Outbreak investigation of Pseudomonas aeruginosa infections in a neonatal intensive care unit

Extensively Drug-Resistant Pseudomonas aeruginosa Outbreak Associated With Artificial Tears

BACKGROUND

Carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) are extensively drug-resistant bacteria. We investigated the source of a multistate CP-CRPA outbreak.

METHODS

Cases were defined as a US patient's first isolation of P. aeruginosa sequence type 1203 with carbapenemase gene blaVIM-80 and cephalosporinase gene blaGES-9 from any specimen source collected and reported to the Centers for Disease Control and Prevention during 1 January 2022-15 May 2023. We conducted a 1:1 matched case-control study at the post-acute care facility with the most cases, assessed exposures associated with case status for all case-patients, and tested products for bacterial contamination.

RESULTS

We identified 81 case-patients from 18 states, 27 of whom were identified through surveillance cultures. Four (7%) of 54 case-patients with clinical cultures died within 30 days of culture collection, and 4 (22%) of 18 with eye infections underwent enucleation. In the case-control study, case-patients had increased odds of receiving artificial tears versus controls (crude matched OR, 5.0; 95% CI, 1.1-22.8). Overall, artificial tears use was reported by 61 (87%) of 70 case-patients with information; 43 (77%) of 56 case-patients with brand information reported use of Brand A, an imported, preservative-free, over-the-counter (OTC) product. Bacteria isolated from opened and unopened bottles of Brand A were genetically related to patient isolates. Food and Drug Administration inspection of the manufacturing plant identified likely sources of contamination.

CONCLUSIONS

A manufactured medical product serving as the vehicle for carbapenemase-producing organisms is unprecedented in the United States. The clinical impacts from this outbreak underscore the need for improved requirements for US OTC product importers.

Study of Combined Effect of Bacteriophage vB3530 and Chlorhexidine on the Inactivation of Pseudomonas aeruginosa

BACKGROUND

Chlorhexidine (CHG) is a disinfectant commonly used in hospitals. However, it has been reported that the excessive use of CHG can cause resistance in bacteria to this agent and even to other clinical antibiotics. Therefore, new methods are needed to alleviate the development of CHG tolerance and reduce its dosage. This study aimed to explore the synergistic effects of CHG in combination with bacteriophage against CHG-tolerant Pseudomonas aeruginosa (P. aeruginosa) and provide ideas for optimizing disinfection strategies in clinical environments as well as for the efficient use of disinfectants.

METHODS

The CHG-tolerant P. aeruginosa strains were isolated from the First Affiliated Hospital of Wenzhou Medical University in China. The bacteriophage vB3530 was isolated from the sewage inlet of the hospital, and its genome was sequenced. Time-killing curve was used to determine the antibacterial effects of vB3530 and chlorohexidine gluconate (CHG). The phage sensitivity to 16 CHG-tolerant P. aeruginosa strains and PAO1 strain was detected using plaque assay. The emergence rate of resistant bacterial strains was detected to determine the development of phage-resistant and CHG-tolerant strains. Finally, the disinfection effects of the disinfectant and phage combination on the surface of the medical devices were preliminarily evaluated.

RESULTS

The results showed that (1) CHG combined with bacteriophage vB3530 significantly inhibited the growth of CHG-resistant P. aeruginosa and reduced the bacterial colony forming units (CFUs) after 24 h. (2) The combination of CHG and bacteriophage inhibited the emergence of phage-resistant and CHG-tolerant strains. (3) The combination of CHG and bacteriophage significantly reduced the bacterial load on the surface of medical devices.

CONCLUSIONS

In this study, the combination of bacteriophage vB3530 and CHG presented a combined inactivation effect to CHG-tolerant P. aeruginosa and reduced the emergence of strains resistant to CHG and phage. This study demonstrated the potential of bacteriophage as adjuvants to traditional disinfectants. The use of bacteriophage in combination with commercial disinfectants might be a promising method for controlling the spread of bacteria in hospitals.

