Cluster of urinary tract infections due to XDR Pseudomonas aeruginosa. Dr Marie Hallin Service de Microbiologie Hôpital Erasme

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1 Dr Marie Hallin Service de Microbiologie Hôpital Erasme

2 ULB-Hôpital Erasme: 800 beds Nephrology/Renal transplantation 3300 urines/month

3 15/05/10-2 Urines 13/05/10: BG (M) 1946 ER WBC: 123/µL RBC: 4/µL Bacteria <3500/µL CFU/ml P.aeruginosa BG (F) Neurochir WBC : 20/µL RBC : 10/µL Bacteria <3500/µL CFU/ml P.aeruginosa?Inversion error during sample process?

4 A few days later.. AST Sediment analysis results (/µl) Date of sampling Hospitalization Unit 2 further cases Outbreak? Pipe-tazo Catzidime Cefepime Aztreonam Imipenem Meropenem Gentamicin Amikacin Tobramycin Ciprofloxacin Colistin WBC RBC Bacteria 13/05/10 Neurosurgery R R R R R R R S R R S < Infection control alert Semiquantitative culture (CFU/mL) 13/05/10 ER R R R R R R R S R R S < /05/10 Outpatient R R R R R R R S R R S /05/10 ICU R R R R I R R S R R S

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6 Outbreak? 1 st Case definition: patients with positive culture for P. aeruginosa ceftazidime, imipenem, meropenem and ciprofloxacin I/R No increase in the frequency of XDR P. aeruginosa in non-urine samples Urines Other jan 18 jan 5 avr 19 avr 3 mai 17 mai 31 mai 14 juin 28 juin 12 juil Nb of culture positive for P. aeruginosa ceftazidime, imipenem, meropenem and ciprofloxacin I/R 26 juil

7 Pseudo-outbreak? No epidemiological link between patients Dissociation between ECBU/semi-quantitative culture bacterial count AST Sediment analysis results (/µl) Date of sampling Hospitalization Unit Pipe-tazo Catzidime Cefepime Aztreonam Imipenem Meropenem Gentamicin Amikacin Tobramycin Ciprofloxacin Colistin WBC RBC Bacteria 13/05/10 Neurosurgery R R R R R R R S R R S < Semiquantitative culture (CFU/mL) 13/05/10 ER R R R R R R R S R R S < /05/10 Outpatient R R R R R R R S R R S /05/10 ICU R R R R I R R S R R S

8 Pseudo-Outbreak Analytical contamination? Standard Procedure: Collection in sterile containers transferred (vacuum system) in sterile tubes Semi-quantitative urinoculture on CLED medium Sediment analysis - UF1000i Urine flow cytometry analyser (Sysmex) Dipstick - Aution Max AX-4280 (Menarini)

9 Pseudo-Outbreak Analytical contamination? Sampling of the analysers: Vacutainer sterile tubes (n=6) filled with Schaedler broth Semi-quantitative culture on CLED medium Processed as routine urine samples serially and in parallel on both analysers (UF1000i and/or Aution max) Semi-quantitative culture on CLED medium 1 2

