infection control & hospital epidemiology july 2017, vol. 38, no. 7 original article
Pseudomonas aeruginosa Outbreak in a Neonatal Intensive Care Unit Attributed to Hospital Tap Water
Cara Bicking Kinsey, PhD;1 Samir Koirala,MBBS;1 Benjamin Solomon, MD;1 Jon Rosenberg, MD;2 Byron F. Robinson, PhD;1 Antonio Neri, MD;1 Alison Laufer Halpin, PhD;3 Matthew J. Arduino, DrPH;3 Heather Moulton-Meissner, PhD;3 Judith Noble-Wang, PhD;3 Nora Chea, MD;1,3 Carolyn V. Gould, MD3
objective. To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit. design. Infection control assessment, environmental evaluation, and case-control study. setting. Newly built community-based hospital, 28-bed neonatal intensive care unit. patients. Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014.
methods. Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness.
results. In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16–∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75–37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39–30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms.
conclusions. This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short- term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities.
Infect Control Hosp Epidemiol 2017;38:801–808
Pseudomonas aeruginosa is a gram-negative nonfermenting bacillus in water and soil that has been implicated in healthcare- associated infections in intensive care settings.1,2 Patients in neonatal intensive care units (NICUs) are particularly vulnerable to infection because of underdeveloped immune systems, limited skin barrier functions, and exposure to invasive procedures and devices.3 Multiple P. aeruginosa outbreaks have been documented in NICUs and have been attributed to con- taminated medications, respiratory equipment, laryngoscopes, and personnel hand contamination.4–12 Pseudomonas aeruginosa outbreaks have also been associated with contaminated hospital tap water11–14 because the organism is hardy and can form biofilms in plumbing fixtures that resist chemical treatment.15 In fall 2013, a P. aeruginosa outbreak involving 15 patients and 2 deaths occurred in a 28-bed NICU that admits
370–450 patients/year. The NICU has private patient rooms each with 1 sink, and is located in a newly constructed building that opened to patient care in May 2013. During outbreak response, the hospital notified the county health department, diverted admissions to another NICU, and performed water
remediation, including installation of disposable membrane filtration point-of-use (POU) filters on faucets in November 2013. Environmental samples collected during November 2013–May 2014 from prefiltered water in the NICU yielded P. aeruginosa, but no strain types matched patient isolates. During May 21–June 9, 2014, new faucets were installed in the NICU and POU filters were removed. Starting June 22, 2014, a second cluster of cases occurred, including 1 patient death. Again, admissions to NICU were diverted. On September 23, 2014, the state health department invited the Centers for
Affiliations: 1. Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia; 2. Healthcare-
Associated Infections Program, Center for Health Care Quality, California Department of Public Health, Richmond, California; 3. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3807-0006. DOI: 10.1017/ice.2017.87 Received November 28, 2016; accepted March 29, 2017; electronically published May 18, 2017
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