Infection Control & Hospital Epidemiology (2019), 40, 217–220 doi:10.1017/ice.2018.331


Concise Communication


A metallo-beta-lactamase producing Enterobacteriaceae outbreak from a contaminated tea dispenser at a children’s hospital in Japan


Kenta Ito MD1, Hitoshi Honda MD, PhD2, Makiko Yoshida PhD, MPH3, Kotaro Aoki PhD4, Yoshikazu Ishii PhD4,


Shigeko Miyokawa5 and Yuho Horikoshi MD1 1Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children’s Medical Center, Fuchu, Tokyo, Japan, 2Division of Infectious Diseases, Department of Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan, 3Department of Infection Control and Laboratory Diagnostics, Tohoku University Graduate School of Medicine, Sendai, Japan, 4Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan and 5Department of Nursing, Tokyo Metropolitan Children’s Medical Center, Fuchu, Tokyo, Japan. (Present affiliation: Department of General Pediatrics, Aichi Children’s Health and Medical Center, Ohbu, Aichi, Japan [K.I.].)


Abstract


An outbreak of metallo-β-lactamase (MBL) producing Klebsiella pneumoniae occurred at a children’s hospital in Japan. MBL-producing K. pneumoniae was detected in tea dispenser in the hospital, the use of which was associated with the acquisition of the MBL-producing Enterobacteriaceae. The outbreak ceased after use of the tea dispenser was banned.


(Received 4 September 2018; accepted 13 November 2018)


The emergence of carbapenemase-producing Enterobacteriaceae (CPE) is a public health threat requiring global action.1 Although CPE is still considered rare and constitutes<1% of the Enter- obacteriaceae isolated in Japan,2 the clinical impact of CPE infec- tions on morbidity and mortality are substantial; the mortality rate due to CPE sepsis among adult patients in Japan was reportedly as high as 40%.3


Healthcare-related outbreaks of metallo-β-lactamase (MBL)-


producing Enterobacteriaceae have been reported in various settings including pediatric wards and pediatric intensive care units.4 We experienced an outbreak ofMBL-producing Enterobacteriaceae lasting from May to December 2014 in a pediatric ward at Tokyo Metro- politan Children’sMedical Center.We report the subsequent outbreak investigation and the infection control measuresimplemented.


Methods


The MBL-producing Enterobacteriaceae outbreak occurred at a single, pediatric, joint cardiology and ophthalmologyward with 27 beds. Apart from this outbreak, a patient colonized by MBL-producing Enterobacteriaceae had been hospitalized in isolation in the same ward for a prolonged period. In May 2014, MBL-producing


Author for correspondence: Kenta Ito MD, 2-8-29 Musashi-dai Fuchu-shi, Tokyo,


Japan. E-mail: peaceplease1981@gmail.com Or Yuho Horikoshi MD, 2-8-29Musashi-dai Fuchu-shi, Tokyo, Japan. E-mail: yuho_horikoshi@tmhp.jp PREVIOUS PRESENTATION: These data were presented at IDWeek 2015, October


8, 2015, in San Diego, California, as the winning entry in the International Investigator Awards.


Cite this article: Ito K, et al. (2019). A metallo-beta-lactamase producing


Enterobacteriaceae outbreak from a contaminated tea dispenser at a children’shospitalin Japan. Infection Control & Hospital Epidemiology 2019, 40, 217–220. doi: 10.1017/ice.2018.331


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


Klebsiella pneumoniae was discovered incidentally while testing for Clostridium difficile in a stool culture of a patient with chronic diarrhea. The results of the test were negative for Clostridioides difficile. Shortly thereafter, MBL-producing Enterobacteriaceae were detected in 2 more patients in the same ward. Immediate active surveillance for the pathogen was implemented. Initial active surveillance by rectal swab identified 6 more patients colonized by the same pathogen. The unusually high occurrence of this strain confirmed an MBL-producing Enterobacteriaceae outbreak in the ward. The Ethics Committee of Tokyo Metro- politan Children’s Medical Center approved the study protocol (No. H26-108) Weekly active surveillance to detect MBL-producing Enter-


obacteriaceae was conducted for all patients in the ward without a previous history of colonization or infection due to MBL-producing Enterobacteriaceae.5 Rectal swab cultures were obtained from hospitalized patients once weekly. Rectal swabs were inoculated onto a cefpodoxime-containing


agar (ChromID ESBL SYSMEX, bioMerieux, Japan). The resulting blue or purple colonies were planted onto blood agar with a cefoxitin disc and boronic acid to inhibit the isolates from overproducing AmpC β-lactamase. The sodiummercaptoacetate (SMA) test (Eiken Chemical, Japan) was performed on these isolates to detect MBL-producing Enterobacteriaceae. Two discs containing ceftazidime with or without SMA were placed on Mueller-Hinton agar 4–5cm apart. The bacterial strain was diluted by saline to the 0.5 McFarland standard and placed on Mueller-Hinton agar. A difference>5mm in the growth inhibitory zone was considered evidence of the MBL-producing strain.6 We conducted the molecular biological analysis of the isolated MBL-producing Enterobacteriaceae (see Supplemental Materials online). To investigate possible contaminants in the immediate


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