Outbreak investigation of Elizabethkingia meningoseptica at a tertiary care hospital

Pragathi Kottapalli; Chintha Deepika; S Jyothi; Rincy Mol; YV Sadhana; P Naveen Chander Reddy

doi:10.4103/jpsic.jpsic_20_22

PAPERS PRESENTED AT THE XVII ANNUAL CONFERENCE OF HOSPITAL INFECTION

Year : 2021 | Volume : 9 | Issue : 3 | Page : 77-82

Outbreak investigation of Elizabethkingia meningoseptica at a tertiary care hospital

Pragathi Kottapalli¹, Chintha Deepika², S Jyothi², Rincy Mol², YV Sadhana¹, P Naveen Chander Reddy³
¹ Department of Microbiology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
² Department of Nursing, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
³ Hospital Administration, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

Date of Submission	16-Apr-2022
Date of Acceptance	07-Jun-2022
Date of Web Publication	22-Jul-2022

Correspondence Address:
Dr. Pragathi Kottapalli
Department of Microbiology, Asian Institute of Gastroenterology, Hyderabad, Telangana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpsic.jpsic_20_22

Abstract

Aim and Objective of the Study: The aim and objective of this study were to do a prospective study on patients with Elizabethkingia meningoseptica infection at AIG Hospitals and to identify the possible source of E. meningoseptica in our hospital.
Materials and Methods: Outbreak of infection with E. meningoseptica was identified in intensive care units (ICUs) in February 2021. A prospective study was taken up and environmental surveillance swab cultures were collected along with clinical data from case sheets using a pro forma to identify the possible risk factors associated with E. meningoseptica infection. Interventional strategies were planned by infection control team along with hospital administration.
Results: A total of 10 E. meningoseptica bacteraemia and pneumonia cases were documented between March 2021 and May 2021. It was more common among patients with COVID-19, with prolonged ICU stay, and on multiple antibiotics and was associated with poor outcomes. Surveillance swab cultures collected from various sources showed growth of E. meningoseptica in the tap water of some ICUs.
Conclusion: Considering that E. meningoseptica are usually resistant to multiple antibiotics and that inappropriate antimicrobial therapy is an independent risk factor for mortality, early diagnosis and adequate antibiotic treatment are vital for patients with E. meningoseptica infection.

Keywords: Elizabethkingia, multidrug resistant, outbreak

How to cite this article:
Kottapalli P, Deepika C, Jyothi S, Mol R, Sadhana Y V, Chander Reddy P N. Outbreak investigation of Elizabethkingia meningoseptica at a tertiary care hospital. J Patient Saf Infect Control 2021;9:77-82

How to cite this URL:
Kottapalli P, Deepika C, Jyothi S, Mol R, Sadhana Y V, Chander Reddy P N. Outbreak investigation of Elizabethkingia meningoseptica at a tertiary care hospital. J Patient Saf Infect Control [serial online] 2021 [cited 2023 Jun 7];9:77-82. Available from: https://www.jpsiconline.com/text.asp?2021/9/3/77/351739

Introduction

Flavobacterium meningoseptica was renamed as Elizabethkingia meningoseptica by Elizabeth O. King in 1959.^[1] It is an emerging hospital pathogen and a Gram-negative, non-fermenting, non-motile, non-sporing and oxidase-positive bacilli.^[2],[3] Elizabethkingia is a genus of bacteria commonly found in the environment worldwide. It has been detected in hospital water supplies, sinks, taps and saline solution used for flushing procedures, disinfectants and medical devices, including feeding tubes, respirators and arterial catheters.^[4] It is resistant to chlorine compounds and can survive in chlorine-treated municipal water supplies, often colonising sink basins and taps, intubation tubes, humidifiers, incubators for newborns, ice chests and syringes. Saline, lipid as well as chlorhexidine gluconate solutions have been implicated as sources of infection following outbreak investigations.^[4],[5]

E. meningoseptica is mostly associated with infections among extremes of age groups and has caused meningitis or bloodstream and respiratory infections in people with weakened immune systems. Elizabethkingia spp. are resistant to multiple antibiotics and it is a cause of high mortality in critically ill patients in intensive care units (ICUs).^[6]

Hence, E. meningoseptica is considered a potential threat to patients in ICUs due to its multidrug-resistant nature and ability to survive in adverse conditions.

