Paige Gable

Objective: To investigate and halt transmission of Burkholderia multivorans at hospitals reporting B. multivorans outbreaks in California between September 2020 and February 2023. Methods: Case-patients were defined as adults without cystic fibrosis with B. multivorans isolated from any specimen source collected while an inpatient at an affected facility from January 2020 through February 2023 and confirmed as the outbreak strain by random amplified polymorphic DNA testing and repetitive extragenic palindromic polymerase chain reaction. We reviewed medical records to describe case-patients and identify common exposures; observations and staff interviews were completed to detect exposures to non-sterile water. Environmental samples and commercial products were tested for presence of B. multivorans. All B. multivorans isolates underwent whole genome sequencing. Results: We identified 25 case-patients. Most case-patients (n = 22, 88%) were hospitalized at the same hospital and received care in an intensive care unit (n = 17, 68%). Healthcare personnel reported using water and ice from ice machines for patient bathing, swallow evaluations, and pain relief. B. multivorans was identified from two ice machines at the hospital with the most case-patients in March 2022 and July 2022. All hospitals used the same brand of ice machine, filters, descaling, and sanitizing products. Clinical and ice machine B. multivorans isolates matched the outbreak strain. Conclusions: The use of water and ice from contaminated ice machines likely contributed to this outbreak. Ice machines can serve as reservoirs for Burkholderia spp. and should be investigated as sources of transmission during outbreaks of water-associated organisms in healthcare settings.

Objective: Nontuberculous mycobacteria (NTM) are commonly found in healthcare facility water systems and can lead to serious and difficult-to-treat infections. We analyzed Centers for Disease Control and Prevention (CDC) consultations of water-related healthcare-associated infections (HAI) investigations involving NTM. Design: Retrospective observational study. Methods: We searched CDC consultation records from January 1, 2018, through December 31, 2024, using water-related terms and organisms, excluding Legionella , to identify and review investigations involving potential or confirmed transmission of water-related organisms; we reviewed investigations that involved NTM. Results: Among 1,458 consultations, we identified 639 (43.8%) water-related investigations involving 4,685 patients and 60 different organisms. Investigations involving NTM accounted for 10.3% (n = 66) with 15 NTM species identified. Among NTM-related investigations, almost half involved M. abscessus (n = 31, 47.0%) and two-thirds (n = 44, 66.7%) involved extrapulmonary infections only. More than half of identified NTM investigations (n = 37, 56.1%) occurred in hospitals and over one-third (n = 23, 34.8%) in outpatient settings. Exposures to surgery (n = 27, 40.9%) and medical products (e.g., medical devices, medications, and biological products) (n = 35, 53.0%) were common. Conclusions: Over this seven-year period, approximately one-tenth of CDC healthcare water-related consultations involved NTM. The majority involved extrapulmonary infections, with surgery and exposure to contaminated medical products representing the most common exposures of concern. These findings highlight the potential for NTM infections when water-related healthcare exposures occur. Healthcare facilities are encouraged to identify the potential for exposure to nonsterile water during surgery, during the use of medical devices, and during the preparation and administration of medications to reduce the risk from NTM.

A pictographic representation of the text abstract showing wastewater and epidemiologic data flow and data integration. To understand the utility of healthcare facility-level wastewater surveillance (WWS) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is important to correlate wastewater SARS-CoV-2 RNA detection with the number of clinical infections. WWS for SARS-CoV-2 was performed at three skilled nursing facilities (SNFs) over 25 weeks. Electronegative membrane filtration (enMF) and Nanotrap® Magnetic Virus Particles (NP) virus concentration methods were compared. Extracts were tested by droplet digital polymerase chain reaction. Spearman's correlations (ρ) between wastewater virus RNA concentrations and infection counts were calculated. From split wastewater samples, enMF recovered higher SARS-CoV-2 RNA concentrations than NP. Combining data from all facilities, the median concentrations were 53.0 versus 38.6 gc/100 mL for enMF and NP, respectively (p = 0.001). Using enMF, correlations were moderate to strong at SNF A (ρ ranged 0.67–0.86, all p-values <0.001). Weak to moderate correlations may reflect the sampled manhole not representing the entire facility (SNF B, ρ ranged 0.47–0.72, p-values ranged <0.001–0.12) and longitudinal data gaps from summer heat and equipment maintenance (SNF C, ρ ranged 0.14–0.59, p-values ranged<0.01 to 0.52). WWS can be a valuable tool for tracking dynamics of SARS-CoV-2 infections in healthcare facilities.

The purpose of this study was to determine the feasibility of facility-level wastewater surveillance in the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in skilled nursing facility (SNF) wastewater using three concentration methods, as well as a proof-of-concept for antimicrobial resistance (AR) genes/organisms detection. Wastewater effluent samples were collected from an SNF over an 8-week period. Wastewater was concentrated using electronegative membrane filtration (enMF), polyethylene glycol precipitation, and Nanotrap® magnetic virus particles (NP). Quantification of the genome copy concentration from SARS-CoV-2 and bovine respiratory syncytial virus (BRSV), a SARS-CoV-2 surrogate spiked into all samples, was performed with droplet digital polymerase chain reaction (ddPCR). Wastewater sample aliquots were also enriched in microbiological culture media and screened for organisms with AR phenotypes on selective and differential agars. Multiplex real-time PCR was used to detect a broad array of carbapenem resistance genes. SARS-CoV-2 was detected and quantified from a single enMF-concentrated wastewater sample. The highest concentration of BRSV came from enMF-concentrated samples. Klebsiella, Enterobacter, Citrobacter, and Escherichia coli exhibiting AR phenotypes were successfully detected using culture-dependent approaches. Culture-independent, multiplex PCR indicated that blaKPC was the main carbapenemase gene detected in wastewater samples. Facility-level wastewater surveillance could be a useful strategy for SNFs.

