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

Abstract

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.

Droplets generated from toilets during urination as a possible vehicle of carbapenem-resistant Klebsiella pneumoniae

“…A study conducted between 2016 and 2019 in a haematological ward of a French teaching hospital investigated a persistent outbreak of CPE producing OXA-48 carbapenemase and highlighted the role of contaminated toilets in transmission. The incidence of CPE cases declined after intensive toilet cleaning, subsequent replacement with rimless toilets and improved patient hygiene [ 15 ].…”

Outbreak of carbapenem-resistant enterobacteria in a thoracic-oncology unit through clonal and plasmid-mediated transmission of the blaOXA-48 gene in Southern France

“…Recently in the north of France, an outbreak of OXA-48 carbapenemase -producing Enterobacteriaceae species, including Enterobacter sp. and C. freundii ST22, has been reported in a haematological ward ( Jolivet et al., 2021 ).…”

“…Many Gram-negative species can survive on these surfaces for as long as several months ( Pantel et al., 2016 ). One reason for the persistent transmission of OXA-48 C. freundii in a hematology department was the presence of contaminated toilets which constituted a potential reservoir ( Jolivet et al., 2021 ). In our case, the same clone of C. freundii was present in four different patients, hospitalized in different rooms, at different times, which is worrying.…”

Investigation of an Enterobacter hormaechei OXA-436 carbapenemase outbreak: when everything goes down the drain

“…In this case, a likely source of the outbreak was the two shower drains as the outbreak was terminated after the drains had been replaced. Other explanations may well exist, but It is well known, that the hospital environment and sewer systems can be a source of transmission [ [6] , [7] , [8] , [9] , [10] ]. This outbreak underlines the importance of maintaining department facilities and sewer systems and that staff are trained to report non-functioning installations, in addition to general hygiene measures to prevent transmission of bacteria between patients.…”