Hostname: page-component-5b777bbd6c-5mwv9 Total loading time: 0 Render date: 2025-06-22T00:58:30.134Z Has data issue: false hasContentIssue false
  • English
  • Français

Sink-traps are a major source for carbapenemase-producing Enterobacteriaceae transmission

Published online by Cambridge University Press:  27 December 2023

Gili Regev-Yochay ,
Ili Margalit Open the ORCID record for Ili Margalit [Opens in a new window] ,
Gillian Smollan ,
Rotem Rapaport ,
Ilana Tal ,
William P. Hanage ,
Nani Pinas Zade ,
Hanaa Jaber ,
Bradford P. Taylor  and
You Che
...Show all authors
Gili Regev-Yochay*
Affiliation:
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Ili Margalit
Affiliation:
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Gillian Smollan
Affiliation:
Microbiology laboratory, Sheba Medical Center, Ramat-Gan, Israel
Rotem Rapaport
Affiliation:
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Ilana Tal
Affiliation:
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel
William P. Hanage
Affiliation:
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
Nani Pinas Zade
Affiliation:
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel
Hanaa Jaber
Affiliation:
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel
Bradford P. Taylor
Affiliation:
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
You Che
Affiliation:
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
Galia Rahav
Affiliation:
Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Infectious Disease Unit, Sheba Medical Center, Ramat-Gan, Israel
Eyal Zimlichman
Affiliation:
Sheba Medical Center Management, Ramat-Gan, Israel
Nati Keller
Affiliation:
Microbiology laboratory, Sheba Medical Center, Ramat-Gan, Israel Ariel University, Ari’el, Samaria
*
Corresponding author: Gili Regev-Yochay; Email: Gili.regev@sheba.health.gov.il
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

We studied the extent of carbapenemase-producing Enterobacteriaceae (CPE) sink contamination and transmission to patients in a nonoutbreak setting.

Methods:

During 2017–2019, 592 patient-room sinks were sampled in 34 departments. Patient weekly rectal swab CPE surveillance was universally performed. Repeated sink sampling was conducted in 9 departments. Isolates from patients and sinks were characterized using pulsed-field gel electrophoresis (PFGE), and pairs of high resemblance were sequenced by Oxford Nanopore and Illumina. Hybrid assembly was used to fully assemble plasmids, which are shared between paired isolates.

Results:

In total, 144 (24%) of 592 CPE-contaminated sinks were detected in 25 of 34 departments. Repeated sampling (n = 7,123) revealed that 52%–100% were contaminated at least once during the sampling period. Persistent contamination for >1 year by a dominant strain was common. During the study period, 318 patients acquired CPE. The most common species were Klebsiella pneumoniae, Escherichia coli, and Enterobacter spp. In 127 (40%) patients, a contaminated sink was the suspected source of CPE acquisition. For 20 cases with an identical sink-patient strain, temporal relation suggested sink-to-patient transmission. Hybrid assembly of specific sink-patient isolates revealed that shared plasmids were structurally identical, and SNP differences between shared pairs, along with signatures for potential recombination events, suggests recent sharing of the plasmids.

Conclusions:

