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

Published online by Cambridge University Press:  27 December 2023

Gili Regev-Yochay*
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Ili Margalit
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Gillian Smollan
Microbiology laboratory, Sheba Medical Center, Ramat-Gan, Israel
Rotem Rapaport
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Ilana Tal
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel
William P. Hanage
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
Nani Pinas Zade
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel
Hanaa Jaber
Infection Prevention & Control Unit, Sheba Medical Center, Ramat Gan, Israel
Bradford P. Taylor
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
You Che
Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
Galia Rahav
Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Infectious Disease Unit, Sheba Medical Center, Ramat-Gan, Israel
Eyal Zimlichman
Sheba Medical Center Management, Ramat-Gan, Israel
Nati Keller
Microbiology laboratory, Sheba Medical Center, Ramat-Gan, Israel Ariel University, Ari’el, Samaria
Corresponding author: Gili Regev-Yochay; Email:



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


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.


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.


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.

Original Article
© The Author(s), 2024. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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