title: Multidrug-resistant Pseudomonas aeruginosa outbreaks in two hospitals: association with contaminated hospital waste-water systems.
abstract: BACKGROUND
  Multidrug-resistant Pseudomonas aeruginosa (MDR-P) expressing VIM-metallo-beta-lactamase is an emerging infection control problem. The source of many such infections is unclear, though there are reports of hospital outbreaks of P. aeruginosa related to environmental contamination, including tap water.
  
  
  OBJECTIVE
  We describe two outbreaks of MDR-P, sensitive only to colistin, in order to highlight the potential for hospital waste-water systems to harbour this organism.
  
  
  METHODS
  The outbreaks were investigated by a combination of descriptive epidemiology, inspection and microbiological sampling of the environment, and molecular strain typing.
  
  
  RESULTS
  The outbreaks occurred in two English hospitals; each involved a distinct genotype of MDR-P. One outbreak was hospital-wide, involving 85 patients, and the other was limited to four cases in one specialized medical unit. Extensive environmental sampling in each outbreak yielded MDR-P only from the waste-water systems. Inspection of the environment and estates records revealed many factors that may have contributed to contamination of clinical areas, including faulty sink, shower and toilet design, clean items stored near sluices, and frequent blockages and leaks from waste pipes. Blockages were due to paper towels, patient wipes, or improper use of bedpan macerators. Control measures included replacing sinks and toilets with easier-to-clean models less prone to splashback, educating staff to reduce blockages and inappropriate storage, reviewing cleaning protocols, and reducing shower flow rates to reduce flooding. These measures were followed by significant reductions in cases.
  
  
  CONCLUSIONS
  The outbreaks highlight the potential of hospital waste systems to act as a reservoir of MDR-P and other nosocomial pathogens.
authors: St George's Healthcare NHS Trust, London, UK. aodhan.breathnach@stgeorges.nhs.uk
authors: A S
authors: AS
authors: Breathnach
authors: M D
authors: MD
authors: Cubbon
authors: R N
authors: RN
authors: Karunaharan
authors: C F
authors: CF
authors: Pope
authors: T D
authors: TD
authors: Planche
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D004196:Disease Outbreaks; D024901:Drug Resistance, Multiple, Bacterial; D006761:Hospitals; D006801:Humans; D008826:Microbial Sensitivity Tests; D058889:Molecular Typing; D011552:Pseudomonas Infections / Q000453:epidemiology* / Q000382:microbiology; D011550:Pseudomonas aeruginosa / Q000145:classification / Q000187:drug effects* / Q000302:isolation & purification*; D062065:Wastewater / Q000382:microbiology*
chemical_list: D000900:Anti-Bacterial Agents; D062065:Wastewater