CPE-contaminated sinks are an important source of transmission to patients. Although traditionally person-to-person transmission has been considered the main route of CPE transmission, these data suggest a change in paradigm that may influence strategies of preventing CPE dissemination.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 45 , Issue 3 , March 2024 , pp. 284 - 291
Check for updates
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Antibiotic resistance threats in the United States, 2019. Centers for Disease Control and Prevention website. https://www.cdc.gov/drugresistance/biggest-threats.html. Published 2019. Accessed December 8, 2023.Google Scholar
Tzouvelekis, LS, Markogiannakis, A, Piperaki, E, Souli, M, Daikos, GL. Treating infections caused by carbapenemase-producing Enterobacteriaceae. Clin Microbiol Infect 2014;20:862–872.CrossRefGoogle ScholarPubMed
Grundmann, H, Glasner, C, Albiger, B, et al. Occurrence of carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in the European survey of carbapenemase-producing Enterobacteriaceae (EuSCAPE): a prospective, multinational study. Lancet Infect Dis 2017;17:153–163.CrossRefGoogle ScholarPubMed
Schwaber, MJ, Carmeli, Y. An ongoing national intervention to contain the spread of carbapenem-resistant Enterobacteriaceae. Clin Infect Dis 2014;58:697–703.CrossRefGoogle ScholarPubMed
Regev-Yochay, G, Smollan, G, Tal, I, et al. Sink traps as the source of transmission of OXA-48–producing Serratia marcescens in an intensive care unit. Infect Control Hosp Epidemiol 2018;39:1307–1315.CrossRefGoogle Scholar
Nordmann, P, Poirel, L. The difficult-to-control spread of carbapenemase producers among Enterobacteriaceae worldwide. Clin Microbiol Infect 2014;20:821–830.CrossRefGoogle ScholarPubMed
Nordmann, P, Cuzon, G, Naas, T. The real threat of Klebsiella pneumoniae carbapenemase-producing bacteria. Lancet Infect Dis 2009;9:228–236.CrossRefGoogle ScholarPubMed
Goren, MG, Chmelnitsky, I, Carmeli, Y, Navon-Venezia, S. Plasmid-encoded OXA-48 carbapenemase in Escherichia coli from Israel. J Antimicrob Chemother 2011;66:672–673.CrossRefGoogle ScholarPubMed
Lerner, A, Solter, E, Rachi, E, et al. Detection and characterization of carbapenemase-producing Enterobacteriaceae in wounded Syrian patients admitted to hospitals in northern Israel. Eur J Clin Microbiol Infect Dis 2016;35:149–154.CrossRefGoogle ScholarPubMed
Kassem, DF, Hoffmann, Y, Shahar, N, et al. Multidrug-resistant pathogens in hospitalized Syrian children. Emerg Infect Dis 2017;23:166–168.CrossRefGoogle ScholarPubMed
Friedman, ND, Carmeli, Y, Walton, AL, Schwaber, MJ. Carbapenem-resistant Enterobacteriaceae: a strategic roadmap for infection control. Infect Control Hosp Epidemiol 2017;38:580–594.CrossRefGoogle ScholarPubMed
Kizny Gordon, AE, Mathers, AJ, Cheong, EYL, et al. The hospital water environment as a reservoir for carbapenem-resistant organisms causing hospital-acquired infections—a systematic review of the literature. Clin Infect Dis 2017;64:1435–1444.CrossRefGoogle ScholarPubMed
Fernando, SA, Phan, T, Parker, C, Cai, T, Gottlieb, T. Increased detection of carbapenemase-producing Enterobacteriaceae on post-clean sampling of a burns unit’s wet surfaces. J Hosp Infect 2019;101:179–182.CrossRefGoogle ScholarPubMed
Weingarten, RA, Johnson, RC, Conlan, S, et al. Genomic analysis of hospital plumbing reveals diverse reservoir of bacterial plasmids conferring carbapenem resistance. mBio 2018;9:e02011–17.CrossRefGoogle ScholarPubMed
Mathers, AJ, Vegesana, K, German Mesner, I, et al. Intensive care unit wastewater interventions to prevent transmission of multispecies Klebsiella pneumoniae carbapenemase-producing organisms. Clin Infect Dis 2018;67:171–178.CrossRefGoogle ScholarPubMed
