title: Bad design, bad practices, bad bugs: frustrations in controlling an outbreak of Elizabethkingia meningoseptica in intensive care units.
abstract: BACKGROUND
  Elizabethkingia meningoseptica is a nosocomial-adapted Gram-negative bacillus intrinsically resistant to antibiotics commonly used in the intensive care setting. An outbreak investigation commenced when five patients developed E. meningoseptica infection in two intensive care units (ICUs).
  
  
  METHODS
  Analysis of laboratory data, case reviews, ICU workflows and extensive environmental sampling were undertaken. Molecular typing was performed using repetitive element palindromic polymerase chain reaction. Follow-up studies after interventions included environmental monitoring and a survey of staff compliance with interventions.
  
  
  RESULTS
  Laboratory data revealed increasing incidence of E. meningoseptica colonization or infection in ICU patients compared with preceding years. E. meningoseptica was cultured from 44% (35/79) of taps, but not from other sources. Hand hygiene sinks were used for disposal of patient secretions and rinsing re-usable patient care items. Sinks misused in this way were contaminated more often than sinks that were not misused (odds ratio 4.38, 95% confidence interval 1.68-11.39; P = 0.004). Molecular typing revealed that patient isolates had identical patterns to several isolates from hand hygiene taps. An urgent education programme was instituted to change these practices. Taps were cleaned systematically and aerators were changed. A temporary reduction in case numbers was achieved. Recolonization of taps was demonstrated on follow-up environmental screening, and cases recurred after two months. A survey revealed that 77.3% (163/213) of nursing staff still misused sinks due to time constraints or other problems adhering to the interventions.
  
  
  CONCLUSIONS
  Introduction of non-sanctioned practices due to suboptimal unit design may have unintentional consequences for ICU patients. Room design and staff workflows must be optimized for patient safety as lapses in procedure can inadvertently put patients at risk.
authors: Infection Control Team, National University Hospital, Singapore; Microbiology, Department of Laboratory Medicine, National University Hospital, Singapore.
authors: M N D
authors: MN
authors: Balm
authors: S
authors: S
authors: Salmon
authors: R
authors: R
authors: Jureen
authors: C
authors: C
authors: Teo
authors: R
authors: R
authors: Mahdi
authors: T
authors: T
authors: Seetoh
authors: J T W
authors: JT
authors: Teo
authors: R T P
authors: RT
authors: Lin
authors: D A
authors: DA
authors: Fisher
mesh_terms: D003422:Critical Care / Q000379:methods / Q000458:organization & administration; D004196:Disease Outbreaks; D004783:Environmental Microbiology; D041965:Flavobacteriaceae / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D045826:Flavobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology; D005838:Genotype; D006801:Humans; D017053:Infection Control / Q000379:methods*; D007362:Intensive Care Units; D017720:Molecular Epidemiology; D058889:Molecular Typing; D010362:Patients' Rooms / Q000458:organization & administration
keywords: Elizabethkingia meningoseptica; Gram-negative non-fermenter; Intensive care outbreak; Tap contamination