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Fig. 1. Summary of wastewater drain carbapenem-resistant organism outbreak characteristics. As summarized in Figure 1, our rapidly evolving under-
standing of the role of patient-zone WWDs in CRO transmission clarifies the urgent need for further research to qualify and quantify the role of wet biofilm in healthcare environments with respect to both the epidemiology of CROs as well as other Enterobacteriaceae, yeasts, and possibly fungi in a range of healthcare settings. Given the finding that multiple, apparently initially successful, WWD mitigation interventions were later found to be substantially or completely unsuccessful (often after a delay of many months), an assessment of the effectiveness of interventions to mitigate drain biofilm-associated pathogen con- tamination and transmission might initially be best evaluated by mock-up sink laboratory investigations such as those described by Kotay et al.35 Additionally, the likely role of healthcare worker hands in the transmission of WWD CROs36 and the doc- umentation that bla-KPC–carrying K. pneumonia was cultivable on plastic and steel for up to 5–6 days, and thereafter viable but noncultivable,48 support the need for studies to clarify the role of intermediate fomites in CRO outbreaks. However, the potential role of WWD colonization in CRO outbreaks is not widely recognized. A review published in May 2017 providing detailed recommendations for interventions to optimize recog- nition and control of CRO stated, “Carbapenem-resistant Enterobactericae have been found infrequently in the environ- ment of infected or colonized patients,”49(p.586) but these researchers failed to consider the possible role of WWDs in CRO acquisition. Although none of the 6 CRO outbreaks reported in 2017 investigated WWDs as a possible source for ongoing patient acquisition,50–56 greater awareness of the potential for WWDs to perpetuate CRO dissemination may lead to the routine evaluation of these sites in all CRO outbreak investigations in the future. Clearly, further studies are needed to clarify and quantify the
dynamics of WWD biofilm plasmid exchange because it is now clear that, as Wendel noted, “Drains may serve as a melting pot for horizontal gene transfer, for dissemination into new species, and as a reservoir to propagate future hospital outbreaks.”45(p.3605)
While developing effective interventions to prevent transmission ofWWDpathogens to patients is of immediate importance, it will be equally critical to concomitantly evaluate and mitigate WWD biofilm-colonizing plasmid-mediated antimicrobial resistance.
Acknowledgments
Financial support. No financial support was sought or received for this study.
Potential conflicts of interest. The author reports no conflicts interest relevant to this report.
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