Hospital-wide healthcare-associated carbapenemase-producing Enterobacterales outbreak: risks of electric floor scrubbers in catering facilities and kitchens

Abstract

Background: Carbapenemase-producing Enterobacterales (CPE) are associated with poor clinical outcomes and can spread rapidly in healthcare settings. Environmental reservoirs are increasingly recognized as playing an important part in some nosocomial outbreaks.

Aim: To describe the investigation and control of a CPE outbreak, lasting several years, across two separate hospital sites within one organization.

Methods: Investigation of multiple ward-level CPE cross-transmissions with a number of sporadic cases. Environmental sampling of ward environments, catering facilities and electric floor scrubbers was undertaken.

Findings: Eleven patients over a 19-month period were identified as carrying healthcare-associated New Delhi metallo-beta-lactamase (NDM)-producing Enterobacter cloacae, and a further patient carried NDM Escherichia coli. E. cloacae isolates were indistinguishable on pulsed-field gel electrophoresis typing, supporting acquisition with a single point source. Environmental sampling found contamination of the electric floor scrubbers used for cleaning the hospital catering facilities and in the associated toilets. Standard outbreak response measures achieved control of ward outbreaks. Sporadic cases and hospital-wide cross-transmission were controlled after interventions on the central food-handling unit and by decommissioning affected floor scrubbers. Electric floor scrubbers were found to have the potential to disperse Gram-negative bacteria into the surrounding environment under experimental conditions.

Conclusion: This outbreak report demonstrates that catering facilities and kitchens can be involved in widespread healthcare outbreaks of enteric organisms. This is also the first report of the potential role of electric floor scrubbers in causing significant environmental contamination with CPE which may indicate a role in nosocomial transmission.

Keywords: Carbapenemase-producing Enterobacterales (CPE); Environment; Floor scrubber; Kitchen; New Delhi metallo-beta-lactamase (NDM); Outbreak.