Replacing contaminated sinks did not stop drug-resistant outbreak in pediatric ward

April 15, 2024

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Key takeaways:

• Replacing sinks in a pediatric ward did not end an outbreak of drug-resistant bacteria but core infection prevention measures did.
• Bacteria may have been transmitted between adjoining rooms via sink drains.

Replacing contaminated sinks did not end an outbreak of multidrug-resistant bacteria in a Japanese pediatric ward but other infection prevention measures did, such as forbidding mouth-washing using sink water, researchers reported.

Over the years, numerous reports have detailed the spread of multidrug-resistant organisms via hospital sinks, sink drains and plumbing, and the potential for bacteria to colonize patients and other areas.

A combination of infection prevention steps helped stop a monthslong CPE outbreak in a pediatric ward in Tokyo. Image: Adobe Stock

Facilities have even replaced parts of plumbing systems to stop outbreaks, to no avail. One hospital replaced sink drains and traps to stop an outbreak in its ICU and was hit with a new, different outbreak.

The new study, which was published in the American Journal of Infection Control, describes a roughly 7-month multispecies outbreak of carbapenemase-producing Enterobacterales (CPE) in a pediatric ward in Tokyo in 2017. The outbreak included strains of Klebsiella pneumoniae and Escherichia coli, among other bacteria.

The outbreak occurred at Toho University Omori Medical Center, a 916-bed academic medical center with 55 pediatric inpatient beds. According to the study, the first infection was detected in a 1-year-old male patient hospitalized with cardiac disease for 4 months. The patient was diagnosed with Klebsiella variicola in June 2016.

A second infection — with Klebsiella quasipneumoniae containing the same resistance gene as the first patient — was detected 9 months later in March 2017 in a 15-year-old boy. Within 20 days, two more patients were diagnosed based on urine samples and the hospital declared an outbreak in April 2017. By October 2017, when the outbreak was declared over, there had been a total of 19 patients who tested positive for CPE.

The hospital conducted an epidemiological investigation to determine the route of transmission between patients, which included sampling patient room and implementing active surveillance for all pediatric stool samples submitted for lab testing.

The investigation detected CPE in nine sinks in the hospital’s pediatric ward, including in six hospital rooms, a nurse center, a waste room and an ice machine. Of 16 patient rooms, seven had a history of patients with CPE during the surveillance period and six of the seven rooms had CPE-positive sinks.

The investigation also found evidence that pathogens were transmitted between sinks in adjoining rooms through the drains and connected plumbing.

An infection control team reviewed routine infection prevention practices — including hand hygiene, use of gowns and gloves and antimicrobial use — and disinfected all sinks and related areas. The bacteria proved difficult to eradicate, however, leading the hospital to replace all sinks in the pediatric ward in June 2017, and to disinfect the new sinks with hydrogen peroxide.

Still, CPE contamination persisted until the infection prevention team recommended several additional measures that eventually stopped the outbreak:

• hand disinfection after using a sink;
• restricting items placed near sinks;
• using disposable tools to clean sinks;
• disinfecting all sinks with hydrogen peroxide;
• prohibiting mouth-washing using sink water;
• disinfection and drying procedures for water-exposed items;
• staff re-education on hand hygiene and infection control practices; and
• accepting of external guidance and evaluation

“After months of intense infection control protocols, we were at last able to declare an end to this outbreak,” Sadako Yoshizawa, MD, PhD, deputy director of the clinical laboratory at Toho University Omori Medical Center, said in a press release. “Our experience highlights the importance of focusing on sinks and other water-related areas in hospital wards, as these are critical for CPE transmission and, therefore, major fronts in the fight against antibiotic resistance,” Yoshizawa said.

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