The hospital environment is a potential reservoir of bacteria with plasmids conferring carbapenem resistance. Our Hospital Epidemiology Service routinely performs extensive sampling of high-touch surfaces, sinks, and other locations in the hospital. Over a 2-year period, additional sampling was conducted at a broader range of locations, including housekeeping closets, wastewater from hospital internal pipes, and external manholes. We compared these data with previously collected information from 5 years of patient clinical and surveillance isolates. Whole-genome sequencing and analysis of 108 isolates provided comprehensive characterization of bla KPC /bla NDM -positive isolates, enabling an in-depth genetic comparison. Strikingly, despite a very low prevalence of patient infections with bla KPC -positive organisms, all samples from the intensive care unit pipe wastewater and external manholes contained carbapenemase-producing organisms (CPOs), suggesting a vast, resilient reservoir. We observed a diverse set of species and plasmids, and we noted species and susceptibility profile differences between environmental and patient populations of CPOs. However, there were plasmid backbones common to both populations, highlighting a potential environmental reservoir of mobile elements that may contribute to the spread of resistance genes. Clear associations between patient and environmental isolates were uncommon based on sequence analysis and epidemiology, suggesting reasonable infection control compliance at our institution. Nonetheless, a probable nosocomial transmission of Leclercia sp. from the housekeeping environment to a patient was detected by this extensive surveillance. These data and analyses further our understanding of CPOs in the hospital environment and are broadly relevant to the design of infection control strategies in many infrastructure settings.IMPORTANCE Carbapenemase-producing organisms (CPOs) are a global concern because of the morbidity and mortality associated with these resistant Gramnegative bacteria. Horizontal plasmid transfer spreads the resistance mechanism to new bacteria, and understanding the plasmid ecology of the hospital environment can assist in the design of control strategies to prevent nosocomial infections. A 5-year genomic and epidemiological survey was undertaken to study the CPOs in the patient-accessible environment, as well as in the plumbing system removed from the patient. This comprehensive survey revealed a vast, unappreciated reservoir of CPOs in wastewater, which was in contrast to the low positivity rate in both the patient population and the patient-accessible environment. While there were few patient-environmental isolate associations, there were plasmid backbones common to both populations. These results are relevant to all hospitals for which CPO colonization may not yet be defined through extensive surveillance.

In September 2014, the National Institutes of Health (NIH) Clinical Center admitted as a patient a physician who had been working in an Ebola treatment unit in Sierra Leone and who had sustained a high-risk needle-stick exposure to Ebola virus. He was flown to the United States, and was admitted to the NIH Clinical Center's Special Clinical Studies Unit (SCSU), a high-containment infectious diseases ward. Although the patient arrived with symptoms consistent with Ebola virus disease (EVD), he fortunately did not develop the infection and was discharged 10 days later. In October 2014, a nurse who was diagnosed with EVD after providing care to a Liberian man who had developed fulminant EVD and died at the Dallas hospital where she worked was transferred to our hospital. She received supportive care, recovered, and was discharged 8 days later.

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BackgroundThe NIH Clinical Center conducts patient and environmental surveillance for carbapenemase-producing organisms (CPO). Previous investigation revealed that sink drains can become colonized with CPO. Subsequent surveillance targets included potential aqueous reservoirs, such as floor drains of environmental services (EVS) closets.MethodsPremoistened swabs were used to culture sink drains, floor drains, and equipment for CPO. Perirectal swabs were ordered monthly for all patients in non-behavioral health wards. Specimens were plated to CRE- and ESBL-selective media, and colonies identified by MALDI-TOF. The presence of the blaKPC gene was confirmed by PCR. When environmental CPO isolates were detected, EVS procedures and practices were reviewed.ResultsIn June 2016, blaKPC+ Leclercia adecarboxylata was isolated from an EVS closet floor drain, and in August 2016, from drains in four additional closets. In the previous 10 years, Leclercia sp. was isolated just once from a clinical culture. In September 2016, routine surveillance revealed new-onset blaKPC+ L. adecarboxylata colonization in a stem cell transplant recipient. Investigation included 33 cultures collected from sink and floor drains, EVS equipment, and other items. EVS equipment, especially mop buckets, were identified as a likely point source due to their use in patient care areas and closets with contaminated floor drains. Among seven mop buckets sampled, one grew blaKPC+ L. adecarboxylata. Whole genome sequencing demonstrated genetic relatedness of the Leclercia isolates. Floor cleaner was changed to a disinfectant solution. Extensive decontamination of 67 EVS closets and equipment was performed urgently. No further patient or environmental cultures have grown blaKPC+ L. adecarboxylata.ConclusionThe recovery of a highly unusual organism, rarely found in clinical specimens, that was also carrying a blaKPC+ plasmid, allowed us to detect environmental spread of this organism in the hospital. The ability to track this organism using genome sequencing provided strong evidence of the mode of spread, leading to effective remediation. No evidence-based methods exist for remediating drain contamination, which can serve as a potential reservoir for transmission.Disclosures All authors: No reported disclosures.