1. Pseudomonas aeruginosa Outbreak
Richard Catlin, 26/09/17

2. Bolton NICU & SCBU

3. Bolton NICU & SCBU

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. August
We undertook environmental sampling on SCBU
Five positives!!

18. 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

19. …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

20. Crimped piping

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

22. 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

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

24. 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

25. 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