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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.
Highlights
Carbapenems represent a last resort antibiotic therapy for patients infected with extended-spectrum β-lactamase-producing Enterobacterales
carbapenemase-producing Enterobacterales (CPE) cases were detected in the haematological ward (Figure 1 and Supplementary Table S1)
We focused our attention on C. freundii since all acquired isolates (n = 17) belonged to the same sequence type (ST-22)
Summary
Carbapenems represent a last resort antibiotic therapy for patients infected with extended-spectrum β-lactamase-producing Enterobacterales. Enterobacterales (CPE) is of great concern since carbapenemase production is associated with an increased mortality rate [1]. In 2018, data reported to the European Antimicrobial Resistance. Surveillance Network (EARS-Net) concerning invasive isolates indicated that 0.1% and 7.5% of Escherichia coli and Klebsiella pneumoniae, respectively, were resistant to carbapenem [3]. In France, the number of cases (infections and colonisations) and outbreaks of CPE has steadily increased since 2009. Patient-to-patient cross-transmission is the main spreading mechanism of CPE during nosocomial outbreaks. Environmental reservoirs, such as contaminated sinks, have been reported as sources of Figure 1
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