Objective: We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying bla_VIM (VIM-CRPA) and Enterobacterales carrying bla_KPC (KPC-CRE) at a long-term acute-care hospital (LTACH A).Methods: We defined an incident case as the first detection of bla_KPC or bla_VIM from a patient’s clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing.Results: From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had bla_KPC, 11 had bla_VIM, and 7 had bla_VIM and bla_KPC. Also, bla_KPC were identified from 7 Enterobacterales, and all bla_VIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates.Conclusions: Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. Epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of VIM-CRPA and KPC-CRE and to the transfer of carbapenemase genes across different bacteria species and strains. Improved infection control, including interventions that minimized potential spread from wastewater premise plumbing, stopped transmission.

Among nursing home outbreaks of coronavirus disease 2019 (COVID-19) with ≥3 breakthrough infections when the predominant severe acute respiratory coronavirus virus 2 (SARS-CoV-2) variant circulating was the SARS-CoV-2 δ (delta) variant, fully vaccinated residents were 28% less likely to be infected than were unvaccinated residents. Once infected, they had approximately half the risk for all-cause hospitalization and all-cause death compared with unvaccinated infected residents.

Oral fluids offer a noninvasive sampling method for the detection of Abs. Quantification of IgA and IgG Abs in saliva allows studies of the mucosal and systemic immune response after natural infection or vaccination. We developed and validated an enzyme immunoassay (EIA) to detect and quantify salivary IgA and IgG Abs against the prefusion-stabilized form of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein expressed in suspension-adapted HEK-293 cells. Normalization against total Ab isotype was performed to account for specimen differences, such as collection time and sample volume. Saliva samples collected from 187 SARS-CoV-2 confirmed cases enrolled in 2 cohorts and 373 prepandemic saliva samples were tested. The sensitivity of both EIAs was high (IgA, 95.5%; IgG, 89.7%) without compromising specificity (IgA, 99%; IgG, 97%). No cross-reactivity with endemic coronaviruses was observed. The limit of detection for SARS-CoV-2 salivary IgA and IgG assays were 1.98 ng/ml and 0.30 ng/ml, respectively. Salivary IgA and IgG Abs were detected earlier in patients with mild COVID-19 symptoms than in severe cases. However, severe cases showed higher salivary Ab titers than those with a mild infection. Salivary IgA titers quickly decreased after 6 wk in mild cases but remained detectable until at least week 10 in severe cases. Salivary IgG titers remained high for all patients, regardless of disease severity. In conclusion, EIAs for both IgA and IgG had high specificity and sensitivity for the confirmation of current or recent SARS-CoV-2 infections and evaluation of the IgA and IgG immune response.

Objective: To characterize and compare severe acute respiratory coronavirus virus 2 (SARS-CoV-2)–specific immune responses in plasma and gingival crevicular fluid (GCF) from nursing home residents during and after natural infection.Design: Prospective cohort.Setting: Nursing home.Participants: SARS-CoV-2–infected nursing home residents.Methods: A convenience sample of 14 SARS-CoV-2–infected nursing home residents, enrolled 4–13 days after real-time reverse transcription polymerase chain reaction diagnosis, were followed for 42 days. After diagnosis, plasma SARS-CoV-2–specific pan-Immunoglobulin (Ig), IgG, IgA, IgM, and neutralizing antibodies were measured at 5 time points, and GCF SARS-CoV-2–specific IgG and IgA were measured at 4 time points.Results: All participants demonstrated immune responses to SARS-CoV-2 infection. Among 12 phlebotomized participants, plasma was positive for pan-Ig and IgG in all 12 participants. Neutralizing antibodies were positive in 11 participants; IgM was positive in 10 participants, and IgA was positive in 9 participants. Among 14 participants with GCF specimens, GCF was positive for IgG in 13 participants and for IgA in 12 participants. Immunoglobulin responses in plasma and GCF had similar kinetics; median times to peak antibody response were similar across specimen types (4 weeks for IgG; 3 weeks for IgA). Participants with pan-Ig, IgG, and IgA detected in plasma and GCF IgG remained positive throughout this evaluation, 46–55 days after diagnosis. All participants were viral-culture negative by the first detection of antibodies.Conclusions: Nursing home residents had detectable SARS-CoV-2 antibodies in plasma and GCF after infection. Kinetics of antibodies detected in GCF mirrored those from plasma. Noninvasive GCF may be useful for detecting and monitoring immunologic responses in populations unable or unwilling to be phlebotomized.

On November 1, 2016, a point prevalence survey was conducted at a Chicago skilled nursing facility with ventilated residents to understand the prevalence of carbapenemase-producing organisms in health care facilities in the Chicago region. The survey identified 20 patients with Verona integron-encoded metallo-beta-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa.