Intensive Care Unit Wastewater Interventions to Prevent Transmission of Multispecies Klebsiella pneumoniae Carbapenemase-Producing Organisms

Clin Infect Dis. 2018 Jul 2;67(2):171-178. doi: 10.1093/cid/ciy052.


Background: The increasing prevalence of nosocomial carbapenemase-producing Enterobacteriaceae is a concern. However, the role of the environment in multispecies outbreaks remains poorly understood. There is increasing recognition that hospital wastewater plumbing may play a role.

Methods: Covers were installed on all hoppers (a "toilet-like" waste disposal system) in adult intensive care units (ICUs) of a university hospital; additionally in the surgical ICU, sink trap heating and vibration devices were also installed. Patient acquisitions of Klebsiella pneumoniae carbapenemase-producing organisms (KPCOs) for patients who were admitted to an intervention unit were compared for 18-month preintervention and intervention periods.

Results: Sixty hopper covers and 23 sink trap devices were installed. Fifty-six new multispecies KPCO acquisitions occurred preintervention compared to 30 during the intervention. Decreases for all KPCO acquisitions (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31-0.81; P = .003) and KPCO-positive clinical cultures (OR, 0.29; 95% CI, 0.17-0.48; P < .001) per admission in patients exposed to an intervention unit were observed. The incidence rate ratio was 0.51-fold (95% CI, 0.43-0.61) lower for all KPCO acquisitions during the intervention. The effect of the sink trap devices alone could not be determined, although the proportion of sink drain cultures positive for KPCO decreased (12/15 [80%] sites sampled preintervention vs 40/840 [5%] sampled during the intervention; P = .001).

Conclusions: An intervention targeting wastewater plumbing fixtures, by installation of hopper covers, demonstrated a decrease in patient KPCO acquisitions. Considering wastewater reservoirs in nosocomial transmission of multispecies carbapenemase-producing Enterobacteriaceae may be critical.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Bacterial Proteins / metabolism
  • Bathroom Equipment / microbiology
  • Carbapenem-Resistant Enterobacteriaceae / isolation & purification
  • Carrier State / microbiology
  • Cross Infection
  • Disease Outbreaks / prevention & control
  • Hospitals, University
  • Humans
  • Infection Control / instrumentation
  • Infection Control / methods*
  • Intensive Care Units*
  • Klebsiella Infections / prevention & control*
  • Klebsiella pneumoniae / enzymology
  • Klebsiella pneumoniae / isolation & purification*
  • Prospective Studies
  • Sanitary Engineering / methods
  • Wastewater / microbiology*
  • beta-Lactamases / metabolism


  • Bacterial Proteins
  • Waste Water
  • beta-Lactamases
  • carbapenemase