Dr Marie Hallin Service de Microbiologie Hôpital Erasme
ULB-Hôpital Erasme: 800 beds Nephrology/Renal transplantation 3300 urines/month
15/05/10-2 Urines 13/05/10: BG100504717 (M) 1946 ER WBC: 123/µL RBC: 4/µL Bacteria <3500/µL 75.000 CFU/ml P.aeruginosa BG100504757 (F) 1957 - Neurochir WBC : 20/µL RBC : 10/µL Bacteria <3500/µL 100.000 CFU/ml P.aeruginosa?Inversion error during sample process?
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 20 10 <3500 10 5 Infection control alert Semiquantitative culture (CFU/mL) 13/05/10 ER R R R R R R R S R R S 123 4 <3500 7.5 10 4 17/05/10 Outpatient R R R R R R R S R R S 65 123 77429 10 5 17/05/10 ICU R R R R I R R S R R S 142 290 9225 7.5 10 4
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 6 5 4 3 Urines Other 2 1 0 4 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
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 20 10 <3500 10 5 Semiquantitative culture (CFU/mL) 13/05/10 ER R R R R R R R S R R S 123 4 <3500 7.5 10 4 17/05/10 Outpatient R R R R R R R S R R S 65 123 77429 10 5 17/05/10 ICU R R R R I R R S R R S 142 290 9225 7.5 10 4
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)
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
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 + 19 26 <3500 2 10 4 08/01/10 Nephrolgy R R R S R R S I R R S + 12 7 <3500 >10 5 13/04/10 Pneumology S I I S R R S R R R S + 15 12 <3500 2 10 4 13/05/10 Neurosurgery R R R R R R R S R R S + 20 10 <3500 10 5 13/05/10 ER R R R R R R R S R R S + 123 4 <3500 7.5 10 4 17/05/10 Outpatient R R R R R R R S R R S + 65 123 77429 10 5 17/05/10 ICU R R R R I R R S R R S + 142 290 9225 7.5 10 4 18/05/10 ICU S I I S R R S R R R S + 62 111 <3500 10 5 19/05/10 Outpatient R R R R R R R S R R S + 5 7 <3500 7.5 10 4 28/05/10 Outpatient R R R R R R R S R R S + 25 7 <3500 >10 5 28/05/10 Urology R R R R R R R S R R S + 5927 8934 <3500 105 31/05/10 Surgery R R R R R R R S R R S + 2 21 <3500 5 10 4 07/06/10 ICU R R R R R R R S R R S + 195 199 <3500 7.5 10 4 11/06/10 R R R R R R R S R R S + 564 84 43419 >10 5 16/06/10 Outpatient R R R R R R R S R R S ND 17 47 <3500 10 5 17/06/10 Outpatient R R R R R R R S R R S ND 576 15 3673 5 104 18/06/10 ER R R R R R R R S R R S ND 63 28 <3500 105 18/06/10 ER R R R R R R R S R R S ND 17 16 <3500 >10 5 08/07/10 Urology R R R R R R R R R R S - 20613 498 59712 5 10 4 11/07/10 ER R R R R R R R S R R S + 5990 336 <3500 5 10 4 16/07/10 Gastrology R R R R R R S I R R S + 758 71 <3500 5 10 4 26/07/10 Gynecology R R R R R R R S R R S + 211 46 <3500 10 4 11/07/10 ICU R R R R R R R S R R S + 5 40 <3500 7.5 10 4
Typing Results 16 clinical isolates + isolate from the UF1000i: Same XDR AST profile Same PFGE type (clinical isolates =13) 6 clinical isolates unrelated 40 60 80 100 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
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
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