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Pseudomonas aeruginosa Outbreak in a Neonatal Intensive Care Unit Attributed to Hospital Tap Water

Published online by Cambridge University Press:  18 May 2017

Cara Bicking Kinsey*
Affiliation:
Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia
Samir Koirala
Affiliation:
Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia
Benjamin Solomon
Affiliation:
Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia
Jon Rosenberg
Affiliation:
Healthcare-Associated Infections Program, Center for Health Care Quality, California Department of Public Health, Richmond, California
Byron F. Robinson
Affiliation:
Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia
Antonio Neri
Affiliation:
Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia
Alison Laufer Halpin
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Matthew J. Arduino
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Heather Moulton-Meissner
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Judith Noble-Wang
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Nora Chea
Affiliation:
Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Carolyn V. Gould
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Address correspondence to Cara Bicking Kinsey, 625 Forster Street, Room 933, Harrisburg, PA 17120 (cbickingkinsey@gmail.com).

Abstract

OBJECTIVE

To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit.

DESIGN

Infection control assessment, environmental evaluation, and case-control study.

SETTING

Newly built community-based hospital, 28-bed neonatal intensive care unit.

PATIENTS

Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014.

METHODS

Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness.

RESULTS

In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16–∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75–37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39–30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms.

CONCLUSIONS

This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities.

Infect Control Hosp Epidemiol 2017;38:801–808

Type
Original Articles
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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