Risk Assessment After a Severe Hospital-Acquired Infection Associated With Carbapenemase-Producing Pseudomonas aeruginosa

Joost Hopman,Ad F T M Verhagen,Wim J Morshuis,Michel M Van Den Heuvel,Mohammad R Ghamati,Shaheen Mehtar,Andreas Voss,Nikki Kenters,Heiman F L Wertheim,Reinout Van Crevel,Corianne Meijer,Jordy P M Coolen

doi:10.1001/jamanetworkopen.2018.7665

Abstract

ImportanceResistance of gram-negative bacilli to carbapenems is rapidly emerging worldwide. In 2016, the World Health Organization defined the hospital-built environment as a core component of infection prevention and control programs. The hospital-built environment has recently been reported as a source for outbreaks and sporadic transmission events of carbapenemase-producing gram-negative bacilli from the environment to patients.ObjectiveTo assess risk after the identification of an unexpected, severe, and lethal hospital-acquired infection caused by carbapenemase-producing Pseudomonas aeruginosa in a carbapenemase-low endemic setting.Design, Settings, and ParticipantsA case series study in which a risk assessment was performed on all 11 patients admitted to the combined cardiothoracic surgery and pulmonary diseases ward and the hospital-built environment in the Radboud University Medical Center, the Netherlands, in February 2018.ExposuresWater and aerosols containing carbapenemase-producing (Verona integron-mediated metallo-β-lactamase [VIM]) P aeruginosa.Main Outcomes and MeasuresColonization and/or infection of patients and/or contamination of the environment after the detection of 1 patient infected with carbapenemase-producing (VIM) P aeruginosa.ResultsA total of 5 men (age range, 60-84 years) and 6 women (age range, 55-74 years) were admitted to the combined cardiothoracic surgery and pulmonary diseases ward. The risk assessment was performed after carbapenemase-producing (VIM) P aeruginosa was unexpectedly detected in a man in his early 60s, who had undergone a left-sided pneumonectomy and adjuvant radiotherapy. No additional cases (colonization or infection) of carbapenemase-producing (VIM) P aeruginosa were detected. Plausible transmission of carbapenemase-producing P aeruginosa from the hospital environment to the patient via the air was confirmed by whole-genome sequencing, which proved the relation of Pseudomonas strains from the patient, the shower drains in 8 patient rooms, 1 sink, and an air sample.Conclusions and RelevanceThis study suggests that rethinking the hospital-built environment, including shower drains and the sewage system, will be crucial for the prevention of severe and potential lethal hospital-acquired infections.

Highlights

The identification of carbapenemase-producing Enterobacteriaceae in environmental samples from New Delhi, India, in 2011 had important clinical implications for people living in low-resource settings who are dependent on public water and sanitation facilities.[1]
The risk assessment was performed after carbapenemase-producing (VIM) P aeruginosa was unexpectedly detected in a man in his early 60s, who had undergone a left-sided pneumonectomy and adjuvant radiotherapy
Plausible transmission of carbapenemase-producing P aeruginosa from the hospital environment to the patient via the air was confirmed by whole-genome sequencing, which proved the relation of Pseudomonas strains from the patient, the shower drains in 8 patient rooms, 1 sink, and an air sample

Summary

Introduction

The identification of carbapenemase-producing Enterobacteriaceae in environmental samples from New Delhi, India, in 2011 had important clinical implications for people living in low-resource settings who are dependent on public water and sanitation facilities.[1] To ensure early detection and international surveillance of resistance, it was advised to incorporate environmental sampling as well as examination of clinical isolates in screening strategies.[1,2] Currently, carbapenem-resistant strains, including Pseudomonas aeruginosa and Acinetobacter baumannii, are spreading rapidly to and within high-resource countries.[3,4] the World Health Organization (WHO) has issued measures to control the spread of carbapenemase-producing microorganisms, focusing on Enterobacteriaceae, P aeruginosa, and A baumannii.[5] One of the strategies to halt the spread of multidrug-resistant microorganisms is through implementing the WHO infection prevention and control core components, of which the hospital-built environment is added as one of the new core elements.[6] Sinks are part of this hospital-built environment; the removal of sinks from rooms in the intensive care unit has resulted in the reduction of colonization and infections with multidrugresistant microorganisms.[7,8,9] In addition, waste water has been recently identified as a source of transmission of carbapenemase-producing Enterobacteriaceae in an intensive care unit in the United States.[10] hospital plumbing systems have been revealed as a reservoir of carbapenem resistance by genomic analysis,[11] and shower faucets have been shown to be important in the level of air contamination in an experimental shower unit.[12] We report the results of a risk assessment conducted after the identification of an unexpected, severe, and lethal hospital-acquired infection caused by carbapenemase-producing P aeruginosa in a carbapenemase-low endemic setting

Methods

Results

Discussion

Conclusion