Hopman, J, Meijer, C, Kenters, N, et al. Risk assessment after a severe hospital-acquired infection associated with carbapenemase-producing Pseudomonas aeruginosa . JAMA Netw Open 2019;2:e187665.CrossRefGoogle ScholarPubMed
Hota, S, Hirji, Z, Stockton, K, et al. Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design. Infect Control Hosp Epidemiol 2009;30:25–33.CrossRefGoogle ScholarPubMed
Kotay, SM, Donlan, RM, Ganim, C, Barry, K, Christensen, BE, Mathers, AJ. Droplet- rather than aerosol-mediated dispersion is the primary mechanism of bacterial transmission from contaminated hand-washing sink traps. Appl Environ Microbiol 2019;85:e01997–18.CrossRefGoogle ScholarPubMed
Kotay, S, Chai, W, Guilford, W, Barry, K, Mathers, AJ. Spread from the sink to the patient: in situ study using green fluorescent protein (GFP)-expressing Escherichia coli to model bacterial dispersion from hand-washing sink-trap reservoirs. Appl Environ Microbiol 2017;83:e03327–16.CrossRefGoogle Scholar
Potter, RF, Wallace, MA, McMullen, AR, et al. blaIMP-27 on transferable plasmids in Proteus mirabilis and Providencia rettgeri . Clin Microbiol Infect 2018;24:1019.e5–1019.e8.CrossRefGoogle Scholar
Martin, J, Phan, HTT, Findlay, J, et al. Covert dissemination of carbapenemase-producing Klebsiella pneumoniae (KPC) in a successfully controlled outbreak: long- and short-read whole-genome sequencing demonstrate multiple genetic modes of transmission. J Antimicrob Chemother 2017;72:3025–3034.CrossRefGoogle Scholar
Di Luca, MC, Sørum, V, Starikova, I, et al. Low biological cost of carbapenemase-encoding plasmids following transfer from Klebsiella pneumoniae to Escherichia coli . J Antimicrob Chemother 2017;72:85–89.CrossRefGoogle ScholarPubMed
Decraene, V, Phan, HTT, George, R, et al. A large, refractory nosocomial outbreak of Klebsiella pneumoniae carbapenemase-producing Escherichia coli demonstrates carbapenemase gene outbreaks involving sink sites require novel approaches to infection control. Antimicrob Agents Chemother 2018;62:e01689–18.CrossRefGoogle ScholarPubMed
Carling, PC. Wastewater drains: epidemiology and interventions in 23 carbapenem-resistant organism outbreaks. Infect Control Hosp Epidemiol 2018;39:972–979.CrossRefGoogle ScholarPubMed
La Forgia, C, Franke, J, Hacek, DM, Thomson, RB, Robicsek, A, Peterson, LR. Management of a multidrug-resistant Acinetobacter baumannii outbreak in an intensive care unit using novel environmental disinfection: a 38-month report. Am J Infect Control 2010;38:259–263.CrossRefGoogle Scholar
Breathnach, AS, Cubbon, MD, Karunaharan, RN, Pope, CF, Planche, TD. Multidrug-resistant Pseudomonas aeruginosa outbreaks in two hospitals: association with contaminated hospital wastewater systems. J Hosp Infect 2012;82:19–24.CrossRefGoogle Scholar
Vergara-López, S, Domínguez, MC, Conejo, MC, Pascual, Á, Rodríguez-Baño, J. Wastewater drainage system as an occult reservoir in a protracted clonal outbreak due to metallo-β-lactamase–producing Klebsiella oxytoca . Clin Microbiol Infect 2013;19:E490–E498.CrossRefGoogle Scholar
Jones, LD, Mana, TSC, Cadnum, JL, et al. Effectiveness of foam disinfectants in reducing sink-drain gram-negative bacterial colonization. Infect Control Hosp Epidemiol 2020;41:280–285.CrossRefGoogle ScholarPubMed
Ramos-Castaneda, JA, Faron, ML, Hyke, J, et al. How frequently should sink drains be disinfected? Infect Control Hosp Epidemiol 2020;41:358–360.CrossRefGoogle ScholarPubMed
Buchan, BW, Arvan, JA, Graham, MB, et al. Effectiveness of a hydrogen peroxide foam against bleach for the disinfection of sink drains. Infect Control Hosp Epidemiol 2019;40:724–726.CrossRefGoogle ScholarPubMed
Supplementary material: File

Regev-Yochay et al. supplementary material

Regev-Yochay et al. supplementary material

Download Regev-Yochay et al. supplementary material(File)
File 1.6 MB