Intensive care unit sinks are persistently colonized with multidrug resistant bacteria and mobilizable, resistance-conferring plasmids

Contamination of hospital sinks with microbial pathogens presents a serious potential threat to patients, but our understanding of sink colonization dynamics is largely based on infection outbreaks. Here, we investigate the colonization patterns of multidrug-resistant organisms (MDROs) in intensive care unit sinks and water from two hospitals in the USA and Pakistan collected over 27 months of prospective sampling. Using culture-based methods, we recovered 822 bacterial isolates representing 104 unique species and genomospecies. Genomic analyses revealed long-term colonization by Pseudomonas spp. and Serratia marcescens strains across multiple rooms. Nanopore sequencing uncovered examples of long-term persistence of resistance-conferring plasmids in unrelated hosts. These data indicate that antibiotic resistance (AR) in Pseudomonas spp. is maintained both by strain colonization and horizontal gene transfer (HGT), while HGT maintains AR within Acinetobacter spp. and Enterobacterales, independent of colonization. These results emphasize the importance of proactive, genomic-focused surveillance of built environments to mitigate MDRO spread. IMPORTANCE Hospital sinks are frequently linked to outbreaks of antibiotic-resistant bacteria. Here, we used whole-genome sequencing to track the long-term colonization patterns in intensive care unit (ICU) sinks and water from two hospitals in the USA and Pakistan collected over 27 months of prospective sampling. We analyzed 822 bacterial genomes, representing over 100 different species. We identified long-term contamination by opportunistic pathogens, as well as transient appearance of other common pathogens. We found that bacteria recovered from the ICU had more antibiotic resistance genes (ARGs) in their genomes compared to matched community spaces. We also found that many of these ARGs are harbored on mobilizable plasmids, which were found shared in the genomes of unrelated bacteria. Overall, this study provides an in-depth view of contamination patterns for common nosocomial pathogens and identifies specific targets for surveillance.

Influence of Temperature on Growth of Four Different Opportunistic Pathogens in Drinking Water Biofilms

High drinking water temperatures occur due to climate change and could enhance the growth of opportunistic pathogens in drinking water systems. We investigated the influence of drinking water temperatures on the growth of Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Mycobacterium kansasii and Aspergillus fumigatus in drinking water biofilms with an autochthonous microflora. Our results reveal that the growth of P. aeruginosa and S. maltophilia in the biofilm already occurred at 15.0 °C, whereas M. kansasii and A. fumigatus were able to grow when temperatures were above 20.0 °C and 25.0 °C, respectively. Moreover, the maximum growth yield of P. aeruginosa, M. kansasii and A. fumigatus increased with increasing temperatures up to 30 °C, whereas an effect of temperature on the yield of S. maltophilia could not be established. In contrast, the maximum ATP concentration of the biofilm decreased with increasing temperatures. We conclude from these results that high drinking water temperatures caused by, e.g., climate change can result in high numbers of P. aeruginosa, M. kansasii and A. fumigatus in drinking water systems, which poses a possible risk to public health. Consequently, it is recommended for countries with a more moderate climate to use or maintain a drinking water maximum standard temperature of 25 °C.

Outbreak investigations after identifying carbapenem-resistant Pseudomonas aeruginosa: a systematic review

BACKGROUND

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) are a serious cause of healthcare-associated infections. Part of the infection prevention and control measures are outbreak investigations (OI) of patients, healthcare workers (HCW), and the environment after identifying a CRPA in order to identify carriers and environmental reservoirs, so that targeted actions can be taken to prevent further transmission. However, little is known on when and how to perform such OI. Therefore, this systematic review aims to summarize OI performed after detection of CRPA in the endemic and epidemic hospital setting.

MAIN TEXT

Articles related to our research question were identified through a literature research in multiple databases (Embase, Medline Ovid, Cochrane, Scopus, Cinahl, Web of Science, and Google Scholar) until January 12, 2022 (Prospero registration number CRD42020194165). Hundred-twenty-six studies were included. In both the endemic and the epidemic setting, a median number of two out of seven predefined components of OI were identified. In the endemic setting, the most frequent component of OI was screening of the environment (28 studies, 62.2%). In the epidemic setting, screening of the environment (72 studies, 88.9%), and screening of patients during hospitalization (30 studies, 37%) were most frequently performed. Only 19 out of 126 studies (15.1%) reported screening of contact patients, and 37 studies reported screening of healthcare workers (HCW, 29.4%).

CONCLUSION

Due to probable underreporting of OI in the literature, the available evidence for the usefulness of the individual components of OI is scarce. This could lead to inhomogeneous performance of OI after detection of CRPA in the healthcare setting, and with this, potential under- or overscreening. While we could show evidence for the usefulness for environmental screening in order to identify the mode of transmission, evidence for HCW screening is scarce and might not lead to the identification of modes of transmission. Further studies are needed to better understand CI in different settings and, finally, develop guidance on when and how to best perform OI.

A comparison of bacterial colonization between nasogastric and orogastric enteral feeding tubes in infants in the neonatal intensive care unit

OBJECTIVE

Feeding tubes harbor microbial contaminants; studies to date have not explored differences between orogastric (OG) and nasogastric (NG) tube biofilms. We sought to extend a previous analysis by comparing bacterial colonization by location (OG v NG) and by evaluating clinical factors that may affect tube bacterial populations.

