p.aeruginosa outbreak in an nicu 803


results Case Finding and Confirmation


We identified 31 cases that occurred in 2 distinct clusters, September–November 2013 and August–September 2014 (Figure 1) and included 3 deaths. Clinical cases (n=17) con- sisted of blood, respiratory, urine, and eye cultures; surveillance cases (n=14) included respiratory, groin, and nasal cultures. Most case patients were Hispanic (58%); approximately half (52%) were male (Table 1). Approximately half (52%) had a birth weights of ≤1,000 g. For comparison, <10% of patients admitted to this NICU were extremely low birth weight (≤1,000 g) during the study period. Cases occurred in patients occupying different rooms and areas in the NICU (Figure 2).


Infection Control Assessment


Before our investigation, the hospital implemented multiple infection control measures, including contact precautions for patients with a positive P. aeruginosa culture. NICU policy required personnel to use gloves during all patient contact. Our investigation revealed inconsistent hand-hygiene prac-


tices among direct patient care personnel, including use of soap and water over alcohol-based hand rub (ABHR) when not indicated (Figure 3). NICU policy was changed to specify preferential use of ABHR on October 2, 2014. No risk factors


for colonization (eg, hot tub use) or skin breakdown on personnel hands were identified. Review of feeding practices revealed that breast pump parts


were washed in tap water, according tomanufacturer instructions; however, the manufacturer recommendation for daily sanitation of breast pump parts was not performed. Other infection control audits by the investigation team did not reveal breaches or other evidence of tap water exposure to NICU patients.


Environmental Evaluation


Our investigation revealed that although NICU patient care had been moved to the new hospital building in May 2013, water treatment, system flushing, and water testing after the construc- tion process was complete were completed in February 2013. From February to May 2013, water in the hospital pipes was idle. After the first cluster of NICU P. aeruginosa cases was


identified in the autumn of 2013, interventions were exercised given suspicion that hospital water supply was the bacteria source. The hospital removed aerators from faucets; cleaned,


disinfected, and removed mineral deposits on faucets and sink fixtures; and performed multiple hyperchlorination flushes of the building’s water system (Figure 1). The hospital also installed POU filters on all NICUfaucets in December 2013. In May 2014, the hospital removed POU filters when NICU faucets were replaced with a different model thought less likely


figure 1. Epidemic curve for Pseudomonas aeruginosa cases (n=31) including environmental and engineering interventions in the neonatal intensive care unit, June 2013–September 2014.


Environmental and engineering interventions overlaying the epidemiologic curve. A, Aerators removed from faucets hospital wide. B, Laminar flow devices replaced in all neonatal intensive care unit (NICU) rooms. C, Hyperchlorination of NICU and part of labor and delivery. D, Descaling of all sink fixtures building wide. E, Laminar flow devices exchanged with antimicrobial devices. Sink fixtures cleaned building wide. F, Cleaning and disinfection of all faucet fixtures positive for P. aeruginosa.G,Point-of-use (POU) filters installed. H, NICU faucets replaced and POU filters removed. J, Hyperchlorination performed building wide and continuous chlorine dioxide treatment initiated.


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