Aim and objective of the study

The aim and objective of this study were to do a prospective study on patients with E. meningoseptica infection at AIG Hospitals to identify the possible source of E. meningoseptica in our hospital.

The study also aimed at various risk factors which predispose to and clinical features of E. meningoseptica sepsis, along with antimicrobial susceptibility patterns of E. meningoseptica isolates and successful infection control and prevention measures to control the outbreak.

Materials and Methods

Setting

The outbreak occurred in medical ICUs of a tertiary care hospital in Hyderabad, Telangana. This hospital is a 720-bedded multispeciality hospital, accredited by the National Accreditation Board for Hospitals and has comprehensive institutional policies for infection prevention and control, and the team provides support with antimicrobial prescription, surveillance cultures for multidrug-resistant organisms and antimicrobial stewardship.

Methods

Outbreak of infection with E. meningoseptica was identified when endotracheal aspirates and blood cultures of patients admitted to Medical ICUs showed growth of E. meningoseptica. About three cases were reported in February when an outbreak was declared.

Outbreak investigation

Case definition

All inpatients from whom E. meningoseptica was isolated from culture samples were defined as CASES.

Heads of respective departments and hospital administration were notified about the outbreak. Multidisciplinary meetings were held to identify the possible source of infection. Probable causes of the outbreak were reviewed, and corrective and preventive actions were planned.

Steps of outbreak investigation are as follows:

Meetings were held by infection control team with critical care doctors, ICU nurses in charges, nursing administration and hospital administration
A prospective study was planned in March 2021 to identify the possible source of infection
Microbiological analysis of water samples from all ICUs and water treatment plants (WTPs)
Environmental swabs were collected from Monitor, Syringe pump, Intravenous stand, Bed-Side rail, Pendant, Suction Jar, Ventilator, Sink Basin, Tracheostomy tube, Heat and moisture exchanger (HME) filter, central venous catheter (CVC) Port, feeding tube, arterial line, Bacterial Filter, skin swab, staff fingerprints, tap water, saline solution and Side Locker Trolley to identify the source of infection
Swabs from the hands of clinicians, nurses and other health-care workers were sent for culture to rule out horizontal transmission
Chart reviews of all-case patients were done to determine age, gender, underlying comorbidities, hospital course of treatment, time elapsed from hospital admission to the E. meningoseptica infection, length of ICU stay, haemodialysis and other procedures, antibiotic therapy following infection and clinical outcome [Table 1]
All the data were entered in the healthcare-associated infection surveillance forms.

Table 1: Clinical details of concerned patients

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Microbiological investigation

Patient samples and surveillance swab cultures were sent to the microbiology laboratory for culture and identification of pathogen. The bacterial identification was done in VITEK2 automated system (bioMerieux, Marcy I'Etoile, France) along with Minimal Inhibitory Concentration (MIC)-based antibiotic sensitivity. Surveillance cultures collected from tap water of medical ICUs showed growth of E. meningoseptica.

After the source of infection was identified necessary corrective actions were taken and it was planned to reaudit after 3 months.

Interventional strategies

Urgent education programme was taken up along with monitoring of hand hygiene practices of all ICU staff by infection control nurses
Heightened awareness among clinicians and nurses on the potential of this bacterium to cause outbreaks
Reinforcement of standard infection control measures to break the chain of transmission
Immediate isolation and implementation of contact precautions as soon as the case is identified
Dedicated nursing and housekeeping staff
Use of disposable bed sheets in all ICUs
Terminal cleaning of ICUs
Area-wise cleaning and disinfection of water tanks were done
WTP preventive and annual maintenance schedules were verified along with adherence to the user manual
Installation of ultraviolet (UV) device inside one of the ICU taps was done for demo purpose and pre-and post-cultures were taken
Both pre-and post-test cultures showed growth of Elizabethkingia
Ozonation of tap water proved to be successful in the prevention of the outbreak.

However, recolonisation of water taps is common and the only way to prevent recurrent outbreaks in the future is regular environmental monitoring and strict adherence to infection control practices.

Results

In our study, E. meningoseptica was predominantly seen among COVID patients (70%), in males (60%) and majority of them were in the age group of 61–70 years (30%). Most of them had comorbidities such as diabetic mellitus and hypertension. Patients developed infection with E. meningoseptica after 21–30 days of ICU stay and these patients had a poor clinical outcome resulting in death in 60% of patients.

