New environmental reservoir of CPE in hospitals

The incidence of multidrug-resistant carbapenemase-producing Enterobacteriaceae (CPE) is steadily increasing, and maximal infection control and prevention strategies should be implemented to limit their spread in health-care settings.1 WHO guidelines, published in 2017, recommend hand hygiene compliance, screening, contact precautions, environmental disinfection, and educational sessions to prevent the transmission of CPE, and surveillance cultures of the environment are advised to be undertaken with caution.2 Drains, sinks, and faucets have been identified as vehicles for the transmission of bacteria, mainly Acinetobacter baumannii and Pseudomonas aeruginosa.3,4 Based on expert opinion, environmental cultures are most appropriate for analysis if these organisms are involved.2 To our knowledge, we describe the first detection of CPE in toilet bowls and traps and subsequent hospital-associated transmission of Citrobacter freundii producing OXA-48 to four patients in one ward. Weekly rectal screening of all patients residing in the ward for 2 weeks following the identification of the first two infections revealed no other CPE-positive cases. 1 month after discharge of both patients, a 90-year-old man was admitted to the same index room and his urine sample tested positive for C freundii OXA-48; the other patient concurrently residing in the same room tested negative for CPE. [...]toilet bowls and traps in a hospital environment are a possible source of CPE, which pose a risk for hospital-acquired infections and propagation of outbreaks. Besides patient CPE screening, environmental sampling might allow earlier detection of unexpected reservoirs.