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Sink traps in ICU harbor antibiotic-resistant bacteria
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Researchers in Israel said they contained a prolonged outbreak of carbapenemase-producing Enterobacteriaceae, or CPE, in a hospital ICU after discovering that sink traps were the source of repeated infections in patients.
The outbreak included 32 cases of CPE — mostly caused by OXA-48-producing Serratia marcescens — occurring from January 2016 to May 2017 at the Sheba Medical Center near Tel Aviv, researchers reported in Infection Control & Hospital Epidemiology. Three patients died.
“Carbapenemase-producing Enterobacteriaceae can produce a broad spectrum of infections [and are] associated with high mortality and very limited therapeutic options,” Gili Regev-Yochay, MD, MS, director of the hospital’s infection prevention and control unit, and colleagues wrote. “Particularly troubling are Serratia and Proteus, which are innately resistant to colistin, one of the last-resort therapeutic options. Patient-to-patient cross transmission is the main mechanism of spread of multidrug-resistant (MDR) Enterobacteriaceae nosocomial outbreaks.”
“Environmental transmission has been considered to have a negligible role in CPE outbreaks and CPE transmission, while patient-to-patient transmission via the hands of health care workers has been considered a major route of transmission,” they wrote. “However, the hospital water environment is increasingly recognized as a potential source of carbapenem-resistant organism (CRO) transmission.”
Researchers performed active CPE surveillance in the ICU, including twice-weekly rectal screening of all patients. They defined an outbreak case as a patient found to have an OXA-48 CPE infection more than 72 hours after admission.
According to Regev-Yochay and colleagues, 81% of the infections were caused by S. marcescens and a single clone was the cause of all but the first two cases. Their investigation found that the common link between all cases was the use of relatively large amounts of tap water. They discovered the outbreak clone in two sink outlets and 16 sink traps.
To contain the outbreak, during which 11 patients developed clinical infections and three deaths were directly attributed to infection, various sink decontamination efforts were undertaken, but Regev-Yochay and colleagues reported that they only eliminated the bacteria from sink drains temporarily. They engaged ICU teams in education interventions, leading to a high adherence to sink contamination prevention guidelines, according to the study. No additional cases were detected for 12 months.
Researchers in the United States recently tested a novel plastic drain cover and found that it was a simple way to reduce the dissemination of pathogens from contaminated sinks. The researchers said addressing sink contamination is a serious challenge because sink drains provide an ideal environment for pathogen colonization, biofilm formation and are difficult to clean and disinfect. The drain cover prevents running water from splashing pathogens up from the drain, into the sink and onto the counter.
“Currently, there seems to be no complete solution for preventing CRO transmission from sink traps to patients. Patient room architecture and sink designs should be carefully conceived,” Regev-Yochay and colleagues wrote. “Eliminating sinks in ICU rooms has been suggested, but this would raise many difficulties because hand-washing is frequently necessary, even in the era of alcohol-based hand hygiene, mainly when handling patients with [Clostridium difficile] infections. A technical plumbing solution should be sought. Meanwhile health care teams should be educated to understand the important role of this hidden reservoir: the sink trap.” – by Caitlyn Stulpin
Disclosures: The authors report no relevant financial disclosures.
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