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Sink traps as the source of transmission of OXA-48–producing Serratia marcescens in an intensive care unit

  • Gili Regev-Yochay (a1) (a2), Gill Smollan (a3), Ilana Tal (a1), Nani Pinas Zade (a1), Yael Haviv (a4), Valery Nudelman (a4), Ohad Gal-Mor (a2) (a5), Hanaa Jaber (a1), Eyal Zimlichman (a6), Nati Keller (a3) (a7) and Galia Rahav (a2) (a8)...

Carbapenemase-producing Enterobacteriaceae (CPE) outbreaks are mostly attributed to patient-to-patient transmission via healthcare workers.


We describe successful containment of a prolonged OXA-48–producing S. marcescens outbreak after recognizing the sink traps as the source of transmission.


The Sheba Medical Center intensive care unit (ICU), contains 16 single-bed, semi-closed rooms. Active CPE surveillance includes twice-weekly rectal screening of all patients. A case was defined as a patient detected with OXA-48 CPE >72 hours after admission. A root-cause analysis was used to investigate the outbreak. All samples were inoculated on chrom-agar CRE, and carbapenemase genes were detected using commercial molecular Xpert-Carba-R. Environmental and patient S. marcescens isolates were characterized using PFGE.


From January 2016 to May 2017, 32 OXA-48 CPE cases were detected, and 81% of these were S. marcescens. A single clone was the cause of all but the first 2 cases. The common factor in all cases was the use of relatively large amounts of tap water. The outbreak clone was detected in 2 sink outlets and 16 sink traps. In addition to routine strict infection control measures, measures taken to contain the outbreak included (1) various sink decontamination efforts, which eliminated the bacteria from the sink drains only temporarily and (2) educational intervention that engaged the ICU team and lead to high adherence to ‘sink-contamination prevention guidelines.’ No additional cases were detected for 12 months.


Despite persistence of the outbreak clones in the environmental reservoir for 1 year, the outbreak was rapidly and successfully contained. Addressing sink traps as hidden reservoirs played a major role in the intervention.

