The Antimicrobial Resistance-Water-Corporate Interface: Exploring the Connections Between Antimicrobials, Water, and Pollution

Antibiotic resistance is a public health emergency, with ten million deaths estimated annually by the year 2050. Water systems are an important medium for the development and dissemination of antibiotic resistance from a variety of sources, explored in this perspective review. Hospital wastewater and wastewater systems more broadly are breeding grounds for antibiotic resistance because of the nature of their waste and how it is processed. Corporations from various sectors contribute to antibiotic resistance in many direct and indirect ways. Pharmaceutical factory runoff, agricultural antibiotic use, agricultural use of nitrogen fertilizers, heavy metal pollution, air pollution (atmospheric deposition, burning of oil and/or fossil fuels), plastic/microplastic pollution, and oil/petroleum spills/pollution have all been demonstrated to contribute to antibiotic resistance. Mitigation strategies to reduce these pathways to antibiotic resistance are discussed and future directions hypothesized.

Plasmid Dissemination in Multispecies Carbapenemase-Producing Enterobacterales Outbreaks Involving Clinical and Environmental Strains: A Narrative Review

Outbreaks involving carbapenemase-producing enterobacteria (CPE) have become a common occurrence in healthcare settings. While clonal dissemination is firmly established as a cause for these outbreaks, horizontal gene transfers (HGTs) between different species of Enterobacterales found in clinical and environmental isolates are less so. To gather evidence backing up this hypothesis, a review covering the 2013-2024 period was performed. HGTs between different species of clinical and environmental Enterobacterales were identified in thirteen papers, half of those published within the last three years. A combination of short- and long-read whole genome sequencing (WGS) was predominantly used to identify mobile genetic elements and plasmids. The more frequently reported carbapenemases were KPCs, followed by NDMs and IMPs. Predictably, broad-host-range plasmids were responsible for over 50% of HGTs, with the IncA/C group being in the lead. Klebsiella pneumoniae and Enterobacter cloacae complexes were the most frequent species identified in clinical samples, while Citrobacter freundii dominated environmental ones. Drains and pipework frequently constituted CPE reservoirs in protracted outbreaks, alternating epidemic outbursts with silent phases. Including WGS in a systematic environmental surveillance would help in swiftly identifying those CPE reservoirs and possibly help better control plasmid outbursts by allowing the implementation of adequate infection prevention and control measures.

A persistent sink reservoir as a potential source of Pseudomonas aeruginosa infections in pediatric oncology patients

Objective

Outbreaks of Pseudomonas aeruginosa infections have been linked to water-related sources. We describe the investigation of a suspected outbreak of five P. aeruginosa infections in pediatric oncology patients in 2021 that triggered a retrospective review and prospective monitoring of additional cases, environmental sampling, and bacterial genomic analysis.

Setting and patients

Pediatric oncology center.

Methods

Medical records of patients with P. aeruginosa were reviewed and staff were interviewed to identify common exposures. Environmental samples were cultured for P. aeruginosa. Patient and environmental isolates underwent whole genome sequencing and core genome multi-locus sequence typing (cgMLST) and sequences were added to a previously existing library of P. aeruginosa clinical isolates collected in 2017 and onwards to determine strain relatedness.

Findings

During 2019-2022, 82 patients with 110 episodes of P. aeruginosa infections were identified and 132 isolates of P. aeruginosa were sequenced. Twenty-three environmental samples were collected, of which two grew P. aeruginosa in culture. CgMLST demonstrated four multi-patient isolate clusters but no genetic relatedness among the isolates from the patients in the suspected outbreak. Two sink-derived isolates from 2021 were genetically related to patient-derived isolates from 2018 and 2017.

Conclusions

Sequencing revealed there is no common source or linkage between the isolates of the suspected P. aeruginosa outbreak in 2021. However, it revealed genetic relatedness of previous patient strains to later strains collected from hospital sinks, suggesting persistent colonization of a reservoir with P. aeruginosa.

Greening Infection Prevention and Control: Multifaceted Approaches to a Sustainable Future

Infection prevention and control, or IP&C, is a critical stakeholder in advancing environmental sustainability in health care. IP&C activities seek to ensure safety of processes in health care from an infection perspective, but how these are performed can drive substantial waste and pollution. There are certain IP&C measures that can, without compromising safety or efficiency, be adapted to more environmentally friendly practices and have a high impact benefit to sustainability without affecting patient outcomes. Moreover, IP&C practice stands to be significantly altered by climate change and pollution. Here, we describe the complex interdependence between sustainability, climate change, and IP&C, and opportunities for IP&C to be at the leading edge of optimizing healthcare's environmental footprint.

First Report of Carbapenem-Resistant Klebsiella michiganensis Co-Harboring bla KPC-2 and TmexCD2-ToprJ2 Isolated from Wastewater at a Tertiary Hospital in Beijing

Background

Klebsiella michiganensis is an emerging human pathogen that causes nosocomial infections. Its prevalence and spread in the environment should not be ignored. This study identified and characterized Klebsiella michiganensis co-harboring bla KPC-2 and TmexCD2-ToprJ2 in hospital wastewater samples.

Methods

Twelve K. michiganensis strains were isolated from wastewater samples collected at a tertiary hospital in Beijing, China. The genomic characteristics of K. michiganensis strains were analyzed using whole-genome sequences, providing information on the comparison between the genome of K. michiganensis strains and the reference genome, antibiotic resistance genes (ARGs), virulence genes, secretion systems, and mobile genetic elements (plasmids, insertion sequences [ISs], and prophages).

Results

Genome analysis showed that the twelve multi-drug resistant (MDR) strains carried a variety of ARGs and virulence genes, as well as four macromolecular secretion systems (T1SS, T2SS, T5aSS, T5bSS, and T4aP). The genetic environments of both the TmexCD2-ToprJ2 gene cluster and bla KPC-2 gene contained ISs. The plasmids carrying TmexCD2-ToprJ2 gene cluster of nine strains in clade 1 and two strains in clade 2 were annotated as IncR plasmid and rep_cluster_1254 type, respectively. The plasmids carrying bla KPC-2 in 10 strains in clade 1 were identified as IncU, and the plasmids carrying bla KPC-2 in the k11 and k12 strains in clade 2 were IncU and IncX6. The phylogenetic tree and heatmap revealed that the secretion system of type VI (T6SSi) existed in 10 strains in clade 1, and Type IV (T4SS) only existed in the k11 strain in clade 2. In addition, K. michiganensis strains carried 13 plasmids, 14 ISs, and 138 prophages.

Conclusion

In this study, the whole genome sequencing demonstrated the diversity of K. michiganensis genome despite 12 K. michiganensis strains from a hospital wastewater, which lays the foundation for further genetic research and drug resistance gene transmission.

Successful control of an environmental reservoir of NDM-producing Klebsiella pneumoniae associated with nosocomial transmissions in a low-incidence setting

BACKGROUND

The hospital wastewater system has been reported as a source of nosocomial acquisition of carbapenemase producing Enterobacteriaceae (CPE) in various settings. Cleaning and disinfection protocols or replacement of contaminated equipment often fail to eradicate these environmental reservoirs, which can lead to long-term transmission of CPE. We report a successful multimodal approach to control a New Delhi metallo-beta-lactamase positive Klebsiella pneumoniae (NDM-KP) nosocomial outbreak implicating contamination of sink traps in a low-incidence setting.

METHODS

Following the incidental identification of NDM-KP in a urine culture of an inpatient, we performed an epidemiological investigation, including patient and environmental CPE screening, and whole genome sequencing (WGS) of strains. We also implemented multimodal infection prevention and control (IPC) measures, namely the isolation of cases, waterless patient care, replacement of contaminated P-traps and connecting pieces, and bleach and steam disinfection of sinks for 6 months, followed by patient and environmental screenings for eradication.

RESULTS

Between February and May 2022, five NDM-KP cases were identified in an eight-bed neurosurgical intermediate care unit. Among the eight sink traps of the unit, three were positive for NDM-KP. Patient and environmental isolates belonged to multilocus sequence typing ST-268. All isolate genomes were genetically very similar suggesting cross-transmission and a potential role of the environment as the source of transmissions. Following the introduction of combined IPC measures, no new case was subsequently detected and sink traps remained negative for NDM-KP within 6 months after the intervention.

