- Email: [email protected]
Using a vanA polymerase chain reaction to detect environmental contamination during a vancomycin-resistant enterococci outbreak
Accepted Manuscript Using a vanA PCR to detect environmental contamination during a VancomycinResistant Enterococci outbreak Mark I. Garvey, Craig Bradley, Anna Casey, Victoria Clewer, Elisabeth Holden PII:
S0195-6701(17)30458-9
DOI:
10.1016/j.jhin.2017.08.014
Reference:
YJHIN 5203
To appear in:
Journal of Hospital Infection
Received Date: 14 August 2017 Revised Date:
0195-6701 0195-6701
Accepted Date: 16 August 2017
Please cite this article as: Garvey MI, Bradley C, Casey A, Clewer V, Holden E, Using a vanA PCR to detect environmental contamination during a Vancomycin-Resistant Enterococci outbreak, Journal of Hospital Infection (2017), doi: 10.1016/j.jhin.2017.08.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Using a vanA PCR to detect environmental contamination during a Vancomycin-Resistant Enterococci outbreak
RI PT
Mark I. Garvey, Craig Bradley, Anna Casey, Victoria Clewer and Elisabeth Holden
Infection Prevention and Control Team, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham,
M AN U
SC
B15 2WB
Keywords: Vancomycin Resistant Enterococci, Cleaning, PCR, Environmental Sampling, outbreak, haematology
TE D
Running title: Using PCR to detect environmental VREs
* Corresponding author
EP
Email: [email protected]
AC C
Tel: 0121 371 3787
1
ACCEPTED MANUSCRIPT Dear Sirs, We recently reported in this journal how we used a PCR assay to identify environmental contamination with carbapenemase-producing Enterobacteriaceae (CPE), and to determine the effectiveness of a standard terminal clean.1 We showed
RI PT
that use of a PCR assay facilitated much more rapid microbiological assessment than standard culture and visual inspection combined.1 In addition, the PCR was useful in determining whether an area was decontaminated effectively following a
SC
terminal clean.1
Vancomycin-resistant enterococci (VRE) are another group of bacteria that
M AN U
are important causes of healthcare associated infections,2-5 and can survive in hospital environments for weeks.2 Acquisition of VRE has been associated with prolonged hospital stay and duration of previous hospitalisation, neutropaenia, antibiotic
treatment,
exposure
to
high-dose
corticosteroids
and
TE D
immunosuppression.2-4 Patients with haematologic malignancies have many of these predisposing factors; they are at high-risk for VRE colonisation and infection,3 and outbreaks of VRE have been described on haematology units.3
EP
In the current report, we describe the use of a PCR assay to detect
AC C
environmental contamination during a VRE outbreak on a haematology ward. We detail how we used the assay for environmental monitoring during the outbreak and how we identified specific ward areas that were contaminated with VRE; this enabled more enhanced clean to be undertaken and quicker turnaround of the bed spaces. University Hospitals Birmingham NHS Foundation Trust (UHB) is a secondary and tertiary teaching hospital in Birmingham, UK that provides clinical services to nearly 1 million patients every year. It is a specialist cancer and regional referral centre for haematology and bone marrow transplants, being one of only two such
2
ACCEPTED MANUSCRIPT centres in the English West Midlands. Between April and June 2017 six patients on the haematology ward were newly found to be colonized with VRE. All the isolates were sent to the Public Health England Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) reference laboratory for typing via Pulsed Field Gel
RI PT
Electrophoresis (PFGE);7 with all being unique types via PFGE. Out of the six newly colonised patients with VRE, five went on to develop VRE bacteraemias. This outcome is not uncommon in haematology patients;6 a meta-analysis of patients with
SC
solid or haematologic malignancies showed that those colonised with VRE were 24
colonised patients.6
M AN U
times more likely to develop bloodstream infection with VRE than were non-
In response to the increased incidence of VRE on the haematology ward, an outbreak meeting was held and a raft of infection control initiatives implemented. This included enhanced hand hygiene, restriction of broad spectrum antimicrobial isolation
of
patient
carriers
and
enhanced
environmental
cleaning.
