“Down the drain”: carbapenem‐resistant bacteria in intensive care unit patients and handwashing sinks

Kotsanas, Despina; Wijesooriya, W.R.P.L.I.; Korman, Tony M.; Gillespie, Elizabeth; Wright, Louise; Snook, Kylie; Williams, Natalie M.; Bell, Jan M.; Li, Hua Y.; Stuart, Rhonda L.

doi:10.5694/mja12.11757

Cited by 119 publications

(87 citation statements)

References 9 publications

(7 reference statements)

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“…23 Drain biofilms harbour large populations of bacteria, 24 including antibioticresistant strains and hospital sink drains have been implicated in a number of outbreaks of multidrug-resistant bacteria. [25][26][27][28][29] Our study confirmed that the drain of the handwash basin in patient room is a potential reservoir for ESBLproducing Enterobacteriacae and P. aeruginosa. It accounted for 62% of ESBL-positive sites.…”

Section: Discussionsupporting

confidence: 66%

ESBL-producing Gram-negative organisms in the healthcare environment as a source of genetic material for resistance in human infections

Muzslay

Moore

Alhussaini

et al. 2017

Journal of Hospital Infection

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SUMMARY BackgroundThe increasing prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriacae in the healthcare setting and in the community despite established infection control guidelines indicates that these microorganisms may possess survival strategies that allow them to persist in the environment. Aims To determine the extent and variation in endemic ESBL-carrying species in different ward environments. To investigate the potential for cephalosporin resistance to be transferred from environmental isolates to human pathogens. Methods Conventional microbiological methods were used to sample 1436 environmental surfaces for ESBL-producing bacteria. Transconjugation assays (broth mating experiments) were performed using environmental ESBL-producing isolates as donors and streptomycin-resistant Escherichia coli (NCTC 50237) as the recipient. FindingsThe prevalence of ESBL-producing bacteria on surfaces in a non-outbreak setting was low (45/1436; 3.1%). The sites most likely to be contaminated were the drains of handwash basins (28/105; 26.7%) and floors (14/160; 8.8%). Fifty-nine ESBL-carrying organisms were isolated. Of these, Klebsiella spp (33.9%), Enterobacter spp (20.3%), Pantoea spp (15.3%) and Citrobacter spp (13.6%), were the most common isolates. ESBL determinants were successfully transferred from three representative environmental isolates (Pantoea calida, Klebsiella oxytoca, Raoultella ornithinolytica) to the human pathogen E. coli. Conclusion ESBL-producing Gram-negative isolates were recovered from the hospital environment in the absence of any ESBL infection on the wards. The drains of hand wash basins should be considered potential long-term reservoirs of multi-drug resistant bacteria and drug resistance genes. These genes can reside in various genera of hardy environmental organisms and be a potential source of ESBL for more common human pathogens.

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Section: Discussionsupporting

confidence: 66%

ESBL-producing Gram-negative organisms in the healthcare environment as a source of genetic material for resistance in human infections

Muzslay

Moore

Alhussaini

et al. 2017

Journal of Hospital Infection

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“…Hospital sinks represent one of the most frequently implicated reservoirs for MDR Gram-negative bacilli, including MDR coliforms (93,94). K. pneumoniae strains demonstrating prolonged survival within plumbing components are also more likely to harbor extended-spectrum ␤-lactamases (95).…”

Section: Multidrug-resistant Gram-negative Bacillimentioning

confidence: 99%

Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination

2014

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SUMMARY There is increasing interest in the role of cleaning for managing hospital-acquired infections (HAI). Pathogens such as vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Gram-negative bacilli, norovirus, and Clostridium difficile persist in the health care environment for days. Both detergent- and disinfectant-based cleaning can help control these pathogens, although difficulties with measuring cleanliness have compromised the quality of published evidence. Traditional cleaning methods are notoriously inefficient for decontamination, and new approaches have been proposed, including disinfectants, steam, automated dispersal systems, and antimicrobial surfaces. These methods are difficult to evaluate for cost-effectiveness because environmental data are not usually modeled against patient outcome. Recent studies have reported the value of physically removing soil using detergent, compared with more expensive (and toxic) disinfectants. Simple cleaning methods should be evaluated against nonmanual disinfection using standardized sampling and surveillance. Given worldwide concern over escalating antimicrobial resistance, it is clear that more studies on health care decontamination are required. Cleaning schedules should be adapted to reflect clinical risk, location, type of site, and hand touch frequency and should be evaluated for cost versus benefit for both routine and outbreak situations. Forthcoming evidence on the role of antimicrobial surfaces could supplement infection prevention strategies for health care environments, including those targeting multidrug-resistant pathogens.

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“…Indeed, contaminated rinse water used during endoscope reprocessing, coupled with inadequate drying of the ERCP endoscope's internal channels after terminal water rinsing, is a commonly documented contributor to bacterial transmissions via contaminated GI endoscopes [2,7,8,11,12] . For certain, in addition to a human's GI tract, water (and soil) is a documented reservoir of CRE [2,44,45,[51][52][53][54] . That another unrecognized factor altogether may have been the primary cause of (or a contributor to) Hospital X's CRE outbreak also remains plausible.…”

Section: High-level Disinfection: Does It Rapidly Destroy Cre and Relmentioning

confidence: 99%

Risk of transmission of carbapenem-resistantEnterobacteriaceaeand related “superbugs” during gastrointestinal endoscopy

Muscarella¹

2014

WJGE

114

110

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To evaluate the risk of transmission of carbapenemresistant Enterobacteriaceae (CRE) and their related superbugs during gastrointestinal (GI) endoscopy. Reports of outbreaks linked to GI endoscopes contaminated with different types of infectious agents, including CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE's emergence, these reports were obtained by searching the peer-reviewed medical literature (via the United States National Library of Medicine's "MEDLINE" database); the Food and Drug Administration's Manufacturer and User Facility Device Experience database, or "MAUDE"; and the Internet (via Google's search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at "Hospital X" located in the suburbs of Chicago (IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital's patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Control and Prevention (CDC), which published a report about this outbreak in Morbidity and Mortality Weekly Report (MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X's infection control practices following this CRE outbreak, were also reviewed. While this article focuses primarily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infectious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently associated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospital X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer's labeling, supplemented as needed with professional organizations' published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including bronchoscopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related su...

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“Down the drain”: carbapenem‐resistant bacteria in intensive care unit patients and handwashing sinks

Abstract: This report highlights the importance of identification of potential environmental reservoirs, such as sinks, for control of outbreaks of environmentally hardy multiresistant organisms.

Cited by 119 publications

References 9 publications

ESBL-producing Gram-negative organisms in the healthcare environment as a source of genetic material for resistance in human infections

ESBL-producing Gram-negative organisms in the healthcare environment as a source of genetic material for resistance in human infections

Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination

Risk of transmission of carbapenem-resistantEnterobacteriaceaeand related “superbugs” during gastrointestinal endoscopy

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