Pseudomonas aeruginosa Outbreak Richard Catlin, 26/09/17

Bolton NICU & SCBU

Bolton NICU & SCBU

Index Case Baby born at Bolton Baby positive for Pseudomonas aeruginosa (PA) 03/04/17 (sample 28/03/17) PA isolated from a nasopharyngeal aspirate Started on appropriate treatment Admitted to NICU 25/10/16 Isolated 04/04/17

Case 2 One of two twins Admitted to Bolton from another hospital for respiratory support Baby positive for PA 01/06/17 (sample from 28/05/17) Positive from respiratory sample Commenced on appropriate antibiotics NOT isolated NOT considered to be linked with the index case Twin NEVER became PA positive Samples sent to the reference lab for typing

Case 3 Baby born at Bolton Baby PA positive 16/06/17 (sample 13/06/17) Positive from a respiratory sample – bronchial lavage taken routinely Commenced on appropriate antibiotics Isolated 16/06/17

1st Meeting Outbreak team met 16/06/17 No confidence that there was an outbreak Long time between cases 1 & 2 No clear link between any of the cases Actions: Reinforced hand hygiene Reinforced hand gelling AFTER hand washing Review of HWB cleaning process Third sample sent for typing

The typing results for cases 1 & 2 came back on the afternoon of the 16th – both samples were identical and it was an uncommon type: Bolton Outbreak Strain

2nd Meeting Outbreak confirmed and key actions agreed: Water sampling from NICU Environmental sampling from NICU Basins Taps Drains ‘Wet’ areas Ventilator tubing Incubators Screening of the other patients Needed to get consent from the parents – without raising too much alarm

Next steps All babies screened Environmental screens taken – 100 in total Water sampling undertaken Audits of practice Cleaning of hand wash basins Hand hygiene practices

Results Patients Environment Audits 1 x further baby identified from screening Unrelated to the other three babies Environment A few positive from basins and taps; outlets: N24 N25 Audits Real issues with domestic cleaning of the hand wash basins Staff excellent at hand washing, not as good at gelling afterwards

Next steps Weekly screens of babies Monthly screens of HWB Water sampling as indicated by screening Weekly auditing of staff hand hygiene 2 members of staff couldn’t use the alcohol hand rub which had to be resolved Samples sent for typing

Water sampling Outlet 03/06/2017 23/06/2017 27/06/2017 29/06/2017 N01 Not tested Neg (pre) Neg (post) N02 N07 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26H N26C Outlet 03/06/2017 23/06/2017 27/06/2017 29/06/2017 12/08/2017 23/08/2017 01/09/17 (pre mixer) 01/09/17 (outlet) S01 Not tested Neg (pre) Neg (post) Neg (pre) S02 S03H S03C S04 Neg (pre) Neg (post) Neg (cold) Neg (hot) S05H 43 (pre) 6 (post) >150 (pre) >150 (post) Neg S05C (not applicable - auto tap replaced by Horne tap) S06H S06C S07 S08 3 S09 >150 21 (pre) Neg (post) S10 S11H S11C S12 S13 46 (pre) 29 (post) 80 S14H S14C S15 39 (pre) 4 (post) 100 30 (pre) Neg (post) S16H S16C 67 (pre) >150 (post) S17 S18H S18C S19 S20 S21H S21C Visitors toilet

Typing results – Bolton outbreak strain Date Sample Site Type 28/03/17 Patient JK – respiratory sample Bolton outbreak strain 28/05/17 Patient ZM – respiratory sample 13/06/17 Patient BF – respiratory sample 20/06/17 N24 Drain 21/06/17 Patient TC – screening sample 23/06/17 S05 Water sample 03/08/17 S05 Spout S05 Basin 21/08/17 S11 Spout

Typing results – Cluster D Date Sample Site Type 20/06/17 N25 Basin Cluster D N25 Drain 23/06/17 N14 Water sample 03/08/17 S15 Spout S16 Spout 12/08/17 S15 (pre) water sample S15 (post) water sample) S16 (cold, post) water sample S16 (cold, pre) water sample S16 (hot, pre) water sample 21/08/17 S16 Basin S15 Basin

Typing results – Cluster A Date Sample Site Type 03/08/17 S13 Spout Cluster A 12/08/17 S13 Water sample 21/08/17

August We undertook environmental sampling on SCBU Five positives!!

Date Sample Site Type 20/06/17 N25 Basin Cluster D N25 Drain 23/06/17 N14 Water sample 03/08/17 S15 Spout S16 Spout 12/08/17 S15 (pre) water sample S15 (post) water sample) S16 (cold, post) water sample S16 (cold, pre) water sample S16 (hot, pre) water sample 21/08/17 S16 Basin S15 Basin Date Sample Site Type 28/03/17 Patient JK – respiratory sample Bolton outbreak strain 28/05/17 Patient ZM – respiratory sample 13/06/17 Patient BF – respiratory sample 20/06/17 N24 Drain 21/06/17 Patient TC – screening sample 23/06/17 S05 Water sample 03/08/17 S05 Spout S05 Basin 21/08/17 S11 Spout

…Eventually We had to decide whether or not: Or The water system was affected Or The taps were affected We took aseptic samples from the system immediately prior to the tap mixer We took water samples from the taps Compared results We recognised that the pipework used in the build was not in line with guidance: crimped piping connectors were used A sample of pipe was taken out and a) examined and b) sampled

Crimped piping

Results Pre-mixer samples were negative Some of the water samples were positive

Water sampling Outlet 03/06/2017 23/06/2017 27/06/2017 29/06/2017 12/08/2017 23/08/2017 01/09/17 (pre mixer) 01/09/17 (outlet) S01 Not tested Neg (pre) Neg (post) Neg (pre) S02 S03H S03C S04 Neg (pre) Neg (post) Neg (cold) Neg (hot) S05H 43 (pre) 6 (post) >150 (pre) >150 (post) Neg S05C (not applicable - auto tap replaced by Horne tap) S06H S06C S07 S08 3 S09 >150 21 (pre) Neg (post) S10 S11H S11C S12 S13 46 (pre) 29 (post) 80 S14H S14C S15 39 (pre) 4 (post) 100 30 (pre) Neg (post) S16H S16C 67 (pre) >150 (post) S17 S18H S18C S19 S20 S21H S21C Visitors toilet

Results Pre-mixer samples were negative Some of the water samples were positive The samples from the pipework was negative

Conclusions Source…??? Reasons for transmission around the units Unknown Reasons for transmission around the units Combination of: Cleaning processes Hand hygiene practices Reason for continued contamination Sluggish water flow

Plan Continue screening until the last PA positive patient is discharged from NICU Replace all of the automated taps: Improve staff compliance Improve flow Continue to monitor the environment