CONCLUSION

The implementation of multimodal IPC measures, including waterless patient care combined with the replacement and disinfection of P-traps and connecting pieces, was successful in the control of NDM-KP after eight months. In a low-incidence setting, this approach has made it possible to pursue the objective of zero transmission of carbapenemase-producing Enterobacteriaceae (CPE).

A narrative review and update on drain-related outbreaks

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

To summarize recent drain-related outbreaks, investigate whether multi-modal control measures are being implemented, and determine any antecedent factors.

METHODS

Databases were searched for drain-related outbreaks over a 5-year period. Search terms employed included 'healthcare drainage outbreaks', 'drain outbreaks', 'drainage system outbreaks', 'sink outbreaks' and '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 studies were reviewed. The majority of incidents were due to carbapenemase-producing Enterobacterales, and were from critical care settings. Most (16/19) studies recognized the need for a multi-modal approach. Information on the success of interventions was not documented for all incidents, but 13/19 studies 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.

Disinfection of sink drains to reduce a source of three opportunistic pathogens, during Serratia marcescens clusters in a neonatal intensive care unit

OBJECTIVE

Evaluate the effects of five disinfection methods on bacterial concentrations in hospital sink drains, focusing on three opportunistic pathogens (OPs): Serratia marcescens, Pseudomonas aeruginosa and Stenotrophomonas maltophilia.

DESIGN

Over two years, three sampling campaigns were conducted in a neonatal intensive care unit (NICU). Samples from 19 sink drains were taken at three time points: before, during, and after disinfection. Bacterial concentration was measured using culture-based and flow cytometry methods. High-throughput short sequence typing was performed to identify the three OPs and assess S. marcescens persistence after disinfection at the genotypic level.

SETTING

This study was conducted in a pediatric hospitals NICU in Montréal, Canada, which is divided in an intensive and intermediate care side, with individual rooms equipped with a sink.

INTERVENTIONS

Five treatments were compared: self-disinfecting drains, chlorine disinfection, boiling water disinfection, hot tap water flushing, and steam disinfection.

RESULTS

This study highlights significant differences in the effectiveness of disinfection methods. Chlorine treatment proved ineffective in reducing bacterial concentration, including the three OPs. In contrast, all other drain interventions resulted in an immediate reduction in culturable bacteria (4-8 log) and intact cells (2-3 log). Thermal methods, particularly boiling water and steam treatments, exhibited superior effectiveness in reducing bacterial loads, including OPs. However, in drains with well-established bacterial biofilms, clonal strains of S. marcescens recolonized the drains after heat treatments.

CONCLUSIONS

Our study supports thermal disinfection (>80°C) for pathogen reduction in drains but highlights the need for additional trials and the implementation of specific measures to limit biofilm formation.

Outbreak of carbapenemase-producing Citrobacter farmeri in an intensive care haematology department linked to a persistent wastewater reservoir in one hospital room, France, 2019 to 2022

In 2019-2022, a prolonged outbreak of oxacillinase (OXA)-48-producing Citrobacter farmeri due to a persistent environmental contamination, occurred in our haematology intensive care unit. In April 2019, we isolated OXA-48-producing C. farmeri from rectal samples of two patients in weekly screenings. The cases had stayed in the same hospital room but 4 months apart. We screened five patients who had stayed in this room between the two cases and identified a third case. Over the following 3 years, five other cases were detected, the last case in September 2022. In total, eight cases were detected: seven colonised with the bacterium and one infected with a lethal outcome. All cases stayed in the same hospital room. We detected OXA-48-producing C. farmeri from a shower, washbasin drains and wastewater drainage of the bathroom of the hospital room. Molecular typing confirmed that all C. farmeri isolates from the environment and the cases were indistinguishable. Despite bundle measures to control the outbreak, the bacterium persisted in the system, which resulted in transmission to new patients. A design defect in the placement of wastewater drains contributed to the persistence and proliferation of the bacterium. The room was closed after the last case and the bathroom rebuilt.

Concurrent transmission of multiple carbapenemases in a long-term acute-care hospital

OBJECTIVE

We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying blaVIM (VIM-CRPA) and Enterobacterales carrying blaKPC (KPC-CRE) at a long-term acute-care hospital (LTACH A).

METHODS

We defined an incident case as the first detection of blaKPC or blaVIM from a patient's clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing.

RESULTS

From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had blaKPC, 11 had blaVIM, and 7 had blaVIM and blaKPC. Also, blaKPC were identified from 7 Enterobacterales, and all blaVIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates.

CONCLUSIONS

Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. 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.

Infection prevention and control policy implementation for CPE: a cross-sectional national survey of healthcare workers reveals knowledge gaps and suboptimal practices

BACKGROUND

In 2017, Ireland pioneered a unique response to the worsening epidemiology of carbapenemase-producing Enterobacterales (CPE), declaring a national public health emergency. Subsequently, CPE mitigation guidelines and policies were implemented in acute hospitals, focused on patient screening and outbreak management, often by healthcare workers (HCWs) with limited background in infection prevention and control (IPC). CPE risks from sinks and drains remain inadequately controlled.

AIMS

To compare CPE awareness, perceptions of the role of the environment in CPE transmission, and disposal practices of liquid waste from clinical handwashing sinks between IPC HCWs and non-IPC HCWs in Ireland.

METHODS

Between December 2022 and March 2023, HCWs employed in acute hospitals in Ireland between 2017 and 2022 were invited to participate anonymously in a 30-question digital survey.

FINDINGS

Responses (N=283) were received across several clinical disciplines. In total, 21.6% of respondents were working or had previously worked in IPC roles, 84.1% of whom reported no IPC-related learning needs. In comparison with non-IPC HCWs, more IPC HCWs perceived a risk of pathogen transmission from clean water plumbing (68.9% vs 39.2%; P<0.001) and waste/drainage plumbing (81.2% vs 43.7%; P<0.001). Among nursing and medical staff, only 5.6% of IPC HCWs used clinical handwashing sinks for disposal of liquid waste, compared with 60% of non-IPC HCWs (P<0.001). In comparison with non-IPC HCWs, a greater proportion of IPC HCWs reported that they had witnessed colleagues routinely discarding liquid waste (including nutritional products, antimicrobials and patient body fluids) via clinical handwashing sinks (88.9% vs 77.9%) CONCLUSIONS: Although there is general awareness of the role of the built environment in pathogen transmission, including CPE, familiarity with sink/water-related transmission is greater among IPC HCWs. There may be opportunities to improve disposal practices for liquid waste through education targeting non-IPC HCWs.

Sink-traps are a major source for carbapenemase-producing Enterobacteriaceae transmission

OBJECTIVE

We studied the extent of carbapenemase-producing Enterobacteriaceae (CPE) sink contamination and transmission to patients in a nonoutbreak setting.

METHODS

During 2017-2019, 592 patient-room sinks were sampled in 34 departments. Patient weekly rectal swab CPE surveillance was universally performed. Repeated sink sampling was conducted in 9 departments. Isolates from patients and sinks were characterized using pulsed-field gel electrophoresis (PFGE), and pairs of high resemblance were sequenced by Oxford Nanopore and Illumina. Hybrid assembly was used to fully assemble plasmids, which are shared between paired isolates.

RESULTS

In total, 144 (24%) of 592 CPE-contaminated sinks were detected in 25 of 34 departments. Repeated sampling (n = 7,123) revealed that 52%-100% were contaminated at least once during the sampling period. Persistent contamination for >1 year by a dominant strain was common. During the study period, 318 patients acquired CPE. The most common species were Klebsiella pneumoniae, Escherichia coli, and Enterobacter spp. In 127 (40%) patients, a contaminated sink was the suspected source of CPE acquisition. For 20 cases with an identical sink-patient strain, temporal relation suggested sink-to-patient transmission. Hybrid assembly of specific sink-patient isolates revealed that shared plasmids were structurally identical, and SNP differences between shared pairs, along with signatures for potential recombination events, suggests recent sharing of the plasmids.