TE D
use,
Environmental swabbing was performed on multiple macroscopically clean touchpoints throughout the ward (Table 1) as previously described by Garvey et al.,
EP
(2016).8 Any enterococci growing from the environmental sampling agar plates were
AC C
identified via matrix-assisted laser desorption ionization time-of-flight (Vitek MS; Biomerieux) and Vitek (Biomerieux). In addition to culture-based environmental sampling we investigated environmental contamination with VRE using the Cepheid XpertR VRE PCR (Cepheid Inc, Sunnyvale, CA, USA) used in accordance with the manufacturer’s instructions. The PCR assay gave positive results at 6 environmental sites; however, from the culture results no VRE was isolated. As VRE were identified in the environment by PCR after enhanced cleaning, a second clean was ordered using the extra steps previously described.8
3
ACCEPTED MANUSCRIPT Environmental contamination of wards has been shown to be a contributory factor in the spread of VRE.9 Shams et al., (2016) reported that the most common multidrug resistant organism identified from environmental swabbing was VRE.9 VRE often contaminate the surfaces in patient rooms, and such environmental
RI PT
contamination is associated with an increased risk of patient VRE colonisation and infection.9 In the current report, we also found VRE in the environment, but only by employing a PCR assay for VRE were we able to assess the environmental burden
SC
of VRE and the effectiveness of our standard cleaning method. Only after an enhanced clean was VRE not isolated in the environment. The use of a PCR assay
M AN U
facilitated much more rapid microbiological assessment than standard culture (hours rather than days), which aided outbreak management by reducing the environmental contamination of VRE and subsequent transmission to patients. The sites that we found to harbour VRE included communal patient equipment and communal ward
TE D
areas such as the drug preparation area (Table 1).
There are several speculative reasons why we were not able to detect VRE in the environment by culture, although the PCR, which detects the vanA gene, was
EP
positive. The bacteria may have been in a state where they were viable but non
AC C
culturable, or the environmental sampling may not have been sensitive enough to pick up culturable VRE. Conversely another possibility for the observed result is that we were detecting DNA from dead or dying cells as a result of the cleaning and disinfection process with the organisms not being viable. PFGE of the VRE isolates revealed that they were all unique strains. In light of these typing results could it be that the vanA-containing plasmid alone could be independently present in the environment, and transmissible to antibiotic-sensitive strains of enterococci is occurring in the current report. Further work is warranted to explore these
4
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
hypotheses.
5
ACCEPTED MANUSCRIPT ACKNOWLEDGEMENTS We would thank the Infection Prevention and Control Team, staff in Haematology and Facilities at the University Hospitals Birmingham NHS Foundation Trust. We would also like to thank the Dr Jane Turton at PHE for PFGE typing of our VRE
AC C
EP
TE D
M AN U
SC
RI PT
isolates.
6
ACCEPTED MANUSCRIPT REFERENCES 1. Garvey MI, Bradley CW, Casey AL. Using a carbapenemase-producing organism polymerase chain reaction to rapidly determine the efficacy of
RI PT
terminal room disinfection. J Hosp Infect 2017; 95 (3): 329-330. 2. Raven KE, Gouliouris T, Brodrick H, Coll F, Brown NM, Reynolds R, et al. Complex routes of nosocomial vancomycin-resistant Enterococcus faecium
SC
transmission revealed by genome sequencing. Clin Infect Dis 2017; 1:64(7): 886-893.
M AN U
3. Kampmeier S, Knaack D, Kossow A, Willems S, Schliemann C, Berdel WE, et al. Weekly screening supports terminating nosocomial transmissions of vancomycin resistant enterococci on an oncologic ward – a retrospective analysis. Antimicrob Resist Infect Control 2017; 16:6:48.
TE D
4. Brodrick HJ, Raven KE, Harrison EM. Whole genome sequencing reveals transmission of vancomycin resistant Enterococcus faecium in a healthcare network. Genome Med 2016; 12; 8(1):4.
EP
5. Willems RJ, Top J, Van Schaik W, Leavis H, Bonten M, Sirén J, et al. Restricted gene flow among hospital subpopulations of Enterococcus faecium.
AC C
MBio 2012; 17:3(4).
