Environmental contamination with an epidemic strain of Pseudomonas aeruginosa in a Liverpool cystic fibrosis centre, and study of its survival on dry surfaces
Introduction
Pseudomonas aeruginosa is a major pathogen in cystic fibrosis (CF) patients and the leading cause of morbidity and mortality. Most CF patients are ultimately colonized with P. aeruginosa, and once chronic infection is established, it is virtually impossible to eradicate.1, 2 However, the sources of acquisition and the means of transmission of the organism are not well understood. P. aeruginosa is ubiquitous in moist environments and it is found in many natural and domestic reservoirs including hospital sites. It has long been accepted that CF patients become colonized from diverse sources in the general environment.3 Indeed, most unrelated patients typically harbour their own unique strains of P. aeruginosa that persist for many years, indicating a low incidence of patient-to-patient spread or acquisition from a common source.4 On the other hand, cross-infection has been shown to occur in holiday camps5, 6 and there are well-documented reports of outbreaks involving highly transmissible, epidemic strains in a number of CF units including Liverpool.7, 8, 9 The mode of transmission of these epidemic strains is uncertain; however, direct patient-to-patient spread has been suggested given the failure to isolate the strains from the hospital environment. We conducted an environmental survey in the Liverpool adult CF centre in order to determine the extent of environmental contamination with the Liverpool epidemic strain (LES) to identify possible reservoirs and routes of cross-infection. In addition, we studied the survival of LES on dry surfaces compared with that of other CF P. aeruginosa strains to explore factors that might contribute to its high transmissibility.
Section snippets
Accommodation
The inpatient CF ward of the Cardiothoracic Centre, Liverpool, UK, consists of 12 single rooms including five with en-suite facilities. Communal areas include a lounge and kitchen, one bathroom, one shower room and two toilets. Hospitalized patients receive all treatment, including nebulization and physiotherapy, in their own room with the door closed and are advised to avoid social contact with other patients on the ward.
The outpatient clinic is located in another part of the hospital and
Inpatient ward
One hundred and fourteen samples from staff, patients and inanimate surfaces (Table I) and 23 air samples from 11 cubicles, the ward corridor and the lounge were examined (Table II). P. aeruginosa was isolated from the shared bathroom/toilet/shower handles and surfaces, as well as the toilet handles in two cubicles with en-suite facilities, but none of these isolates was LES. Only the shared toilet was persistently positive for P. aeruginosa on repeat sampling. The other sites were positive on
Discussion
Recent reports of epidemic spread of transmissible P. aeruginosa strains among patients attending CF clinics worldwide have provided clear evidence to support the occurrence of cross-infection between CF patients, and have generated controversy on infection control practices and the management of these patients.3, 11, 12 LES not only colonizes most CF patients in Liverpool, but is also found in several other CF centres in the UK.13 We undertook the present study to investigate the means by
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