CONCLUSIONS

CPE-contaminated sinks are an important source of transmission to patients. Although traditionally person-to-person transmission has been considered the main route of CPE transmission, these data suggest a change in paradigm that may influence strategies of preventing CPE dissemination.

Multidrug-Resistant Bacteria Contaminating Plumbing Components and Sanitary Installations of Hospital Restrooms

Antimicrobial resistance (AMR) poses several issues concerning the management of hospital-acquired infections, leading to increasing morbidity and mortality rates and higher costs of care. Multidrug-resistant (MDR) bacteria can spread in the healthcare setting by different ways. The most important are direct contact transmission occurring when an individual comes into physical contact with an infected or colonized patient (which can involve healthcare workers, patients, or visitors) and indirect contact transmission occurring when a person touches contaminated objects or surfaces in the hospital environment. Furthermore, in recent years, toilets in hospital settings have been increasingly recognised as a hidden source of MDR bacteria. Different sites in restrooms, from toilets and hoppers to drains and siphons, can become contaminated with MDR bacteria that can persist there for long time periods. Therefore, shared toilets may play an important role in the transmission of nosocomial infections since they could represent a reservoir for MDR bacteria. Such pathogens can be further disseminated by bioaerosol and/or droplets potentially produced during toilet use or flushing and be transmitted by inhalation and contact with contaminated fomites. In this review, we summarize available evidence regarding the molecular features of MDR bacteria contaminating toilets of healthcare environments, with a particular focus on plumbing components and sanitary installation. The presence of bacteria with specific molecular traits in different toilet sites should be considered when adopting effective managing and containing interventions against nosocomial infections potentially due to environmental contamination. Finally, here we provide an overview of traditional and new approaches to reduce the spreading of such infections.

Sink interventions in the ICU to reduce risk of infection or colonization with Gram-negative pathogens: a systematic review of the literature

BACKGROUND

Healthcare-associated infections (HAIs) are a major problem in intensive care units (ICUs). The hospital water environment is a potential reservoir for Gram-negative bacteria (GNB), and it has been shown that contaminated sinks contribute to the spread of GNB in outbreak and non-outbreak settings. This study aimed to investigate which sink interventions may reduce GNB infection and colonization rates in the ICU.

METHODS

A database search (MEDLINE via PubMed, EMBASE via Ovid and ClinicalTrials.gov) was undertaken without restrictions on language or date of publication. Studies of any design were included if they described an intervention on the water fixtures in patient rooms, and presented data about HAI or colonization rates in non-outbreak settings. Acquisition (infection and/or colonization) rates of GNB and Pseudomonas aeruginosa were analysed as outcomes.

RESULTS

In total, 4404 records were identified. Eleven articles were included in the final analysis. No randomized controlled trials were included in the analysis, and all studies were reported to have moderate to serious risk of bias. Removing sinks and applying filters on taps had a significant impact on GNB acquisition, but there was high heterogeneity among reported outcomes and sample size among the studies.

CONCLUSION

Few studies have investigated the association of sinks in patient rooms with healthcare-associated acquisition of GNB in non-outbreak settings. Heterogeneity in study design made it impossible to generalize the results. Prospective trials are needed to further investigate whether removing sinks from patient rooms can reduce the endemic rate of HAIs in the ICU.

Model-based evaluation of admission screening strategies for the detection and control of carbapenemase-producing Enterobacterales in the English hospital setting

BACKGROUND

Globally, detections of carbapenemase-producing Enterobacterales (CPE) colonisations and infections are increasing. The spread of these highly resistant bacteria poses a serious threat to public health. However, understanding of CPE transmission and evidence on effectiveness of control measures is severely lacking. This paper provides evidence to inform effective admission screening protocols, which could be important in controlling nosocomial CPE transmission.

METHODS

CPE transmission within an English hospital setting was simulated with a data-driven individual-based mathematical model. This model was used to evaluate the ability of the 2016 England CPE screening recommendations, and of potential alternative protocols, to identify patients with CPE-colonisation on admission (including those colonised during previous stays or from elsewhere). The model included nosocomial transmission from colonised and infected patients, as well as environmental contamination. Model parameters were estimated using primary data where possible, including estimation of transmission using detailed epidemiological data within a Bayesian framework. Separate models were parameterised to represent hospitals in English areas with low and high CPE risk (based on prevalence).

RESULTS

The proportion of truly colonised admissions which met the 2016 screening criteria was 43% in low-prevalence and 54% in high-prevalence areas respectively. Selection of CPE carriers for screening was improved in low-prevalence areas by adding readmission as a screening criterion, which doubled how many colonised admissions were selected. A minority of CPE carriers were confirmed as CPE positive during their hospital stay (10 and 14% in low- and high-prevalence areas); switching to a faster screening test pathway with a single-swab test (rather than three swab regimen) increased the overall positive predictive value with negligible reduction in negative predictive value.

CONCLUSIONS

Using a novel within-hospital CPE transmission model, this study assesses CPE admission screening protocols, across the range of CPE prevalence observed in England. It identifies protocol changes-adding readmissions to screening criteria and a single-swab test pathway-which could detect similar numbers of CPE carriers (or twice as many in low CPE prevalence areas), but faster, and hence with lower demand on pre-emptive infection-control resources. Study findings can inform interventions to control this emerging threat, although further work is required to understand within-hospital transmission sources.

Large-scale characterization of hospital wastewater system microbiomes and clinical isolates from infected patients: profiling of multi-drug-resistant microbial species

BACKGROUND

Hospital-acquired infections (HAIs) and infectious agents exhibiting antimicrobial resistance (AMR) are challenges globally. Environmental patient-facing wastewater apparatus including handwashing sinks, showers and toilets are increasingly identified as sources of infectious agents and AMR genes.

AIM

To provide large-scale metagenomics analysis of wastewater systems in a large teaching hospital in the Republic of Ireland experiencing multi-drug-resistant HAI outbreaks.

METHODS

Wastewater pipe sections (N=20) were removed immediately prior to refurbishment of a medical ward where HAIs had been endemic. These comprised toilet U-bends, and sink and shower drains. Following DNA extraction, each pipe section underwent metagenomic analysis.

FINDINGS

Diverse taxonomic and resistome profiles were observed, with members of phyla Proteobacteria and Actinobacteria dominating (38.23 ± 5.68% and 15.78 ± 3.53%, respectively). Genomes of five clinical isolates were analysed. These AMR bacterial isolates were from patients >48 h post-admission to the ward. Genomic analysis determined that the isolates bore a high number of antimicrobial resistance genes (ARGs).

CONCLUSION

Comparison of resistome profiles of isolates and wastewater metagenomes revealed high degrees of similarity, with many identical ARGs shared, suggesting probable acquisition post-admission. The highest numbers of ARGs observed were those encoding resistance to clinically significant and commonly used antibiotic classes. Average nucleotide identity analysis confirmed the presence of highly similar or identical genomes in clinical isolates and wastewater pipes. These unique large-scale analyses reinforce the need for regular cleaning and decontamination of patient-facing hospital wastewater pipes and effective infection control policies to prevent transmission of nosocomial infection and emergence of AMR within potential wastewater reservoirs.

Update on potential interventions to reduce the risk for transmission of health care-associated pathogens from floors and sinks

Health care facility floors and sink drains and other wastewater drainage sites are universally contaminated with potential pathogens and there are plausible mechanisms by which organisms can be disseminated from these sites. However, floors and sink drains are not addressed as potential sources of pathogen transmission in most health care facilities. One factor that has hindered progress in addressing floors and sinks has been the lack of practical and effective measures to reduce the risk for dissemination of organisms from these sites. This article provides an update on some of the potential interventions being used to reduce the risk for transmission of health care-associated pathogens from floors and sinks. Practical approaches to address these sites of contamination are emphasized.

Long-term ICU outbreak of carbapenamase-producing organisms associated with contaminated sink drains

BACKGROUND

Between 2018 and 2022, a Belgian tertiary care hospital faced a growing issue with acquiring carbapenemase-producing organisms (CPO), mainly VIM-producing P. aeruginosa (PA-VIM) and NDM-producing Enterobacterales (CPE-NDM) among hospitalized patients in the adult intensive care unit (ICU). We report the investigation of this ICU long-term CPO outbreak involving multiple species and a persistent environmental reservoir.