6. Alevizakos M, Gaitanidis A, Nasioudis D, Tori K, Flokas ME, Mylomakis E. Colonization with vancomycin-resistant enterococci and risk for bloodstream infection among patients with malignancy: a systematic review and metaanalysis. Open Forum Infect Dis 2016; 7:4(1). 7. Kaufmann ME. Pulsed-field gel electrophoresis: In: Woodford N, Johnson AP, editors. Methods in molecular medicine 15: molecular bacteriology: protocols and clinical applications. New Jersey: Humana Press 1998; 33-50.
7
ACCEPTED MANUSCRIPT 8. Garvey MI, Bradley CW, Jumaa P. Environmental decontamination following occupancy of a burns patient with multiple carbapenemase producing organisms. J Hosp Infect 2016; 93: 136-40. 9. Shams AM, Rose LJ, Edwards JR, Cali S, Harris AD, Jacob JT, et al.
RI PT
Assessment of the overall and multidrug-resistant organism bioburden on environmental surfaces in healthcare facilities. Infect Control Hosp Epidemiol
AC C
EP
TE D
M AN U
SC
2016: 37(12): 1426-1432.
8
ACCEPTED MANUSCRIPT
RI PT
TABLE Table 1. Details of 10 surfaces tested during environmental sampling using polywipe sponges (surface area ~30cm2); both the
vanA positive vanA negative
Bedside TV Fan Door touch points Communal area surfaces tested Drip stand Ward computer Linen trolley IV preparation room
vanA negative vanA negative vanA negative
EP
Fridge Bedside table
AC C
vanA positive vanA positive vanA positive vanA positive
Culture results (before enhanced cleaning) * Staphylococcus haemolyticus Enterococcus faecium and Acinetobacter baumannii Staphylococcus epidermidis Enterococcus faecium and Acinetobacter baumannii Enterococcus faecium Staphylococcus haemolyticus
TE D
Surface tested Surface areas in vicinity of patient vanA positive Bathroom touch points
M AN U
PCR results (before enhanced cleaning)
SC
vanA PCR and culture results are shown.
Pseudomonas putida Enterococcus faecium Negative Negative
*All organisms idnetified via MALDI-TOF and sensitivities confirmed via Vitek.
1
S0195-6701(17)30458-9
DOI:
10.1016/j.jhin.2017.08.014
Reference:
YJHIN 5203
To appear in:
Journal of Hospital Infection
Received Date: 14 August 2017 Revised Date:
0195-6701 0195-6701
Accepted Date: 16 August 2017
Please cite this article as: Garvey MI, Bradley C, Casey A, Clewer V, Holden E, Using a vanA PCR to detect environmental contamination during a Vancomycin-Resistant Enterococci outbreak, Journal of Hospital Infection (2017), doi: 10.1016/j.jhin.2017.08.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Using a vanA PCR to detect environmental contamination during a Vancomycin-Resistant Enterococci outbreak
RI PT
Mark I. Garvey, Craig Bradley, Anna Casey, Victoria Clewer and Elisabeth Holden
Infection Prevention and Control Team, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham,
M AN U
SC
B15 2WB
Keywords: Vancomycin Resistant Enterococci, Cleaning, PCR, Environmental Sampling, outbreak, haematology
TE D
Running title: Using PCR to detect environmental VREs
* Corresponding author
EP
Email: [email protected]
AC C
Tel: 0121 371 3787
1
ACCEPTED MANUSCRIPT Dear Sirs, We recently reported in this journal how we used a PCR assay to identify environmental contamination with carbapenemase-producing Enterobacteriaceae (CPE), and to determine the effectiveness of a standard terminal clean.1 We showed
RI PT
that use of a PCR assay facilitated much more rapid microbiological assessment than standard culture and visual inspection combined.1 In addition, the PCR was useful in determining whether an area was decontaminated effectively following a
SC
terminal clean.1
Vancomycin-resistant enterococci (VRE) are another group of bacteria that
M AN U
are important causes of healthcare associated infections,2-5 and can survive in hospital environments for weeks.2 Acquisition of VRE has been associated with prolonged hospital stay and duration of previous hospitalisation, neutropaenia, antibiotic
treatment,
exposure
to
high-dose
corticosteroids
and
TE D
immunosuppression.2-4 Patients with haematologic malignancies have many of these predisposing factors; they are at high-risk for VRE colonisation and infection,3 and outbreaks of VRE have been described on haematology units.3
EP
In the current report, we describe the use of a PCR assay to detect
AC C
