Wastewater drainage system as an occult reservoir in a protracted clonal outbreak due to metallo-β-lactamase-producing Klebsiella oxytoca

We describe the epidemiology of a protracted nosocomial clonal outbreak due to multidrug-resistant IMP-8 producing Klebsiella oxytoca (MDRKO) that was finally eradicated by removing an environmental reservoir. The outbreak occurred in the ICU of a Spanish hospital from March 2009 to November 2011 and evolved over four waves. Forty-two patients were affected. First basic (active surveillance, contact precautions and reinforcement of surface cleaning) and later additional control measures (nurse cohorting and establishment of a minimum patient/nurse ratio) were implemented. Screening of ICU staff was repeatedly negative. Initial environmental cultures, including dry surfaces, were also negative. The above measures temporarily controlled cross-transmission but failed to eradicate the epidemic MDRKO strain that reappeared two weeks after the last colonized patients in waves 2 and 3 had been discharged. Therefore, an occult environmental reservoir was suspected. Samples from the drainpipes and traps of a sink were positive; removal of the sink reduced the rate number but did not stop new cases that clustered in a cubicle whose horizontal drainage system was connected with the eliminated sink. The elimination of the horizontal drainage system finally eradicated the outbreak. In conclusion, damp environmental reservoirs (mainly sink drains, traps and the horizontal drainage system) could explain why standard cross-transmission control measures failed to control the outbreak; such reservoirs should be considered even when environmental cultures of surfaces are negative.