METHODS

Active case finding, environmental sampling, whole genome sequencing (WGS) analysis of patient and environmental strains and implemented control strategies were described in this study.

FINDINGS

From 2018 to 2022, 37 patients became colonised or infected with PA-VIM and/ or CPE-NDM during their ICU stay. WGS confirmed the epidemiological link between clinical and environmental strains collected from the sink drains with clonal strains dissemination and horizontal gene transfer mediated by plasmid conjugation and/or transposon jumps. Environmental disinfection by quaternary ammonium-based disinfectant and replacement of contaminated equipment failed to eradicate environmental sources. Interestingly, efflux pumps genes conferring resistance to quaternary ammonium compounds were widespread in the isolates. As removing sinks was not feasible, a combination of a foaming product degrading the biofilm and foaming disinfectant based on peracetic acid and hydrogen peroxide has been evaluated and has so far prevented re-colonisation of the proximal sink drain by CPO.

CONCLUSION

The persistence in the hospital environment of antibiotic-and-disinfectant resistant bacteria with the ability to transfer mobile genetic elements poses a serious threat on ICU patients with a risk of shifting towards an endemicity scenario. Innovative strategies are needed to address persistent environmental reservoirs and prevent CPO transmission.

Nutritional drinks and enteral feeds promote the growth of carbapenemase-producing Enterobacterales in conditions that simulate disposal in hospital sinks

BACKGROUND

Studies have shown that nutritional products are discarded via handwash sinks by healthcare workers, and this practice may promote bacterial growth, including growth of pathogens such as carbapenemase-producing Enterobacterales (CPE). Outbreaks and acquisition of CPE in nosocomial settings are associated with negative outcomes for patients and hospitals.

OBJECTIVES

To investigate the potential growth-promoting effect of nutritional support drinks (NSDs) and enteral tube-feed products (ETFPs) on CPE.

METHODS

Six different CPE strains were grown in five different diluted NSDs, five different diluted ETFPs, Mueller-Hinton broth (MHB) and M9 minimal salts media to simulate discarding a small volume of nutritional product in a u-bend, already containing liquid. CPE were enumerated at 0 h, 6 h and 24 h, and compared using two-way analysis of variance and Dunett test, with confidence levels at 95%. Spearman's r was used to measure the strength of correlation between component concentrations in nutritional products and CPE growth.

RESULTS

All NSDs and ETFPs promoted CPE growth that exceeded both M9 (negative growth control) and MHB (positive growth control). In several cases, growth in NSDs/ETFPs was significantly greater compared with growth in MHB.

CONCLUSION

Nutritional products support CPE growth under in-vitro conditions. The propensity of CPE to survive in drain pipework suggests that inappropriate product disposal may further nourish established CPE in these environmental reservoirs. The growth observed in diluted NSDs and ETFPs shows that modifiable practices should be optimized to mitigate the potential risk of CPE transmission from these reservoirs.

Aspects and problems associated with the water services to be considered in intensive care units

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.

Efficacy of Active Rapid Molecular Screening and IPC Interventions on Carbapenem-Resistant Enterobacterales Infections in Emergency Intensive Care Units without Enough Single-Room Isolation

Purpose

To investigate whether rapid active molecular screening and infection prevention and control (IPC) interventions can reduce colonization or infection with carbapenem-resistant Enterobacterales (CRE) in a general emergency intensive care unit (EICU) without enough single-room isolation.

Methods

The study was designed as a before-and-after quasi-experiment. Before the experimental period, the ward was rescheduled and the staff were trained. From May 2018 to April 2021, active screening was performed by seminested real-time fluorescent polymerase chain reaction (PCR) detection with rectal swabs from all patients on admission to the EICU, and the results were reported in 1 hour. Other IPC interventions including hand hygiene, contact precautions, patient isolation, environmental disinfection, environment surveillance, monitoring, auditing and feedback were conducted under strict supervision. The patients' clinical characteristics were collected simultaneously.

Results

In this 3-year study, 630 patients were enrolled and 19.84% of the patients were initially colonized or infected with CRE as shown by active molecular screening. The average drug resistance ratio to carbapenem shown by clinical culture detection of Klebsiella pneumoniae (KPN) before the study was performed was 71.43% in EICU. The drug resistance ratio decreased significantly from 75%, 66.67% to 46.67% in the next 3 years (p<0.05) during which active screening and IPC interventions were strictly executed. While the ratio gaps between EICU and the whole hospital were narrowed from 22.81%, 21.11% to 4.64%. Patients with invasive devices, skin barrier damage, and the recent use of antibiotics on admission were found to have a higher risk of being colonized or infected with CRE (p<0.05).

Conclusion

Active rapid molecular screening and other IPC interventions may significantly reduce CRE nosocomial infections even in wards without enough single-room isolation. The key to reduce the spread of CRE in the EICU is the strict execution of IPC interventions by all medical staff and healthcare workers.

Transmission of Carbapenem-Resistant Klebsiella pneumoniae in US Hospitals

BACKGROUND

Carbapenem-resistant Klebsiella pneumoniae (CRKp) is the most prevalent carbapenem-resistant Enterobacterales in the United States. We evaluated CRKp clustering in patients in US hospitals.

METHODS

From April 2016 to August 2017, 350 patients with clonal group 258 CRKp were enrolled in the Consortium on Resistance Against Carbapenems in Klebsiella and other Enterobacteriaceae, a prospective, multicenter, cohort study. A maximum likelihood tree was constructed using RAxML. Static clusters shared ≤21 single-nucleotide polymorphisms (SNP) and a most recent common ancestor. Dynamic clusters incorporated SNP distance, culture timing, and rates of SNP accumulation and transmission using the R program TransCluster.

RESULTS

Most patients were admitted from home (n = 150, 43%) or long-term care facilities (n = 115, 33%). Urine (n = 149, 43%) was the most common isolation site. Overall, 55 static and 47 dynamics clusters were identified involving 210 of 350 (60%) and 194 of 350 (55%) patients, respectively. Approximately half of static clusters were identical to dynamic clusters. Static clusters consisted of 33 (60%) intrasystem and 22 (40%) intersystem clusters. Dynamic clusters consisted of 32 (68%) intrasystem and 15 (32%) intersystem clusters and had fewer SNP differences than static clusters (8 vs 9; P = .045; 95% confidence interval [CI]: -4 to 0). Dynamic intersystem clusters contained more patients than dynamic intrasystem clusters (median [interquartile range], 4 [2, 7] vs 2 [2, 2]; P = .007; 95% CI: -3 to 0).

CONCLUSIONS

Widespread intrasystem and intersystem transmission of CRKp was identified in hospitalized US patients. Use of different methods for assessing genetic similarity resulted in only minor differences in interpretation.

Understanding the influence of the bioaerosol source on the distribution of airborne bacteria in hospital indoor air

The composition and concentration of airborne microorganisms in hospital indoor air has been reported to contain airborne bacteria and fungi concentrations ranged 10¹-10³ CFU/m³ in inpatients facilities which mostly exceed recommendations from the World Health Organization (WHO). In this work, a deeper knowledge of the performance of airborne microorganisms would allow improving the designs of the air-conditioning installations to restrict hospital-acquired infections (HAIs). A solution containing Escherichia coli (E. coli) as a model of airborne bacteria was nebulized using the Collison nebulizer to simulate bioaerosols in various hospital areas such as patients' rooms or bathrooms. Results showed that the bioaerosol source had a significant influence on the airborne bacteria concentrations since 4.00 10², 6.84 10³ and 1.39 10⁴ CFU mL^-1 were monitored during the aerosolization for 10 min of urine, saliva and urban wastewater, respectively. These results may be explained considering the quite narrow distribution profile of drop sizes around 1.10-1.29 μm obtained for urban wastewater, with much vaster distribution profiles during the aerosolization of urine or saliva. The airborne bacteria concentration may increase up to 10⁷ CFU mL^-1 for longer sampling times and higher aerosolization pressures, causing several cell damages. The cell membrane damage index (I_D) can vary from 0 to 1, depending on the genomic DNA releases from bacteria. In fact, the I_D of E. coli was more than two times higher (0.33 vs. 0.72) when increasing the pressure of air flow was applied from 1 to 2 bar. Finally, the ventilation air flow also affected the distribution of bioaerosols due to its direct relationship with the relative humidity of indoor air. Specifically, the airborne bacteria concentration diminished almost below 3-logs by applying more than 10 L min^-1 during the aerosolization of urine due to their inactivation by an increase in their osmotic pressure.