10 Prospective and Retrospective Search of Cases AST Sediment analysis results (/µl) 2d Case definition: patients with urinoculture positive (>104 CFU/ml) for P. aeruginosa ceftazidime, imipenem, meropenem and ciprofloxacin I/R 23 cases included from 01/01 to 31/07 Date of sampling Hospitalization Unit Pipe-tazo Ctazidime Cefepime Aztreonam Imipenem Meropene Gentamici Amikacin Tobramyci Ciprofloxa Colistin VIM WBC RBC Bacteria Semi-quantitative culture (CFU/mL) 01/01/10 Nephrolgy S I S I R R S S I R S < /01/10 Nephrolgy R R R S R R S I R R S <3500 > /04/10 Pneumology S I I S R R S R R R S < /05/10 Neurosurgery R R R R R R R S R R S < /05/10 ER R R R R R R R S R R S < /05/10 Outpatient R R R R R R R S R R S /05/10 ICU R R R R I R R S R R S /05/10 ICU S I I S R R S R R R S < /05/10 Outpatient R R R R R R R S R R S < /05/10 Outpatient R R R R R R R S R R S <3500 > /05/10 Urology R R R R R R R S R R S < /05/10 Surgery R R R R R R R S R R S < /06/10 ICU R R R R R R R S R R S < /06/10 R R R R R R R S R R S > /06/10 Outpatient R R R R R R R S R R S ND < /06/10 Outpatient R R R R R R R S R R S ND /06/10 ER R R R R R R R S R R S ND < /06/10 ER R R R R R R R S R R S ND <3500 > /07/10 Urology R R R R R R R R R R S /07/10 ER R R R R R R R S R R S < /07/10 Gastrology R R R R R R S I R R S < /07/10 Gynecology R R R R R R R S R R S < /07/10 ICU R R R R R R R S R R S <

11 Typing Results 16 clinical isolates + isolate from the UF1000i: Same XDR AST profile Same PFGE type (clinical isolates =13) 6 clinical isolates unrelated Date of sampling Hospitalization Unit Piperacillin-tazobactam Ctazidime Cefepime Aztreonam Imipenem Meropenem Gentamicin Amikacin Tobramycin Ciprofloxacin Colistin 16/06/10 Outpatient R R R R R R R S R R S ND ND ND 17/06/10 Outpatient R R R R R R R S R R S ND ND ND 18/06/10 ER R R R R R R R S R R S ND ND ND 18/06/10 ER R R R R R R R S R R S ND ND ND 31/05/10 Surgery R R R R R R R S R R S + - ZT4 11/07/10 ER R R R R R R R S R R S + - ZT4 28/05/10 Outpatient R R R R R R R S R R S + - ZT4 07/06/10 ICU R R R R R R R S R R S + - ZT4 26/07/10 Gynecology R R R R R R R S R R S + - ZT4 13/05/10 Neurosurgery R R R R R R R S R R S + - ZT4 11/06/10 R R R R R R R S R R S + - ZT4 11/07/10 ICU R R R R R R R S R R S + - ZT4 13/05/10 ER R R R R R R R S R R S + - ZT4 17/05/10 Outpatient R R R R R R R S R R S + - ZT4 19/05/10 Outpatient R R R R R R R S R R S + - ZT4 28/05/10 Urology R R R R R R R S R R S + - ZT4 17/05/10 ICU R R R R I R R S R R S + - ZT4 UF1000i analyser R R R R R R R S R R S + - ZT4 08/07/10 Urology R R R R R R R R R R S - - FF 13/04/10 Pneumology S I I S R R S R R R S + - X1 18/05/10 ICU S I I S R R S R R R S + - X1 08/01/10 Nephrolgy R R R S R R S I R R S + - X1 01/01/10 Nephrolgy S I S I R R S S I R S + - X1 16/07/10 Gastrology R R R R R R S I R R S + - spor VIM IMP PFGE type

12 Intervention and Corrective measures Reminder to the team : RESPECT the routine samples process: culture performed BEFORE processing on the analysers Standard PROTECTION procedure (gowns and gloves) Extensive disinfection of the UF100i broad spectrum disinfectant: Virkon (potassium peroxymonosulfate + sulfamic acid + sodium dodecylbenzenesulfonate) Replacement of the mixing device Implementation of : weekly disinfection sterility control procedure

13 Conclusions Pseudo-outbreak caused by a VIM positive XDR P. aeruginosa clone due to the contamination of the UF1000i cytometric analyser for urinary sediment 16 cases over 2 months 1 Patient received colistin Users of such analysers should be aware that contamination occur Perform regular sterility control procedures of their analyser Culture have to be performed either before the processing on the analyser on a distinct aliquot