Infection Control & Hospital Epidemiology


standard and contact precautions, implementation of contact pre- cautions, removal of aerators, provision of bottled water for patients, and point-of-use water filtration for clinical care and respiratory devices reprocessing, but new cases occurred. After closing patient- care handwashing stations, sealing hemodialysis drain connections, establishing waterless patient hygiene, redesigning the reprocessing and storage of material, and training in reprocessing, no new cases appeared forthe next 5months(Figure 1). We were unable to assure the real mode of transmission. The


recovery of the same PFGE of C. indologenes, as well as other microorganisms, from drainage sinks and air in its vicinity, demonstrates that contamination of devices close to the sinks is possible by aerosolization of drainage water, which potentially played a role in this outbreak. Also, contamination of respiratory devices during reprocessing could have played an important role because the same PFGE pattern was shared by patients and the air sample close to the sink in the reprocessing room that occa- sionally serves both ICUs. Unfortunately, only 5 of the 11 environmental specimens could be analyzed by PFGE; thus, we were not able to prove the contamination of handwashing sinks as the cause of the outbreak. The immediate control of the outbreak after implementation of the third tier of measures would support both hypotheses. Other hypotheses, such as lapses in hand hygiene between patients, also cannot be ruled out. In conclusion, sinkholes and drains are potentially con-


taminated and can act as a reservoir for NFGNB and other microorganisms. Tap water flushing may spread them to sur- rounding areas. Susceptible patients and their equipment should be protected fromthese splashes because contamination can occur.


Supplementary materials. To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2018.126


Acknowledgments. Financial support. No financial support was provided relevant to this article.


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Conflicts of interest. All authors report no conflicts of interest relevant to this article.


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