Whole genome sequencing reveals hidden transmission of carbapenemase-producing Enterobacterales

Carbapenemase-producing Enterobacterales (CPE) infection control practices are based on the paradigm that detected carriers in the hospital transmit to other patients who stay in the same ward. The role of plasmid-mediated transmission at population level remains largely unknown. In this retrospective cohort study over 4.7 years involving all multi-disciplinary public hospitals in Singapore, we analysed 779 patients who acquired CPE (1215 CPE isolates) detected by clinical or surveillance cultures. 42.0% met putative clonal transmission criteria, 44.8% met putative plasmid-mediated transmission criteria and 13.2% were unlinked. Only putative clonal transmissions associated with direct ward contact decreased in the second half of the study. Both putative clonal and plasmid-mediated transmission associated with indirect (no temporal overlap in patients’ admission period) ward and hospital contact did not decrease during the study period. Indirect ward and hospital contact were identified as independent risk factors associated with clonal transmission. In conclusion, undetected CPE reservoirs continue to evade hospital infection prevention measures. New measures are needed to address plasmid-mediated transmission, which accounted for 50% of CPE dissemination.

Carbapenemase-producing Enterobacterales cause healthcare-associated infections but modes of transmission are not well understood. Here, the authors find evidence of transmission without direct patient contact, indicating presence of undetected environmental reservoirs, whilst half of the transmission events are likely due to plasmid-mediated transmission.

Tracking Klebsiella pneumoniae carbapenemase gene as an indicator of antimicrobial resistance dissemination from a hospital to surface water via a municipal wastewater treatment plant

Antibiotic-resistant bacteria originating from hospitals are ultimately discharged to municipal wastewater treatment plants (WWTP), which may serve as important reservoirs for the spread of antibiotic resistant genes. This study traced and quantified the presence of a rare but clinically relevant antimicrobial resistance gene; Klebsiella pneumoniae carbapenamase (KPC)-and the viable organisms (KPCO) which carried this gene in hospital, non-hospital wastewater discharges, various compartments within a municipal WWTP, receiving water and sediment samples. High concentration of the gene, blaKPC harbored in viable and multispecies KPCO was detected in the hospital wastewater and in the forepart stages of the WWTP, but was not detected in the final effluent following UV disinfection. KPCO were not detected in multiple non-hospital sources of wastewater discharges tested. The treatment train used in the sampled WWTP was found to help remove and reduce KPCO load. Using whole-genome sequencing, a KPC-producing Klebsiella oxytoca strain identical to strains seen in the patients and hospital environment was isolated from the downstream receiving water on one sampling event. KPCO were also found to persist in the biosolids throughout the WWTP, but were not detected in the processed compost-products made from WWTP-biosolids. This study systematically demonstrates dissemination of KPCO from hospital point source to environment via municipal WWTP. Understanding hospitals as the origin and source of spread of some of the most clinically urgent antimicrobial-resistant organisms may help direct interventions that target rate at which antibiotic resistant bacteria evolve and spread via enhancement of wastewater treatment and mitigation of dissemination at source.

Dissemination of carbapenem resistant bacteria from hospital wastewater into the environment

Infections with antibiotic resistant pathogens threaten lives and cause substantial costs. For effective interventions, knowledge of the transmission paths of resistant bacteria to humans is essential. In this study, carbapenem resistant bacteria were isolated from the wastewater of a maximum care hospital during a period of two years, starting in the patient rooms and following the sewer system to the effluent of the wastewater treatment plant (WWTP). The bacteria belonged to six different species and 44 different sequence types (STs). The most frequent STs, ST147 K. pneumoniae (bla_NDM/bla_OXA-48) and ST235 P. aeruginosa (bla_VIM) strains, were present at nearly all sampling sites from the hospital to the WWTP effluent. After core genome multi-locus sequence typing (cgMLST), all ST147 K. pneumoniae strains presented a single epidemiological cluster. In contrast, ST235 P. aeruginosa formed five cgMLST clusters and the largest cluster contained the strain from the WWTP effluent, indicating without doubt, a direct dissemination of both high-risk clones into the environment. Thus, there are - at least two - possible transmission pathways to humans, (i) within the hospital by contact with the drains of the sanitary installations and (ii) by recreational or irrigation use of surface waters that have received WWTP effluent. In conclusion, remediation measures must be installed at both ends of the wastewater system, targeting the drains of the hospital as well as at the effluent of the WWTP.

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.

Preventing infections caused by carbapenemase-producing bacteria in the intensive care unit - Think about the sink

OBJECTIVE

Outbreaks caused by carbapenemase-producing bacteria (CPB) are challenging to manage in critical care settings and can be protracted due to inadvertent and ubiquitous ecological niches within the built unit environment, such as handwashing sinks. We discuss evidence from a narrative review on transmission pathways and interventions for critical care practitioners.

METHODS

A literature review was undertaken using Pubmed, CINAHL and Embase and included outbreaks of CPB, and equivalent bacteria in critical care units, between 1998 and May 2020. Intervention studies targeting elements of sinks that were employed in response to outbreaks in critical care units were included (n = 30).

FINDINGS

We found control measures included sink removal, use of physical barriers or design modification to protect patients from sinks, engineering controls to mitigate bacterial dispersal and administrative controls. A multi-disciplinary approach involving practitioners from critical care, infection prevention and control, engineering and other staff, should be involved in ongoing measures and in outbreak control activities. Ascertaining the optimal method to end CPB outbreaks in critical care is challenging due to the lack of prospective studies available. However, the literature suggests that sinks can and do serve as reservoirs of CPB near critically ill patients, and should be considered hazardous, especially when sub-optimally designed or used.

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.

Non-thermal plasma-based inactivation of bacteria in water using a microfluidic reactor

Failure of conventional water treatment systems may lead to the contamination of water sources, which can cause outbreaks of waterborne healthcare associated infections. Advanced oxidation processing by non-thermal plasma has the potential to treat water without the addition of chemicals. Antibiotic resistant Pseudomonas aeruginosa and Escherichia coli were chosen to investigate the use of non-thermal plasma generated in a microfluidic reactor to disinfect bacteria contaminated water. The microfluidic reactor used in this study utilized a dielectric barrier discharge, in a gas-liquid phase annular flow regime. Microbiological analysis of water inoculated with P. aeruginosa and E. coli was carried out before and after plasma treatment. Using air as the carrier gas, effective disinfection of water was achieved. At the lowest flow rate (35 µL/min), P. aeruginosa and E. coli viability were drastically reduced, with an approximate 8 log maximum decrease in viability following an estimated residence time of 5 s of plasma treatment. Scanning electron microscopy indicated changes in cell morphology due to the plasma treatment. Live/Dead assays revealed that the membranes of the cells had been damaged after plasma treatment. This work demonstrated that non-thermal plasma has the potential to disinfect against microbial contamination in water.

Outbreak of OXA-48-producing Enterobacterales in a haematological ward associated with an uncommon environmental reservoir, France, 2016 to 2019

The hospital water environment, including the wastewater drainage system, is increasingly reported as a potential reservoir for carbapenemase-producing Enterobacterales (CPE). We investigated a persistent outbreak of OXA-48 CPE (primarily Citrobacter freundii) in a haematological ward of a French teaching hospital by epidemiological, microbiological and environmental methods. Between January 2016 and June 2019, we detected 37 new OXA-48 CPE-colonised and/or ‑infected patients in the haematological ward. In October 2017, a unit dedicated to CPE-colonised and/or ‑infected patients was created. Eleven additional sporadic acquisitions were identified after this date without any obvious epidemiological link between patients, except in one case. Environmental investigations of the haematological ward (June–August 2018) identified seven of 74 toilets and one of 39 drains positive for OXA-48 CPE (seven C. freundii, one Enterobacter sakazakii, one Escherichia coli). Whole genome comparisons identified a clonal dissemination of OXA-48-producing C. freundii from the hospital environment to patients. In addition to strict routine infection control measures, an intensive cleaning programme was performed (descaling and bleaching) and all toilet bowls and tanks were changed. These additional measures helped to contain the outbreak. This study highlights that toilets can be a possible source of transmission of OXA-48 CPE.

