa Inkster
- Department of Microbiology, Queen Elizabeth University Hospital, Glasgow, UK.
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Inkster T, Peters C, Seagar AL, Holden MTG, Laurenson IF. Investigation of two cases of Mycobacterium chelonae infection in haemato-oncology patients using whole-genome sequencing and a potential link to the hospital water supply. J Hosp Infect 2021; 114:111-116. [PMID: 33945838 DOI: 10.1016/j.jhin.2021.04.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Haemato-oncology patients are at increased risk of infection from atypical mycobacteria such as Mycobacterium chelonae which are commonly found in both domestic and hospital water systems. AIMS To describe the investigation and control measures following two patient cases of M. chelonae and positive water samples in the study hospital. METHODS Water testing was undertaken from outlets, storage tanks and mains supply. Whole-genome sequencing (WGS) was used to compare patient and positive water samples. The subsequent infection control measures implemented are described. FINDINGS The WGS results showed two main populations of M. chelonae within the group of sampled isolates. The results showed that the patient strains were unrelated to each other, but that the isolate from one patient was closely related to environmental samples from water outlets, supporting nosocomial acquisition. CONCLUSIONS WGS was used to investigate two patient cases of M. chelonae and positive water samples from a hospital water supply. Relevant control measures and the potential for chemical dosing of water systems to enhance proliferation of atypical mycobacteria are discussed.
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Affiliation(s)
- T Inkster
- Queen Elizabeth University Hospital, Glasgow, UK.
| | - C Peters
- Queen Elizabeth University Hospital, Glasgow, UK
| | - A L Seagar
- Scottish Mycobacteria Reference Laboratory, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M T G Holden
- School of Medicine, University of St Andrews, St Andrews, UK
| | - I F Laurenson
- Scottish Mycobacteria Reference Laboratory, Royal Infirmary of Edinburgh, Edinburgh, UK
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Weinbren M, Inkster T. The hospital-built environment: biofilm, biodiversity and bias. J Hosp Infect 2021; 111:50-52. [PMID: 33631235 DOI: 10.1016/j.jhin.2021.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
Affiliation(s)
- M Weinbren
- Department of Microbiology, King's Mill Hospital, Sutton-in-Ashfield, UK.
| | - T Inkster
- Department of Microbiology, Queen Elizabeth University Hospital, Glasgow, UK
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