p.aeruginosaoutbreak in an nicu 807
table 3. Pseudomonas aeruginosa Outbreak in a Neonatal Intensive Care Unit Attributed to Hospital Tap Watera Characteristics
Cases, No. (%) (N=31)
Device exposure Naso or orogastric tube Peripheral IV
Invasive ventilation
Peripherally inserted central catheter Umbilical catheter Eye exam
Medication/nutrition exposure Antibioticsc Breast milk
Total parenteral nutrition Lipids
Blood products Formula
Maintenance fluids
Environment exposure Incubator Humidity
Unfiltered waterd
30 (97) 21 (68) 19 (61) 18 (58) 5 (16) 3 (10)
28 (90) 28 (90) 26 (84) 19 (62) 11 (35) 10 (33) 10 (32)
23 (75) 12 (39) 31 (100)
the 7 days before positive or index culture. bP<.05. cExposure in the 30 days before positive culture or index date. dBased on the median unbiased estimate.
but multiple possibilities were considered, including breaches in infection control or POU filter failure. The state health department considered the outbreak over in
March 2016, after substantial reduction of P. aeruginosa in water samples was achieved and no new cases were reported. The hospital ceased routine patient surveillance cultures at this time. By June 2016, P. aeruginosa was no longer detected in the fixtures in the NICU (<1 CFU/100 mL); the hospital opted to continue using POU filters as an added precaution. Multiple factors limited our investigation. The case-control
study was limited by the size of the NICU population and precluded matching of cases and controls using a ratio greater than 1:1, matching by NICU admission date, or performing multivariable modeling. Our findings are consistent with the statement made by
Williams et al15 that waterborne healthcare-associated infec- tions occur “at the 3-way intersection of nonsterile potable water, susceptible individuals, and a lapse in infection control practices.” All 3 factors likely contributed to this outbreak. Although interruption of the outbreak with POU filters provided a short-term solution, eradication of P. aeruginosa in the hospital water, faucets, and sinks was necessary to protect patients. This outbreak highlights the importance of addressing and understanding the inherent risks (eg, biofilm formation) in healthcare facilities where water has been stagnant for extended periods.
acknowledgments
We acknowledge the substantial contributions of the hospital staff where the outbreak occurred and their commitment to patient safety. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers forDisease Control and Prevention. Financial Support. No financial support was provided relevant to this article. Potential conflicts of interest. All authors report no conflicts of interest
relevant to this article. Address correspondence to Cara Bicking Kinsey, 625 Forster Street,
Room 933, Harrisburg, PA 17120 (
cbickingkinsey@gmail.com). references
1. Centers for Disease Control and Prevention. Pseudomonas aeru- ginosa in Healthcare Settings.
http://www.cdc.gov/hai/organisms/ pseudomonas.html. Published 2014. Accessed February 8, 2017.
2. TrautmannM, Lepper PM, Haller M. Ecology of Pseudomonas aeruginosa in the intensive care unit and the evolving role of water outlets as a reservoir of the
organism.AmJ Infect Control 2005;33: S41–S49.
3. Polin RA, Denson S, Brady MT. Strategies for prevention of health care-associated infections in the NICU. Pediatrics 2012;129:e1085–e1093.
4. Crivaro V, Di Popolo A, Caprio A, et al. Pseudomonas aeruginosa in a neonatal intensive care unit: molecular epidemiol- ogy and infection control measures. BMC Infect Dis 2009;9:70.
Controls, No. (%) (N=31)
25 (81) 19 (61) 8 (26) 6 (19) 7 (22) 4 (13)
20 (65) 26 (84) 20 (65) 18 (58) 6 (19)
13 (43) 12 (39)
17 (54) 9 (29)
14 (45)
5.53 1.54 5.79 7.20 0.80 0.65
1.35 1.52 3.10 1.39 3.02 0.77 0.80
2.76 1.87
37.55
Adjusted Exact OR 95% CI
0.60–270.4 0.46–5.36
1.39–30.62b 1.75–37.30b 0.15–4.17 0.07–5.37
0.35-5.19 0.22–12.11 0.80–13.91 0.42–4.69 0.70–15.92 0.21–2.87 0.20–3.17
0.54–18.77 0.47–7.91 7.16–∞b
NOTE. OR, odds ratio; CI, confidence interval. aExact conditional logistic regression models with pooled matched strata adjusted for gestational age. Exposures occurred in
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