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Corresponding author
Author for correspondence: Gili Regev-Yochay, Infection Prevention and Control Unit, Sheba Medical Center, Ramat Gan, Israel. E-mail:
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1. Schwaber, MJ, Carmeli, Y. An ongoing national intervention to contain the spread of carbapenem-resistant Enterobacteriaceae. Clin Infect Dis 2014;58:697703.
2. Poirel, L, Heritier, C, Tolun, V, Nordmann, P. Emergence of oxacillinase-mediated resistance to imipenem in Klebsiella pneumoniae . Antimicrob Agent Chemother 2004;48:1522.
3. Mataseje, LF, Boyd, DA, Fuller, J, et al. Characterization of OXA-48–like carbapenemase producers in Canada, 2011–2014. J Antimicrob Chemother 2017. doi: 10.1093/jac/dkx462.
4. Adler, A, Solter, E, Masarwa, S, et al. Epidemiological and microbiological characteristics of an outbreak caused by OXA-48–producing Enterobacteriaceae in a neonatal intensive care unit in Jerusalem, Israel. J Clin Microbiol 2013; 51:29262930.
5. Goren, MG, Chmelnitsky, I, Carmeli, Y, Navon-Venezia, S. Plasmid-encoded OXA-48 carbapenemase in Escherichia coli from Israel. J Antimicrob Chemother 2011; 66:672673.
6. Lerner, A, Solter, E, Rachi, E, et al. Detection and characterization of carbapenemase-producing Enterobacteriaceae in wounded Syrian patients admitted to hospitals in northern Israel. Eur J Clin Microbiol Infect Dis 2016;35:149154.
7. Friedman, ND, Carmeli, Y, Walton, AL, Schwaber, MJ. Carbapenem-resistant Enterobacteriaceae: a strategic roadmap for infection control. Infect Control Hosp Epidemiol 2017;38:580594.
8. Ribot, EM, Fair, MA, Gautom, R, et al. Standardization of pulsed-field gel electrophoresis protocols for the subtyping of Escherichia coli O157:H7, Salmonella, and Shigella for PulseNet. Foodborne Pathogen Dis 2006;3:5967.
9. Stjarne Aspelund, A, Sjostrom, K, Olsson Liljequist, B, Morgelin, M, Melander, E, Pahlman, LI. Acetic acid as a decontamination method for sink drains in a nosocomial outbreak of metallo-beta-lactamase–producing Pseudomonas aeruginosa . J Hosp Infect 2016;94:1320.
10. Wolf, I, Bergervoet, PW, Sebens, FW, van den Oever, HL, Savelkoul, PH, van der Zwet, WC. The sink as a correctable source of extended-spectrum beta-lactamase contamination for patients in the intensive care unit. J Hosp Infect 2014;87:126130.
11. Kanamori, H, Weber, DJ, Rutala, WA. Healthcare outbreaks associated with a water reservoir and infection prevention strategies. Clin Infect Dis 2016; 62:14231435.
12. Kizny Gordon, AE, Mathers, AJ, Cheong, EYL, et al. The hospital water environment as a reservoir for carbapenem-resistant organisms causing hospital-acquired infections—a systematic review of the literature. Clin Infect Dis 2017;64:14351444.
13. Lalancette, C, Charron, D, Laferriere, C, et al. Hospital drains as reservoirs of Pseudomonas aeruginosa: multiple-locus variable-number of tandem repeats analysis genotypes recovered from faucets, sink surfaces and patients. Pathogens. 2017;6(3). doi: 10.3390/pathogens6030036.
14. Salm, F, Deja, M, Gastmeier, P, et al. Prolonged outbreak of clonal MDR Pseudomonas aeruginosa on an intensive care unit: contaminated sinks and contamination of ultra-filtrate bags as possible route of transmission? Antimicrob Resist Infect Control 2016; 5: 53.
15. Leitner, E, Zarfel, G, Luxner, J, et al. Contaminated handwashing sinks as the source of a clonal outbreak of KPC-2–producing Klebsiella oxytoca on a hematology ward. Antimicrob Agent Chemother 2015;59:714716.
16. Betteridge, T, Merlino, J, Natoli, J, Cheong, EY, Gottlieb, T, Stokes, HW. Plasmids and bacterial strains mediating multidrug-resistant hospital-acquired infections are coresidents of the hospital environment. Microb Drug Resist 2013; 19:104109.
17. Tofteland, S, Naseer, U, Lislevand, JH, Sundsfjord, A, Samuelsen, O. A long-term low-frequency hospital outbreak of KPC-producing Klebsiella pneumoniae involving intergenus plasmid diffusion and a persisting environmental reservoir. PloS One 2013;8:e59015.
18. De Geyter, D, Blommaert, L, Verbraeken, N, et al. The sink as a potential source of transmission of carbapenemase-producing Enterobacteriaceae in the intensive care unit. Antimicrob Resist Infect Control 2017;6:24.
19. Us, E, Kutlu, HH, Tekeli, A, Ocal, D, Cirpan, S, Memikoglu, KO. Wound and soft-tissue infections of Serratia marcescens in patients receiving wound care: a healthcare-associated outbreak. Am J Infect Control 2017;45:443447.
20. Morillo, A, Torres, MJ, Alonso Salas, MT, Conde, M, Aznar, J. Implication of a national outbreak of Serratia marcescens associated with a contaminated solution of chlorhexidine in a paediatric hospital. An Pediatr (Barc) Mar 2018;88:171172.
21. Merino, JL, Bouarich, H, Pita, MJ, et al. Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience at 4 hospitals. Nefrologia 2016;36:667673.
22. de Frutos, M, Lopez-Urrutia, L, Dominguez-Gil, M, et al. Serratia marcescens outbreak due to contaminated 2% aqueous chlorhexidine. Enferm Infec Microbiol Clin 2017;35:624629.
23. Chiang, PC, Wu, TL, Kuo, AJ, et al. Outbreak of Serratia marcescens postsurgical bloodstream infection due to contaminated intravenous pain control fluids. Int J Infect Dis 2013;17:e718e722.
24. Ivady, B, Szabo, D, Damjanova, I, Pataki, M, Szabo, M, Kenesei, E. Recurrent outbreaks of Serratia marcescens among neonates and infants at a pediatric department: an outbreak analysis. Infection 2014;42:891898.
25. Kotsanas, D, Wijesooriya, WR, Korman, TM, et al. “Down the drain”: carbapenem-resistant bacteria in intensive care unit patients and handwashing sinks. Med J Austral 2013;198:267269.
26. Leung, GH, Gray, TJ, Cheong, EY, Haertsch, P, Gottlieb, T. Persistence of related bla-IMP-4 metallo-beta-lactamase–producing Enterobacteriaceae from clinical and environmental specimens within a burns unit in Australia—a six-year retrospective study. Antimicrob Resist Infect Control 2013;2:35.
27. Mathers, AJ, Vegesana, K, German Mesner, I, et al. Intensive care unit wastewater interventions to prevent transmission of multi-species Klebsiella pneumoniae carbapenemase (KPC) producing organisms. Clin Infect Dis 2018;67:171178.
28. Hota, S, Hirji, Z, Stockton, K, et al. Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design. Infect Control Hosp Epidemiol 2009; 30:2533.
29. Kotay, S, Chai, W, Guilford, W, Barry, K, Mathers, AJ. Spread from the sink to the patient: in situ study using green fluorescent protein (GFP)-expressing Escherichia coli to model bacterial dispersion from hand-washing sink-trap reservoirs. Appl Envir Microbiol 2017;83(8):e0332716.
30. Arana, DM, Saez, D, Garcia-Hierro, P, et al. Concurrent interspecies and clonal dissemination of OXA-48 carbapenemase. Clin Microbiol Infect 2015;21:148:e141e144.
31. Weingarten, RA, Johnson, RC, Conlan, S, et al. Genomic analysis of hospital plumbing reveals diverse reservoir of bacterial plasmids conferring carbapenem resistance. mBio 2018;9:e0201117.
32. Hopman, J, Tostmann, A, Wertheim, H, et al. Reduced rate of intensive care unit acquired gram-negative bacilli after removal of sinks and introduction of ‘water-free’ patient care. Antimicrob Resist Infect Control 2017;6:59.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
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