Multidrug-resistant OXA-48/CTX-M-15 Klebsiella pneumoniae cluster in a COVID-19 intensive care unit: salient lessons for infection prevention and control during the COVID-19 pandemic.

BACKGROUND: Wards caring for COVID-19 patients, including intensive care units (ICUs), have an important focus on preventing transmission of SARS-CoV-2 to other patients and healthcare workers. AIM: To describe an outbreak of carbapenemase-producing Enterobacterales (CPE) in a COVID-19 ICU and to discuss key infection control measures enabling prompt termination of the cluster. METHODS: CPE were isolated from clinical specimens and screening swabs from intensive care patients with COVID-19 disease and from environmental screening. Whole-genome sequencing analysis was instrumental in informing phylogenetic relationships. FINDINGS: Seven clinical isolates and one environmental carbapenemase-producing Klebsiella pneumoniae isolate - all carrying OXA-48, CTX-M-15 and outer membrane porin mutations in ompK35/ompK36 - were identified with ≤1 single nucleotide polymorphism difference, indicative of clonality. A bundle of infection control interventions including careful adherence with contact precautions and hand hygiene, twice weekly screening for multidrug-resistant organisms, strict antimicrobial stewardship, and enhanced cleaning protocols promptly terminated the outbreak. CONCLUSION: Prolonged use of personal protective equipment is common with donning and doffing stations at the ward entrance, leaving healthcare workers prone to reduced hand hygiene practices between patients. Minimizing transmission of pathogens other than SARS-CoV-2 by careful adherence to normal contact precautions including hand hygiene, even during high patient contact manoeuvres, is critical to prevent outbreaks of multidrug-resistant organisms. Appropriate antimicrobial stewardship and screening for multidrug-resistant organisms must also be maintained throughout surge periods to prevent medium-term escalation in antimicrobial resistance rates. Whole-genome sequencing is highly informative for multidrug-resistant Enterobacterales surveillance strategies.

Evidence for decontamination of single-use filtering facepiece respirators.

Single-use filtering face respirators (FFRs) are critical pieces of personal protective equipment for healthcare workers treating patients with suspected upper respiratory tract pathogens. Experiences during pandemics in the 2000s, as well as the ongoing COVID-19 pandemic caused by the SARS-2-CoV-2, have highlighted concerns over the pressures that sustained respiratory virus pandemics may have on supplies of FFRs globally. Decontamination of FFRs has been posited as one solution to support the re-use of FFRs with a growing body of literature over the last 10+ years beginning to examine both the efficacy of disinfection of contaminated FFRs but also the impact of the decontamination process on the FFR's performance. Physical and chemical methods of decontamination have been tested for treatment of FFRs with ultraviolet germicidal irradiation, sterilization by steam, ethylene oxide and vaporous hydrogen peroxide, demonstrating the most promising results thus far. Many of these methods utilize existing equipment that may already be available in hospitals and could be re-purposed for FFR decontamination. Importantly, some methods may also be replicated on household equipment, broadening the utility of FFR decontamination across a range of healthcare settings. Utilizing techniques to experimentally contaminate FFRs with a range of microorganisms, most decontamination methods appear to reduce the risk of the mask as a source of infection to the wearer and others to negligible levels. The performance of the filter, especially the efficiency of particle penetration following treatment, varied greatly depending on the processing method as well as the model of the filter itself, however. Urgent regulatory body-supported research is required to endorse the routine decontamination of FFRs. In emergency settings, these methods should nevertheless be carefully considered as one strategy to address potential shortfalls in supplies of FFRs for healthcare workers.