environmental contamination during a VRE outbreak on a haematology ward. We detail how we used the assay for environmental monitoring during the outbreak and how we identified specific ward areas that were contaminated with VRE; this enabled more enhanced clean to be undertaken and quicker turnaround of the bed spaces. University Hospitals Birmingham NHS Foundation Trust (UHB) is a secondary and tertiary teaching hospital in Birmingham, UK that provides clinical services to nearly 1 million patients every year. It is a specialist cancer and regional referral centre for haematology and bone marrow transplants, being one of only two such
2
ACCEPTED MANUSCRIPT centres in the English West Midlands. Between April and June 2017 six patients on the haematology ward were newly found to be colonized with VRE. All the isolates were sent to the Public Health England Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) reference laboratory for typing via Pulsed Field Gel
RI PT
Electrophoresis (PFGE);7 with all being unique types via PFGE. Out of the six newly colonised patients with VRE, five went on to develop VRE bacteraemias. This outcome is not uncommon in haematology patients;6 a meta-analysis of patients with
SC
solid or haematologic malignancies showed that those colonised with VRE were 24
colonised patients.6
M AN U
times more likely to develop bloodstream infection with VRE than were non-
In response to the increased incidence of VRE on the haematology ward, an outbreak meeting was held and a raft of infection control initiatives implemented. This included enhanced hand hygiene, restriction of broad spectrum antimicrobial isolation
of
patient
carriers
and
enhanced
environmental
cleaning.
TE D
use,
Environmental swabbing was performed on multiple macroscopically clean touchpoints throughout the ward (Table 1) as previously described by Garvey et al.,
EP
(2016).8 Any enterococci growing from the environmental sampling agar plates were
AC C
identified via matrix-assisted laser desorption ionization time-of-flight (Vitek MS; Biomerieux) and Vitek (Biomerieux). In addition to culture-based environmental sampling we investigated environmental contamination with VRE using the Cepheid XpertR VRE PCR (Cepheid Inc, Sunnyvale, CA, USA) used in accordance with the manufacturer’s instructions. The PCR assay gave positive results at 6 environmental sites; however, from the culture results no VRE was isolated. As VRE were identified in the environment by PCR after enhanced cleaning, a second clean was ordered using the extra steps previously described.8
3
ACCEPTED MANUSCRIPT Environmental contamination of wards has been shown to be a contributory factor in the spread of VRE.9 Shams et al., (2016) reported that the most common multidrug resistant organism identified from environmental swabbing was VRE.9 VRE often contaminate the surfaces in patient rooms, and such environmental
RI PT
contamination is associated with an increased risk of patient VRE colonisation and infection.9 In the current report, we also found VRE in the environment, but only by employing a PCR assay for VRE were we able to assess the environmental burden
SC
of VRE and the effectiveness of our standard cleaning method. Only after an enhanced clean was VRE not isolated in the environment. The use of a PCR assay
M AN U
facilitated much more rapid microbiological assessment than standard culture (hours rather than days), which aided outbreak management by reducing the environmental contamination of VRE and subsequent transmission to patients. The sites that we found to harbour VRE included communal patient equipment and communal ward
TE D
areas such as the drug preparation area (Table 1).
There are several speculative reasons why we were not able to detect VRE in the environment by culture, although the PCR, which detects the vanA gene, was
EP
positive. The bacteria may have been in a state where they were viable but non
AC C
culturable, or the environmental sampling may not have been sensitive enough to pick up culturable VRE. Conversely another possibility for the observed result is that we were detecting DNA from dead or dying cells as a result of the cleaning and disinfection process with the organisms not being viable. PFGE of the VRE isolates revealed that they were all unique strains. In light of these typing results could it be that the vanA-containing plasmid alone could be independently present in the environment, and transmissible to antibiotic-sensitive strains of enterococci is occurring in the current report. Further work is warranted to explore these
4
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
hypotheses.
