A Large, Refractory Nosocomial Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Escherichia coli Demonstrates Carbapenemase Gene Outbreaks Involving Sink Sites Require Novel Approaches to Infection Control

Abstract

Carbapenem-resistant (CRE) represent a health threat, but effective control interventions remain unclear. Hospital wastewater sites are increasingly being highlighted as important potential reservoirs. We investigated a large carbapenemase (KPC)-producing outbreak and wider CRE incidence trends in the Central Manchester University Hospital NHS Foundation Trust (CMFT) (United Kingdom) over 8 years, to determine the impact of infection prevention and control measures. Bacteriology and patient administration data (2009 to 2017) were linked, and a subset of CMFT or regional hospital KPC-producing isolates ( = 268) were sequenced. Control interventions followed international guidelines and included cohorting, rectal screening ( = 184,539 screens), environmental sampling, enhanced cleaning, and ward closure and plumbing replacement. Segmented regression of time trends for CRE detections was used to evaluate the impact of interventions on CRE incidence. Genomic analysis ( = 268 isolates) identified the spread of a KPC-producing outbreak clone (strain A, sequence type 216 [ST216]; = 125) among patients and in the environment, particularly on 2 cardiac wards (wards 3 and 4), despite control measures. ST216 strain A had caused an antecedent outbreak and shared its KPC plasmids with other lineages and species. CRE acquisition incidence declined after closure of wards 3 and 4 and plumbing replacement, suggesting an environmental contribution. However, ward 3/ward 4 wastewater sites were rapidly recolonized with CRE and patient CRE acquisitions recurred, albeit at lower rates. Patient relocation and plumbing replacement were associated with control of a clonal KPC-producing outbreak; however, environmental contamination with CRE and patient CRE acquisitions recurred rapidly following this intervention. The large numbers of cases and the persistence of in, including pathogenic lineages, are of concern.

New and emerging infectious diseases (Ebola, Middle Eastern respiratory syndrome coronavirus, carbapenem-resistant Enterobacteriaceae, Candida auris): Focus on environmental survival and germicide susceptibility

“…114 Environmental contamination and survival CRE has been isolated from the environment in the vicinity of hospitalized colonized/infected patients including pillows, infusion pumps, bedside tables, and toilet areas. [115][116][117] The frequency of recovery has varied among studies, but objects closer to the patient are more likely contaminated with 5%-15% of samples from bedrails and over bed tables yielding CRE. 115,116 Fecal continence is an independent predictor of being a nonspreader of CRE.…”

“…[115][116][117] The frequency of recovery has varied among studies, but objects closer to the patient are more likely contaminated with 5%-15% of samples from bedrails and over bed tables yielding CRE. 115,116 Fecal continence is an independent predictor of being a nonspreader of CRE. 117 CRE has also been isolated in the environment of long-term care facilities.…”

Genomic and Metagenomic Approaches for Predictive Surveillance of Emerging Pathogens and Antibiotic Resistance

“…One such study tracked a large K. pneumoniae carbapenemase (KPC)‐producing Escherichia coli outbreak to determine the impact of ARO decontamination intervention after an outbreak. KPC‐producing E. coli are uncommon, and the emergence of an outbreak with carbapenem resistance is a particular concern because of the extremely limited treatment options for such infections . In 2015, a sudden increase of KPC‐producing E. coli colonization was detected in patient fecal samples at the Central Manchester University Hospital NHS Foundation Trust (United Kingdom), spurring a genomic epidemiological study on isolates from patients and the environment.…”

“…Beyond identification and characterization of AROs, it is critical to track and predict antibiotic-resistant outbreaks and reservoirs of AROs and ARGs. 16,17,29 To do this, studies must be able to accurately identify the relatedness and antibiotic resistance profiles of isolates. A recent study in Australia used WGS and culture-based methods to track an emerging pathogen, vanA-possessing vancomycin-resistant Enterococcus faecium (VREfm).…”

“…KPC-producing E. coli are uncommon, and the emergence of an outbreak with carbapenem resistance is a particular concern because of the extremely limited treatment options for such infections. 29 In 2015, a sudden increase of KPC-producing E. coli colonization was detected in patient fecal samples at the Central Manchester University Hospital NHS Foundation Trust (United Kingdom), spurring a genomic epidemiological study on isolates from patients and the environment. While environmental samples were taken from sinks, drains, toilets, sluices, and other high-touch sites, all carbapenem-resistant Enterobacteriaceae cultures were associated with wastewater sites.…”