Our study showed that UV disinfection of water was not very effective but ozonation of WTP was successful in the prevention of the outbreak.

Discussion

Laboratory data revealed an increased incidence of E. meningoseptica infection in ICU patients compared with preceding years. There was a sudden increase in cases with E. meningoseptica infection in ICUs in the month of February. No isolates were identified previously.

Infections with E. meningoseptica are more common among immunosuppressed individuals.^[7] In our study, increased incidence was found among patients with COVID-19, Post-COVID and miliary tuberculosis.

E. meningoseptica infections are common in patients with extremes of age. Our patients were aged between 60–70 years and 60% were males similar to majority of the studies.^[7]

E. meningoseptica is usually a late infection, approximately after 50–70 days after admission to the hospital.^[8] In our study, the time interval between admission of patient to hospital and infection with E. meningoseptica was 21–30 days on an average.

It is predominantly known to cause bloodstream and respiratory infections.^[9] In the present study, it was isolated from blood cultures, endotracheal aspirates and sputum samples of patients admitted to ICU.

E. meningoseptica was isolated from blood cultures of three out of ten patients. In our study, all these patients with bacteraemia had CVC in place. The possible explanation for these could be the presence of organism in the tap water used for handwashing. Poor compliance to hand hygiene practices while handling invasive lines due to work pressure could have been the possible cause for bacteraemia among these patients.

Pneumonia outbreaks related to mechanical ventilation caused by E. meningoseptica are common. Weaver et al. concluded that patients treated with prolonged mechanical ventilation could serve as an important source of transmission for this multidrug-resistant Gram-negative waterborne pathogen.^[10],[11] In our study, all patients who developed infections with E. meningoseptica were on prolonged mechanical ventilation.

E. meningoseptica produces metallo-β-lactamase (GOB-18 and BlaB genes) which can hydrolyse most β-lactam antibiotics and limit their usefulness as a therapeutic option.^{[12],[13],[14],[15],[16],[17]} It is sensitive to antibiotics such as vancomycin, quinolones, trimethoprim-sulfamethoxazole, tigecycline and rifampin which are effective against Gram-positive bacteria.^{[11],[18],[19]} In our study, all the isolates were sensitive to minocycline (100%) and most of them were sensitive to trimethoprim-sulfamethoxazole [Table 2].

Table 2: Antibiotic sensitivity and clinical outcome

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Colonisation or infection of taps and water faucets of the ICU was one of the environmental sources in our hospital [Table 3]. In addition, non-compliance to general infection control practices among the staff, particularly handwashing possibly led to an outbreak.

Table 3: Microbiological analysis of water samples

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Patients with E. meningoseptica bacteraemia have a poor prognosis.^[7] In our study, there was death of all three patients with bacteraemia due to E. meningoseptica. The mortality in the abovementioned patients could also be attributed to their comorbid conditions and underlying disease. A majority of patients in our study had previous infection with organisms such as Klebsiella and Acinetobacter before the diagnosis of E. meningoseptica infection and were treated with broad-spectrum antibiotics. Colistin seems to have acted as a selective factor that allowed E. meningoseptica to emerge in the hospital.^[20],[21]

Infection with E. meningoseptica was predominantly seen in COVID-19 patients with comorbid conditions such as diabetes mellitus (50%) and hypertension (40%), prolonged hospitalisation, treatment with invasive procedures (30%), prior infection (and their treatment with the use of broad-spectrum antimicrobials.

Conclusion

Elizabethkingia has rapidly spread in several countries and causes lethally opportunistic infections in patients. Elizabethkingia species are usually resistant to multiple antibiotics and inappropriate antimicrobial therapy is an independent risk factor for mortality. Hence, early diagnosis and adequate antibiotic treatment are vital for patients with Elizabethkingia infection. Regular surveillance of WTPs and outlets in various ICUs for waterborne infections was a very important part of this outbreak investigation which helped in planning appropriate corrective actions.

We emphasise on the importance of awareness of infections caused by E. meningoseptica, and prompt collaborative action by microbiologists, infection control team, clinicians and hospital administration to control such hospital outbreaks.

Environmental monitoring and staff survey of compliance to infection control practices play an important role in the prevention of infections with E. meningoseptica.

Acknowledgements

We acknowledge the support of hospital administration and engineering department in the implementation of plan for periodical maintenance of water treatment plants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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