Pervasive transmission of a carbapenem resistance plasmid in the gut microbiota of hospitalized patients

Infections caused by carbapenemase-producing enterobacteria (CPE) are a major concern in clinical settings worldwide. Two fundamentally different processes shape the epidemiology of CPE in hospitals: the dissemination of CPE clones from patient to patient (between-patient transfer), and the transfer of carbapenemase-encoding plasmids between enterobacteria in the gut microbiota of individual patients (within-patient transfer). The relative contribution of each process to the overall dissemination of carbapenem resistance in hospitals remains poorly understood. Here, we used mechanistic models combining epidemiological data from more than 9,000 patients with whole genome sequence information from 250 enterobacteria clones to characterize the dissemination routes of a pOXA-48-like carbapenemase-encoding plasmid in a hospital setting over a 2-yr period. Our results revealed frequent between-patient transmission of high-risk pOXA-48-carrying clones, mostly of Klebsiella pneumoniae and sporadically Escherichia coli. The results also identified pOXA-48 dissemination hotspots within the hospital, such as specific wards and individual rooms within wards. Using high-resolution plasmid sequence analysis, we uncovered the pervasive within-patient transfer of pOXA-48, suggesting that horizontal plasmid transfer occurs in the gut of virtually every colonized patient. The complex and multifaceted epidemiological scenario exposed by this study provides insights for the development of intervention strategies to control the in-hospital spread of CPE.

Multispecies Outbreak of Verona Integron-Encoded Metallo-ß-Lactamase-Producing Multidrug Resistant Bacteria Driven by a Promiscuous Incompatibility Group A/C2 Plasmid

BACKGROUND

Antibiotic resistance is often spread through bacterial populations via conjugative plasmids. However, plasmid transfer is not well recognized in clinical settings because of technical limitations, and health care-associated infections are usually caused by clonal transmission of a single pathogen. In 2015, multiple species of carbapenem-resistant Enterobacteriaceae (CRE), all producing a rare carbapenemase, were identified among patients in an intensive care unit. This observation suggested a large, previously unrecognized plasmid transmission chain and prompted our investigation.

METHODS

Electronic medical record reviews, infection control observations, and environmental sampling completed the epidemiologic outbreak investigation. A laboratory analysis, conducted on patient and environmental isolates, included long-read whole-genome sequencing to fully elucidate plasmid DNA structures. Bioinformatics analyses were applied to infer plasmid transmission chains and results were subsequently confirmed using plasmid conjugation experiments.

RESULTS

We identified 14 Verona integron-encoded metallo-ß-lactamase (VIM)-producing CRE in 12 patients, and 1 additional isolate was obtained from a patient room sink drain. Whole-genome sequencing identified the horizontal transfer of blaVIM-1, a rare carbapenem resistance mechanism in the United States, via a promiscuous incompatibility group A/C2 plasmid that spread among 5 bacterial species isolated from patients and the environment.

CONCLUSIONS

This investigation represents the largest known outbreak of VIM-producing CRE in the United States to date, which comprises numerous bacterial species and strains. We present evidence of in-hospital plasmid transmission, as well as environmental contamination. Our findings demonstrate the potential for 2 types of hospital-acquired infection outbreaks: those due to clonal expansion and those due to the spread of conjugative plasmids encoding antibiotic resistance across species.

Carbapenemase-producing Gram-negative bacteria in aquatic environments: a review

Antibiotic resistance is one of the greatest public-health challenges worldwide, especially with regard to Gram-negative bacteria (GNB). Carbapenems are the β-lactam antibiotics of choice with the broadest spectrum of activity and, in many cases, are the last-resort treatment for several bacterial infections. Carbapenemase-encoding genes, mainly carried by mobile genetic elements, are the main mechanism of resistance against carbapenems in GNB. These enzymes exhibit a versatile hydrolytic capacity and confer resistance to most β-lactam antibiotics. After being considered a clinical issue, increasing attention is being giving to the dissemination of such resistance mechanisms in the environment and especially through water. Aquatic environments are among the most significant microbial habitats on our planet, known as a favourable medium for antibiotic gene transfer, and they play a crucial role in the huge spread of drug resistance in the environment and the community. In this review, we present current knowledge regarding the spread of carbapenemase-producing isolates in different aquatic environments, which may help the implementation of control and prevention strategies against the spread of such dangerous resistant agents in the environment.

Long-term contamination of sink drains by carbapenemase-producing Enterobacterales in three intensive care units: characteristics and transmission to patients

This study aimed to describe the contamination of sink drains (SDs) with carbapenemase-producing Enterobacterales (CPE) in three intensive care units (ICUs), and to assess the risk of transmission to hospitalized patients. All SDs were sampled monthly for CPE screening by culture. Rectal screening for CPE carriage was conducted weekly for hospitalized patients. CPE were isolated from 22% of SD samples. Some SDs remained colonized with the same strain for several months. No CPE acquisition occurred among hospitalized patients during the study. Certain strategies, such as systematic sampling of SDs in ICUs for screening for contamination by CPE, should be discouraged apart from during outbreaks.

Transmission of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae: the role of infection control

BACKGROUND

The worldwide spread of carbapenemase-producing Gram-negative bacteria (GNB) in healthcare settings is worrying. Of particular concern is the occurrence of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KP). In recent years, several guidelines and recommendations have focused on the control of carbapenem-resistant GNB. It remains, however, unknown to what extent individual infection control measures are effective. Our aim was to critically review the recent evidence regarding the effectiveness of measures to control KPC-KP spread in healthcare settings.

METHODS

Critical review of the literature aiming to evaluate, in accordance with published recommendations, all available studies reporting infection control (IC) measures to control KPC-KP published in the past 5 years.

RESULTS

Among 11 included studies, the majority consisted of outbreak reports, where application of measures was reported in the absence of control groups. Variability was observed related to the frequency of application of recommended measures for control of KPC-KP. Additional measures were recorded, such as environmental sampling and staff screening, whereas compliance with hand hygiene was measured in relatively few studies. Finally, mortality in patients harbouring KPC-KP was notable, reaching 42.9% of included patients.

CONCLUSIONS

Despite successful control of KPC-KP spread during outbreaks, the impact of individual IC measures is difficult to assess, as the quality of published evidence is low and controlled intervention studies are lacking. The distribution of studies, the number of reported cases and the high mortality rates, clearly show that KPC-KP remains a major healthcare problem worldwide.

Risk Factors Associated with Carbapenemase-Producing Enterobacterales (CPE) Positivity in the Hospital Wastewater Environment

Klebsiella pneumoniae carbapenemase-producing organisms (KPCOs) are bacteria that are resistant to most antibiotics and thus are challenging to treat when they cause infections in patients. These organisms can be acquired by patients who are hospitalized for other reasons, complicating their hospital stay and even leading to death. Hospital wastewater sites, such as sink drains and toilets, have played a role in many reported outbreaks over the past decade. The significance of our research is in identifying risk factors for environmental positivity for KPCOs, which will facilitate further work to prevent transmission of these organisms to patients from the hospital environment.