5
ACCEPTED MANUSCRIPT ACKNOWLEDGEMENTS We would thank the Infection Prevention and Control Team, staff in Haematology and Facilities at the University Hospitals Birmingham NHS Foundation Trust. We would also like to thank the Dr Jane Turton at PHE for PFGE typing of our VRE
AC C
EP
TE D
M AN U
SC
RI PT
isolates.
6
ACCEPTED MANUSCRIPT REFERENCES 1. Garvey MI, Bradley CW, Casey AL. Using a carbapenemase-producing organism polymerase chain reaction to rapidly determine the efficacy of
RI PT
terminal room disinfection. J Hosp Infect 2017; 95 (3): 329-330. 2. Raven KE, Gouliouris T, Brodrick H, Coll F, Brown NM, Reynolds R, et al. Complex routes of nosocomial vancomycin-resistant Enterococcus faecium
SC
transmission revealed by genome sequencing. Clin Infect Dis 2017; 1:64(7): 886-893.
M AN U
3. Kampmeier S, Knaack D, Kossow A, Willems S, Schliemann C, Berdel WE, et al. Weekly screening supports terminating nosocomial transmissions of vancomycin resistant enterococci on an oncologic ward – a retrospective analysis. Antimicrob Resist Infect Control 2017; 16:6:48.
TE D
4. Brodrick HJ, Raven KE, Harrison EM. Whole genome sequencing reveals transmission of vancomycin resistant Enterococcus faecium in a healthcare network. Genome Med 2016; 12; 8(1):4.
EP
5. Willems RJ, Top J, Van Schaik W, Leavis H, Bonten M, Sirén J, et al. Restricted gene flow among hospital subpopulations of Enterococcus faecium.
AC C
MBio 2012; 17:3(4).
6. Alevizakos M, Gaitanidis A, Nasioudis D, Tori K, Flokas ME, Mylomakis E. Colonization with vancomycin-resistant enterococci and risk for bloodstream infection among patients with malignancy: a systematic review and metaanalysis. Open Forum Infect Dis 2016; 7:4(1). 7. Kaufmann ME. Pulsed-field gel electrophoresis: In: Woodford N, Johnson AP, editors. Methods in molecular medicine 15: molecular bacteriology: protocols and clinical applications. New Jersey: Humana Press 1998; 33-50.
7
ACCEPTED MANUSCRIPT 8. Garvey MI, Bradley CW, Jumaa P. Environmental decontamination following occupancy of a burns patient with multiple carbapenemase producing organisms. J Hosp Infect 2016; 93: 136-40. 9. Shams AM, Rose LJ, Edwards JR, Cali S, Harris AD, Jacob JT, et al.
RI PT
Assessment of the overall and multidrug-resistant organism bioburden on environmental surfaces in healthcare facilities. Infect Control Hosp Epidemiol
AC C
EP
TE D
M AN U
SC
2016: 37(12): 1426-1432.
8
ACCEPTED MANUSCRIPT
RI PT
TABLE Table 1. Details of 10 surfaces tested during environmental sampling using polywipe sponges (surface area ~30cm2); both the
vanA positive vanA negative
Bedside TV Fan Door touch points Communal area surfaces tested Drip stand Ward computer Linen trolley IV preparation room
vanA negative vanA negative vanA negative
EP
Fridge Bedside table
AC C
vanA positive vanA positive vanA positive vanA positive
Culture results (before enhanced cleaning) * Staphylococcus haemolyticus Enterococcus faecium and Acinetobacter baumannii Staphylococcus epidermidis Enterococcus faecium and Acinetobacter baumannii Enterococcus faecium Staphylococcus haemolyticus
TE D
Surface tested Surface areas in vicinity of patient vanA positive Bathroom touch points
M AN U
PCR results (before enhanced cleaning)
SC
vanA PCR and culture results are shown.
Pseudomonas putida Enterococcus faecium Negative Negative
*All organisms idnetified via MALDI-TOF and sensitivities confirmed via Vitek.
1