Infection Control & Hospital Epidemiology (2019), 40,40–46 doi:10.1017/ice.2018.263
Original Article
Bronchoscope-associated clusters of multidrug-resistant Pseudomonas aeruginosa and carbapenem-resistant Klebsiella pneumoniae
Alison L. Galdys MD1,2,3,a, Jane W. Marsh PhD1,2,a, Edgar Delgado RRT, FAARC4, A. William Pasculle ScD2,5, Marissa Pacey BS2, Ashley M. Ayres BS, CIC3, Amy Metzger BS, MT (ASCP), CIC, CHI3, Lee H. Harrison MD1,2,3 and
Carlene A. Muto MD, MS1,2,3 1University of Pittsburgh Division of Infectious Diseases, Pittsburgh, Pennsylvania, 2University of Pittsburgh Microbial Genomic Epidemiology Laboratory (MiGEL), Pittsburgh, Pennsylvania, 3University of Pittsburgh Medical Center Presbyterian Infection Prevention and Control, Pittsburgh, Pennsylvania, 4University of Pittsburgh Medical Center Respiratory Care Department, Pittsburgh, Pennsylvania and 5University of Pittsburgh Department of Pathology, Pittsburgh, Pennsylvania
Abstract
Objective: Recovery of multidrug-resistant (MDR) Pseudomonas aeruginosa and Klebsiella pneumoniae from a cluster of patients in the medical intensive care unit (MICU) prompted an epidemiologic investigation for a common exposure. Methods: Clinical and microbiologic data from MICU patients were retrospectively reviewed, MICU bronchoscopes underwent culturing and borescopy, and bronchoscope reprocessing procedures were reviewed. Bronchoscope and clinical MDR isolates epidemiologically linked to the cluster underwent molecular typing using pulsed-field gel electrophoresis (PFGE) followed by whole-genome sequencing. Results: Of the 33 case patients, 23 (70%) were exposed to a common bronchoscope (B1). Both MDR P. aeruginosa and K. pneumonia were recovered from the bronchoscope’s lumen, and borescopy revealed a luminal defect. Molecular testing demonstrated genetic relatedness among case patient and B1 isolates, providing strong evidence for horizontal bacterial transmission. MDR organism (MDRO) recovery in 19 patients was ultimately linked to B1 exposure, and 10 of 19 patients were classified as belonging to an MDRO pseudo-outbreak. Conclusions: Surveillance of bronchoscope-derived clinical culture data was important for early detection of this outbreak, and whole- genome sequencing was important for the confirmation of findings. Visualization of bronchoscope lumens to confirm integrity should be a critical component of device reprocessing.
(Received 11 June 2018; accepted 24 September 2018; electronically published 19 November 2018)
Millions of endoscopic procedures are performed in US hospitals every year.1 Over the last decade, reports have implicated endo- scopes as a source of infectious disease outbreaks and pseudo- outbreaks.2–6 Recently, an increasing number of US hospitals have reported multidrug-resistant (MDR) organism clusters linked to endoscopes.7–9 In November of 2014, a cluster of patients with bronchosco-
pically obtained clinical cultures positive for carbapenem-resistant Klebsiella pneumoniae (CR-KP) and gentamicin-resistant MDR Pseudomonas aeruginosa (MDR-PA) was identified in the medical intensive care unit (MICU) at University of Pittsburgh Medical Center-Presbyterian Hospital (UPMC-P), a 757-bed urban
Author for correspondence: Alison L. Galdys, 420 Delaware Street SE, MMC 250,
Minneapolis, MN 55455. E-mail:
galdys@umn.edu PREVIOUS PRESENTATION: These data were presented in part (abstract 7176) at the Society for Healthcare Epidemiology of America Annual Meeting onMay 14, 2015, in
Orlando, Florida. a Authors of equal contribution.
Cite this article: Galdys AL, et al. (2019). Bronchoscope-associated clusters of
multidrug-resistant Pseudomonas aeruginosa and carbapenem-resistant Klebsiella pneumoniae. Infection Control & Hospital Epidemiology 2019, 40, 40–46. doi: 10.1017/ ice.2018.263
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
teaching hospital in Pittsburgh, Pennsylvania. Each of the patients in this cluster had no prior history of isolation of CR-KP or MDR-PA from clinical cultures. An epidemiologic investigation was conducted under the auspices of the infection prevention department’s role in patient safety to identify a common infection source.
Methods Epidemiologic investigation
In November 2014, CR-KP and MDR-PA isolates were identified in a bronchoalveolar lavage (BAL) specimen from a MICU patient without recent health care. This finding was unexpected. Over the next 3 weeks, clinical cultures taken either during or after a bronchoscopy procedure from an additional 9 MICU patients grew CR-KP and/or MDR-PA, triggering an epidemio- logic investigation. House-wide CR-KP incident isolates were identified, and potential commonalities were investigated. Ana- lysis by patient care area identified the 32-bed MICU as accounting for 17 of 21 (81%) of the newly identified CR KP
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