Hospital wastewater is an increasingly recognized reservoir for resistant Gram-negative organisms. Factors involved in establishment and persistence of Klebsiella pneumoniae carbapenemase-producing organisms (KPCOs) in hospital wastewater plumbing are unclear. This study was conducted at a hospital with endemic KPCOs linked to wastewater reservoirs and robust patient perirectal screening for silent KPCO carriage. Over 5 months, both rooms occupied and rooms not occupied by KPCO-positive patients were sampled at three wastewater sites within each room (sink drain, sink P-trap, and toilet or hopper). Risk factors for KPCO positivity were assessed using logistic regression. Whole-genome sequencing (WGS) identified environmental seeding by KPCO-positive patients. A total of 219/475 (46%) room sampling events were KPCO positive in at least one wastewater site. KPCO-positive patient exposure was associated with increased risk of environmental positivity for the room and toilet/hopper. Previous positivity and intensive care unit room type were consistently associated with increased risk. Tube feeds were associated with increased risk for the drain, while exposure to patients with Clostridioides difficile was associated with decreased risk. Urinary catheter exposure was associated with increased risk of P-trap positivity. P-trap heaters reduced risk of P-trap and sink drain positivity. WGS identified genomically linked environmental seeding in 6 of 99 room occupations by 40 KPCO-positive patients. In conclusion, KPCO-positive patients seed the environment in at least 6% of opportunities; once positive for KPCOs, wastewater sites are at greater risk of being positive subsequently. Increased nutrient exposure, e.g., due to tube food disposal down sinks, may increase risk; frequent flushing may be protective.

IMPORTANCEKlebsiella pneumoniae carbapenemase-producing organisms (KPCOs) are bacteria that are resistant to most antibiotics and thus are challenging to treat when they cause infections in patients. These organisms can be acquired by patients who are hospitalized for other reasons, complicating their hospital stay and even leading to death. Hospital wastewater sites, such as sink drains and toilets, have played a role in many reported outbreaks over the past decade. The significance of our research is in identifying risk factors for environmental positivity for KPCOs, which will facilitate further work to prevent transmission of these organisms to patients from the hospital environment.

Development of a tool to assess evidence for causality in studies implicating sink drains as a reservoir for hospital-acquired gammaproteobacterial infection

BACKGROUND

Decades of studies document an association between Gammaproteobacteria in sink drains and hospital-acquired infections, but the evidence for causality is unclear.

AIM

We aimed to develop a tool to assess the quality of evidence for causality in research studies that implicate sink drains as reservoirs for hospital-acquired Gammaproteobacterial infections.

METHODS

We used a modified Delphi process with recruited experts in hospital epidemiology to develop this tool from a pre-existing causal assessment application.

FINDINGS

Through four rounds of feedback and revision we developed the 'Modified CADDIS Tool for Causality Assessment of Sink Drains as a Reservoir for Hospital-Acquired Gammaproteobacterial Infection or Colonization'. In tests of tool application to published literature during development, mean percent agreement ranged from 46.7% to 87.5%, and the Gwet's AC1 statistic (adjusting for chance agreement) ranged from 0.13 to 1.0 (median 68.1). Areas of disagreement were felt to result from lack of a priori knowledge of causal pathways from sink drains to patients and uncertain influence of co-interventions to prevent organism acquisition. Modifications were made until consensus was achieved that further iterations would not improve the tool. When the tool was applied to 44 articles by two independent reviewers in an ongoing systematic review, percent agreement ranged from 93% to 98%, and the Gwet's AC1 statistic was 0.91-0.97.

CONCLUSION

The modified causality tool was useful for evaluating studies that implicate sink drains as reservoirs for hospital-acquired infections and may help guide the conduct and reporting of future research.

Toilet drain water as a potential source of hospital room-to-room transmission of carbapenemase-producing Klebsiella pneumoniae

BACKGROUND

Carbapenemase-producing Enterobacterales (CPE) have rapidly emerged in Europe, being responsible for nosocomial outbreaks.

AIM

Following an outbreak in the burn unit of Ghent University Hospital, we investigated whether CPE can spread between toilets through drain water and therefrom be transmitted to patients.

METHODS

In 2017, the burn centre of our hospital experienced an outbreak of OXA-48-producing Klebsiella pneumoniae that affected five patients staying in three different rooms. Environmental samples were collected from the sink, shower, shower stretcher, hand rail of the bed, nursing carts, toilets, and drain water to explore a common source. Whole-genome sequencing and phylogenetic analysis was performed on K. pneumoniae outbreak isolates and two random K. pneumoniae isolates.

FINDINGS

OXA-48-producing K. pneumoniae was detected in toilet water in four out of six rooms and drain water between two rooms. The strain persisted in two out of six rooms after two months of daily disinfection with bleach. All outbreak isolates belonged to sequence type (ST) 15 and showed isogenicity (<15 allele differences). This suggests that the strain may have spread between rooms by drain water. Unexpectedly, one random isolate obtained from a patient who became colonized while residing at the geriatric ward clustered with the outbreak isolates, suggesting the outbreak to be larger than expected. Daily application of bleach tended to be superior to acetic acid to disinfect toilet water; however, disinfection did not completely prevent the presence of carbapenemase-producing K. pneumoniae in toilet water.

CONCLUSION

Toilet drain water may be a potential source of hospital room-to-room transmission of carbapenemase-producing K. pneumoniae.

Infectious Disease Research in the Era of Big Data

Infectious disease research spans scales from the molecular to the global—from specific mechanisms of pathogen drug resistance, virulence, and replication to the movement of people, animals, and pathogens around the world. All of these research areas have been impacted by the recent growth of large-scale data sources and data analytics. Some of these advances rely on data or analytic methods that are common to most biomedical data science, while others leverage the unique nature of infectious disease, namely its communicability. This review outlines major research progress in the past few years and highlights some remaining opportunities, focusing on data or methodological approaches particular to infectious disease.

Genomic surveillance of Escherichia coli and Klebsiella spp. in hospital sink drains and patients

Escherichia coli and Klebsiella spp. are important human pathogens that cause a wide spectrum of clinical disease. In healthcare settings, sinks and other wastewater sites have been shown to be reservoirs of antimicrobial-resistant E. coli and Klebsiella spp., particularly in the context of outbreaks of resistant strains amongst patients. Without focusing exclusively on resistance markers or a clinical outbreak, we demonstrate that many hospital sink drains are abundantly and persistently colonized with diverse populations of E. coli, Klebsiella pneumoniae and Klebsiella oxytoca, including both antimicrobial-resistant and susceptible strains. Using whole-genome sequencing of 439 isolates, we show that environmental bacterial populations are largely structured by ward and sink, with only a handful of lineages, such as E. coli ST635, being widely distributed, suggesting different prevailing ecologies, which may vary as a result of different inputs and selection pressures. Whole-genome sequencing of 46 contemporaneous patient isolates identified one (2 %; 95 % CI 0.05-11 %) E. coli urine infection-associated isolate with high similarity to a prior sink isolate, suggesting that sinks may contribute to up to 10 % of infections caused by these organisms in patients on the ward over the same timeframe. Using metagenomics from 20 sink-timepoints, we show that sinks also harbour many clinically relevant antimicrobial resistance genes including blaCTX-M, blaSHV and mcr, and may act as niches for the exchange and amplification of these genes. Our study reinforces the potential role of sinks in contributing to Enterobacterales infection and antimicrobial resistance in hospital patients, something that could be amenable to intervention. This article contains data hosted by Microreact.

Nutrients influence the dynamics of Klebsiella pneumoniae carbapenemase producing enterobacterales in transplanted hospital sinks

Antimicrobial resistance has been recognized as a threat to human health. The role of hospital sinks acting as a reservoir for some of the most concerning antibiotic resistant organisms, carbapenemase producing Enterobacterales (CPE) is evident but not well understood. Strategies to prevent establishment, interventions to eliminate these reservoirs and factors which drive persistence of CPE are not well established. We use a uniquely designed sink lab to transplant CPE colonized hospital sink plumbing with an aim to understand CPE dynamics in a controlled setting, notably exploiting both molecular and culture techniques. After ex situ installation the CPE population in the sink plumbing drop from previously detectable to undetectable levels. The addition of nutrients is followed by a quick rebound in CPE detection in the sinks after as many as 37 days. We did not however detect a significant shift in microbial community structure or the overall resistance gene carriage in longitudinal samples from a subset of these transplanted sinks using whole shotgun metagenomic sequencing. Comparing nutrient types in a benchtop culture study model, protein rich nutrients appear to be the most supportive for CPE growth and biofilm formation ability. The role of nutrients exposure is determining factor for maintaining a high bioburden of CPE in the sink drains and P-traps. Therefore, limiting nutrient disposal into sinks has reasonable potential with regard to decreasing the CPE wastewater burden, especially in hospitals seeking to control an environmental reservoir.