STUDY DESIGN

The pharyngeal segments of 41 infant feeding tubes (14 OG and 27 NG) from 41 infants were analyzed by next generation 16 S rRNA sequencing on the MiSeq platform.

RESULTS

At the phylum level, Proteobacteria had the highest relative abundance of both OG and NG tubes. At the genus/species level, nine taxa differed significantly between OG and NG tubes. Alpha and beta diversity analyses showed significant differences between OG and NG tubes with relatively little contribution from clinical factors.

CONCLUSION

The route of feeding tube insertion (oral vs nasal) had a greater impact on bacterial colonization than the assessed clinical factors.

Epidemiological investigation of Pseudomonas aeruginosa isolates including Multidrug-Resistant serogroup O12 isolates, by use of a rapid and simplified Multiple-Locus Variable-Number of Tandem Repeats Analysis and Whole Genome Sequencing

BACKGROUND

Clustered cases of Pseudomonas aeruginosa infection in immunocompromised patients' wards require rapid characterization of a potential epidemic to guide investigations and identify the potential source of contamination.

AIM

To design and evaluate a rapid and simple typing method for P. aeruginosa in comparison to whole genome sequencing (WGS).

METHODS

We designed and used a simplified PCR based on multiple locus tandem variable number analysis (MLVA) to investigate cases of P. aeruginosa infection and colonization in a paediatric haematology department. The method was compared to WGS by using Illumina method.

FINDINGS

On the 17 isolates recovered from 15 children (8 from blood cultures, 3 from urinary tract infections, 1 from sputum and 5 stool isolates) MLVA distinguished 10 different profiles and 7 isolates from 6 children shared the same profile. Analysis by WGS revealed that these 7 isolates belonged to sequence type ST111 and serotype O12 and permitted to further distinguish at least 3 different genotypes among them. Five environmental strains had 3 MLVA profiles, one shared with a clinical isolate but WGS excluded any relationship.

CONCLUSION

The simplified and inexpensive MLVA method permitted to exclude, in less than five hours, most of unrelated isolates and to focus investigations on a small number of cases while WGS, taking several days of work, drew definitive conclusions concerning the outbreak and the genetic relationships of the ST111 isolates circulating in the department. We conclude that sequential use of both methods is the optimal strategy to investigate grouped cases of P. aeruginosa infections.

Antibiotic-resistant organisms establish reservoirs in new hospital built environments and are related to patient blood infection isolates

Background

Healthcare-associated infections due to antibiotic-resistant organisms pose an acute and rising threat to critically ill and immunocompromised patients. To evaluate reservoirs of antibiotic-resistant organisms as a source of transmission to patients, we interrogated isolates from environmental surfaces, patient feces, and patient blood infections from an established and a newly built intensive care unit.

Methods

We used selective culture to recover 829 antibiotic-resistant organisms from 1594 environmental and 72 patient fecal samples, in addition to 81 isolates from blood cultures. We conducted antibiotic susceptibility testing and short- and long-read whole genome sequencing on recovered isolates.

Results

Antibiotic-resistant organism burden is highest in sink drains compared to other surfaces. Pseudomonas aeruginosa is the most frequently cultured organism from surfaces in both intensive care units. From whole genome sequencing, different lineages of P. aeruginosa dominate in each unit; one P. aeruginosa lineage of ST1894 is found in multiple sink drains in the new intensive care unit and 3.7% of blood isolates analyzed, suggesting movement of this clone between the environment and patients.

Conclusions

These results highlight antibiotic-resistant organism reservoirs in hospital built environments as an important target for infection prevention in hospitalized patients.

Enhancement of photodynamic bactericidal activity of curcumin against Pseudomonas Aeruginosa using polymyxin B

BACKGROUND

Pseudomonas aeruginosa (P. aeruginosa) is an emerging opportunistic pathogen, which can cause bacterial skin diseases such as green nail syndrome, interdigital infections and folliculitis. Curcumin-mediated antimicrobial photodynamic therapy (aPDT) has been demonstrated as a promising therapeutic option for the treatment of skin infection though its inactivation of gram-negative bacteria such as P. aeruginosa.

MATERIALS AND METHODS

In the present study, we examined the adjuvant effect of polymyxin B on the antibacterial activity of curcumin-mediated aPDT against P. aeruginosa. P. aeruginosa was treated with curcumin in the presence of 0.1-0.5 mg/L polymyxin B and irradiated by blue LED light (10 J/cm²). Bacterial cultures treated with curcumin alone served as controls. Colony forming units (CFU) were counted and the viability of P. aeruginosa was calculated after aPDT treatment. The possible underlying mechanisms for the enhanced killing effects were also explored.

