What happens in the dirty utility should stay in the dirty utility

Leanne Houston 1, Jane Stafford 1, Helen Marquand 1, Andrea Bailey 1, Rosalyn Carmichael 1, Mary O’Reilly 1

Eastern Health, Melbourne, VIC, Australia


In April 2016 Carbapenem resistant Pseudomonas aeruginosa (CRPA) was identified in clinical isolates within a 7 day period from two patients who had been admitted to same ward. Both isolates were identified in peritoneal dialysis fluid and neither patient exhibited signs of infection.
An investigation was commenced to identify potential mode of transmission.

A clinical review of both patients including previous hospital admissions at our facility, history of healthcare provided at other facilities or overseas and overseas travel was undertaken. Ward staff were interviewed regarding methods and processes for collecting peritoneal dialysis specimens as it was identified that both specimens had been collected in the same utility room using a method that was not consistent with standard processes.
Following a visual inspection of the implicated utility room environmental samples were taken under the rim of the sink, drain cover and drain of a rim flush sink that was identified as a potential source of contamination. Other environmental samples from items that were identified as potential sources were also taken.

Both clinical isolates and positive environmental isolates identified the blaIMP-7 gene that is uncommon in Australian hospitals. This gene had not previously been identified in any isolates at our facility.

This investigation whilst ongoing has highlighted the importance of collaboration between Infection Prevention & Control, Healthcare Workers and Support Services to reduce the risk to our patients of acquiring infections associated with resistant organisms.

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