Prevalence and characteristics of surgical site hypervirulent Klebsiella pneumoniae isolates

BACKGROUND

We aim to determine the prevalence of hypervirulent Klebsiella pneumoniae (hvKp), which causes surgical site infections (SSIs), and describe the microbiological and molecular characteristics of hvKp isolates.

METHODS

Non-duplicate K. pneumoniae strains were isolated from wound drainage specimens of postoperative patients at the Chinese PLA General Hospital between September 2008 and July 2017. Antimicrobial susceptibility, string test, pulsed-field gel electrophoresis (PFGE), and genome sequencing analyses were performed.

RESULTS

Fifty-one K. pneumoniae strains were isolated from wound drainage specimens collected from postoperative patients. Twenty-six hvKp strains, including 17 (17/37, 46.0%) and 9 (9/14, 64.3%) hvKp strains, were isolated from 37 and 14 patients with SSIs and community-acquired infections (CAIs), respectively. Notably, 4 extended-spectrum beta-lactamase (ESBL)-producing hvKp strains (4/26, 15.4%) and 2 carbapenem-resistant hvKp strains (2/26, 7.7%) were found. Thirteen K1 serotype (13/26, 50.0%) and 7 K2 serotype (7/26, 26.9%) strains were identified. Phylogenetic analysis results showed that 13 K1 serotype isolates exhibited a high degree of clonality, while 7 K2 serotype strains were genetically unrelated. MLST analysis indicated that there was a strong correlation between ST23 and the K1 serotype. ST65, ST86, and ST375 were prevalent in K2 serotype strains. Almost all hvKp strains (24/26, 92.3%) harbored large virulence plasmids with a high degree of homology to pNTUH-K2044 and sizes ranging from 140 to 220 kbp.

CONCLUSIONS

HvKp strains were prevalent in SSIs. Effective surveillance and control measures should be implemented to prevent the dissemination of such organisms, including the ESBL-producing and carbapenem-resistant hvKp strains.

A microbiological survey of handwashing sinks in the hospital built environment reveals differences in patient room and healthcare personnel sinks

Handwashing sinks and their associated premise plumbing are an ideal environment for pathogen-harboring biofilms to grow and spread throughout facilities due to the connected system of wastewater plumbing. This study was designed to understand the distribution of pathogens and antibiotic resistant organisms (ARO) within and among handwashing sinks in healthcare settings, using culture-dependent methods to quantify Pseudomonas aeruginosa, opportunistic pathogens capable of growth on a cefotaxime-containing medium (OPP-C), and carbapenem-resistant Enterobacteriaceae (CRE). Isolates from each medium identified as P. aeruginosa or Enterobacteriaceae were tested for susceptibility to aztreonam, ceftazidime, and meropenem; Enterobacteriaceae were also tested against ertapenem and cefotaxime. Isolates exhibiting resistance or intermediate resistance were designated ARO. Pathogens were quantified at different locations within handwashing sinks and compared in quantity and distribution between healthcare personnel (HCP) and patient room (PR) sinks. ARO were compared between samples within a sink (biofilm vs planktonic samples) and between sink types (HCP vs. PR). The drain cover was identified as a reservoir within multiple sinks that was often colonized by pathogens despite daily sink cleaning. P. aeruginosa and OPP-C mean log₁₀ CFU/cm² counts were higher in p-trap and tail pipe biofilm samples from HCP compared to PR sinks (2.77  ± 2.39 vs. 1.23 ± 1.62 and 5.27 ± 1.10 vs. 4.74 ± 1.06) for P. aeruginosa and OPP-C, respectively. P. aeruginosa and OPP-C mean log₁₀ CFU/ml counts were also higher (p < 0.05) in HCP compared to PR sinks p-trap water (2.21 ± 1.52 vs. 0.89 ± 1.44 and 3.87 ± 0.78 vs. 3.21 ± 1.11) for P. aeruginosa and OPP-C, respectively. However, a greater percentage of ARO were recovered from PR sinks compared to HCP sinks (p < 0.05) for Enterobacteriaceae (76.4 vs. 32.9%) and P. aeruginosa (25.6 vs. 0.3%). This study supports previous work citing that handwashing sinks are reservoirs for pathogens and ARO and identifies differences in pathogen and ARO quantities between HCP and PR sinks, despite the interconnected premise plumbing.

Dissemination of antibiotic resistance and other healthcare waterborne pathogens. The price of poor design, construction, usage and maintenance of modern water/sanitation services

Classical waterborne pathogens (cholera/typhoid) drove the development of safe water and sanitation during the industrial revolution. Whilst effective against these organisms, other bacteria exploited the potential to form biofilm in the narrow pipes of buildings. 1976 saw the discovery of legionella. Despite evidence dating back to 1967 (including paediatric deaths in Manchester in 1995 from splashes from a sink contaminating parenteral nutrition) it required the deaths of four neonates and the might of the Press in 2011 for the UK medical services to accept waterborne transmission of other Opportunistic Plumbing Premise Pathogens (OPPP). Human nature, a healthcare construction industry largely devoid of interest in water safety, and failures in recognising transmission are major forces hindering progress in preventing infection/deaths from waterborne infections. The advent of highly resistant Gram-negative bacteria is highlighting further deficiencies in modern drainage systems. These bacteria are not thought to have special adaptations promoting their dispersal but purely attract our attention to the well-trodden routes used by sensitive organisms, which go undetected. The O'Neill report warns of the bleak future without effective antibiotics. This paper examines the evidence as to why modern water services/sanitation continue to present a risk to patient safety (and the general public) and also suggests their designs may be flawed if they are to stem the modern equivalent of cholera, the dissemination of antibiotic resistance.

High prevalence of contamination of sink drains with carbapenemase-producing Enterobacteriaceae in 4 intensive care units apart from any epidemic context

We report a high prevalence (28%) of sink drains contaminated with carbapenemase-producing Enterobacteriaceae (CPE) in 4 intensive care units with a history of CPE carriage in hospitalized patients within the previous 5 years, but apart from any current epidemic context. Carbapenemase genes, particularly bla_VIM and bla_NDM, were identified by polymerase chain reaction in sink drains in which no CPE was detected, but very few data are available in the literature concerning their presence in sink drains.

Risk factors for Klebsiella pneumoniae carbapenemase (KPC) gene acquisition and clinical outcomes across multiple bacterial species

Introduction

Risk factors for carbapenemase-producing Enterobacterales (CPE) acquisition/infection and associated clinical outcomes have been evaluated in the context of clonal, species-specific outbreaks. Equivalent analyses for complex, multi-species outbreaks, which are increasingly common, are lacking.

Methods

Between December 2010 and January 2017, a case–control study of Klebsiella pneumoniae carbapenemase (KPC)-producing organism (KPCO) acquisition was undertaken using electronic health records from inpatients in a US academic medical centre and long-term acute care hospital (LTACH) with ongoing multi-species KPCO transmission despite a robust CPE screening programme. Cases had a first KPCO-positive culture >48 h after admission, and included colonizations and infections (defined by clinical records). Controls had at least two negative perirectal screens and no positive cultures. Risk factors for KPCO acquisition, first infection following acquisition, and 14-day mortality following each episode of infection were identified using multi-variable logistic regression.

Results

In 303 cases (89 with at least one infection) and 5929 controls, risk factors for KPCO acquisition included: longer inpatient stay, transfusion, complex thoracic pathology, mechanical ventilation, dialysis, and exposure to carbapenems and β-lactam/β-lactamase inhibitors. Exposure to other KPCO-colonized patients was only a risk factor for acquisition in a single unit, suggesting that direct patient-to-patient transmission did not play a major role. There were 15 species of KPCO; 61 (20%) cases were colonized/infected with more than one species. Fourteen-day mortality following non-urinary KPCO infection was 20% (20/97 episodes) and was associated with failure to achieve source control.

Conclusions

Healthcare exposures, antimicrobials and invasive procedures increased the risk of KPCO colonization/infection, suggesting potential targets for infection control interventions in multi-species outbreaks. Evidence for patient-to-patient transmission was limited.