RESULTS

The killing effects of curcumin-mediated aPDT against P. aeruginosa was significantly enhanced by polymyxin B (over 2-log reductions). Moreover, it was also observed that addition of polymyxin B in the curcumin-mediated aPDT led to the apparent bacterial membrane damage with increased leakage of cytoplasmic contents and extensive DNA and protein degradation.

DISCUSSION

The photodynamic action of curcumin against P. aeruginosa could be significantly enhanced by the FDA-approved drug polymyxin B. Our results highlight the potential of introducing polymyxin B to enhance the effects of aPDT treatment against gram-negative skin infections, in particular, P. aeruginosa.

Phage Biocontrol of Pseudomonas aeruginosa in Water

Bacteriophage control of harmful or pathogenic bacteria has aroused growing interest, largely due to the rise of antibiotic resistance. The objective of this study was to test phages as potential agents for the biocontrol of an opportunistic pathogen Pseudomonas aeruginosa in water. Two P. aeruginosa bacteriophages (vB_PaeM_V523 and vB_PaeM_V524) were isolated from wastewater and characterized physically and functionally. Genomic and morphological characterization showed that both were myoviruses within the Pbunavirus genus. Both had a similar latent period (50-55 min) and burst size (124-134 PFU/infected cell), whereas there was variation in the host range. In addition to these environmental phages, a commercial Pseudomonas phage, JG003 (DSM 19870), was also used in the biocontrol experiments. The biocontrol potential of the three phages in water was tested separately and together as a cocktail against two P. aeruginosa strains; PAO1 and the environmental strain 17V1507. With PAO1, all phages initially reduced the numbers of the bacterial host, with phage V523 being the most efficient (>2.4 log10 reduction). For the environmental P. aeruginosa strain (17V1507), only the phage JG003 caused a reduction (1.2 log10) compared to the control. The cocktail of three phages showed a slightly higher decrease in the level of the hosts compared to the use of individual phages. Although no synergistic effect was observed in the host reduction with the use of the phage cocktail, the cocktail-treated hosts did not appear to acquire resistance as rapidly as hosts treated with a single phage. The results of this study provide a significant step in the development of bacteriophage preparations for the control of pathogens and harmful microbes in water environments.

Outbreaks of healthcare-associated infections linked to water-containing hospital equipment: a literature review

BACKGROUND

Healthcare-associated infections (HAIs) are a significant cause of morbidity and mortality in hospitalized patients. Water in the environment can be a source of infection linked to outbreaks and environmental transmission in hospitals. Water safety in hospitals remains a challenge. This article has summarized available scientific literature to obtain an overview of outbreaks linked to water-containing hospital equipment and strategies to prevent such outbreaks.

METHODS

We made a list of water-containing hospital equipment and devices in which water is being used in a semi-closed circuit. A literature search was performed in PubMed with a search strategy containing the names of these medical devices and one or more of the following words: outbreak, environmental contamination, transmission, infection. For each medical device, we summarized the following information: the function of the medical device, causes of contamination, the described outbreaks and possible prevention strategies.

RESULTS

The following water-containing medical equipment  or devices were identified: heater-cooler units, hemodialysis equipment, neonatal incubators, dental unit waterlines, fluid warmers, nebulizers, water traps, water baths, blanketrol, scalp cooling, and thermic stimulators. Of the latter three, no literature could be found. Of all other devices, one or more outbreaks associated with these devices were reported in the literature.

CONCLUSIONS

The water reservoirs in water-containing medical devices can be a source of microbial growth and transmissions to patients, despite the semi-closed water circuit. Proper handling and proper cleaning and disinfection can help to reduce the microbial burden and, consequently, transmission to patients. However, these devices are often difficult to clean and disinfect because they cannot be adequately opened or disassembled, and the manufacturer's cleaning guidelines are often not feasible to execute. The development of equipment without water or fluid containers should be stimulated. Precise cleaning and disinfection guidelines and instructions are essential for instructing healthcare workers and hospital cleaning staff to prevent potential transmission to patients.

The role of the faucet's aerator kit for contamination of drinking water

Experimentally we demonstrated the possibility of retrograde contamination of aerator kits, independent of special design, with Pseudomonas aeruginosa. In a real life setting contamination of aerator kits with typical environmental and water organisms occurred, whether they were changed after 6 or 12 weeks, so we recommend a risk adjusted rather than schedule-based changing regimen in hospitals, eg, if potential retrograde contamination might be a relevant factor in rooms occupied by patients with multiresistant gram-negative organisms.