key: cord-0948565-m5pe8kr4 authors: Farfour, Eric; Lecuru, Marion; Dortet, Laurent; Guen, Morgan Le; Cerf, Charles; Karnycheff, Françoise; Bonnin, Rémy A.; Vasse, Marc; Lesprit, Philippe title: Carbapenemase-producing Enterobacterales outbreak: another dark side of COVID-19 date: 2020-10-02 journal: Am J Infect Control DOI: 10.1016/j.ajic.2020.09.015 sha: ff4be661fc73aa9bfae0d1c69906efc9a78d929f doc_id: 948565 cord_uid: m5pe8kr4 In the hospital department dedicated to COVID-19-patient, infection prevention and control measures were upgraded. Therefore, the cross-transmission of other micro-organisms was thought unlikely to occur. However, we report an outbreak of NDM-5-producing E. coli in a 12-beds ICU dedicated to COVID-19 patients. This outbreak involved 6 patients of which 5 were asymptomatic carriers and 1 was infected. Several findings might have contributed to cross-transmission including the multiple-bedroom configuration of the department, uncomplete compliance for standard and contact precautions, overwork due to the burden of the disease, lack of training of staff for the care of ICU-patients, and misuse of gloves. Furthermore, as infection prevention and control measures were thought to be the applied, contact patients were not screened for eXDR carriage. Applying rigorously standard and contact precautions and performing screening in contact patients when indicated must be the rules in COVID-19 wards. In the hospital department dedicated to COVID-19-patient, infection prevention and control measures were upgraded. Therefore, the cross-transmission of other micro-organisms was thought unlikely to occur. However, we report an outbreak of NDM-5-producing E. coli in a 12-beds ICU dedicated to COVID-19 patients. This outbreak involved 6 patients of which 5 were asymptomatic carriers and 1 was infected. Several findings might have contributed to cross-transmission including the multiple- As recommended by French guidelines, CPE carriage was screened in all contact patients, and those with a previous history of hospitalization outside of France within the past year. 6 Contacts patients were defined as those for whom inpatient care involved sharing para-medical healthcare workers with one or more carrier patients for at least 24 hours and where there has been direct contact between the healthcare workers and the patients. 6 Three consecutive CPE screening separated by at least 5 days were performed in each contact patients as recommended. 6 Discharged patients were considered lost to follow-up. Rectal swabs were processed by a molecular method and/or a selective culture as described in the previous section. NDM-5-producing E. coli isolates were sequenced using Illumina technology as previously described. 9 Total DNA was extracted from colonies using the Ultraclean Microbial DNA Isolation Kit (MO BIO Laboratories, Ozyme, Saint-Quentin, France) following the manufacturer's instructions. The DNA library was prepared as described. 9 De novo assembly and read mappings were performed using CLC Genomics Workbench v12.0 (Qiagen, Les Ulis, France). The acquired antimicrobial resistance genes were identified using Resfinder server v3. The prevention of micro-organisms transmission required a rigorous application of IPC measures, 6 which should be implemented according to a case-by-case analysis risk. In the atypical context of the COVID-19 pandemic, we considered the risk of cross-transmission was low, as contact precautions were upgraded and applied to all patients of the COVID-department. Consequently, we decided not to screen contact patients. This strategy was not effective, as an outbreak involving 6 cases occurs but resolved when screening of contact patients was applied. Several findings might have contributed to the spread of the NDM-5-producing E. coli strain. First, the geographical configuration of the PACU transformed in a multiple bed-room COVID-ICU might have favored the transmission of micro-organisms by inoculation of the environment. However, cleaning was performed at least twice a day and it was previously demonstrated that applying contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single bedroom. 10 But, in the present outbreak, patient's beds were closely located. This latter finding suggests that incomplete compliance of standard and contact precautions was probably a cause of the present outbreak. The overwork due to the burden in care could have led to less vigilance of medical and paramedical staff and punctual low compliance for contact precaution. Understaffing which can be assessed by the healthcare worker: patient ratio was previously associated with a higher risk of eXDR cross-transmission. 4 Despite sufficient staff, the burden of care for these patients in prone positions was high. Then, the implementation of COVID-19 IPC measures that are more restrictive than those for eXDR could have falsely reassured medical and paramedical staff. The lack of training has also been associated with lower adherence to IPC measures. 11 In the present context, medical and paramedical staff were mainly those of the PACU which were not usually in charge of ICU patients. We introduced the practice of wearing gloves and gowns anytime in order to protect staff. However, misuse of PPE has been previously associated with an increased risk of crosstransmission. 12, 13 Specifically, an outbreak of Imipenem-resistant Acinetobacter baumanii related to the misuse of gloves was previously described. 14 16 In conclusion, despite the implementation of upgraded ICP measures in the context of the COVID-19 pandemic, CPE outbreak may occur in COVID-19 departments. Several changes could have contributed to this outbreak such as overwork, misuse of PPE, and low compliance for standard and contact precaution. We believe the absence of screening in contact-patient has probably led to a delay in the identification of the outbreak. Therefore, we emphasize the need for applying rigorously standard precaution at all time. Applying contact precaution for eXDR carriers and performing screening in contact patients must be the rule. The authors state they have no conflict of interest to declare. Scale bar on tree indicates the number of single-nucleotide polymorpisms per position of common sequences. SNPs matrix was obtained from CSI phylogeny (https://cge.cbs.dtu.dk/services/CSIPhylogeny/). Rapidly increasing cumulative incidence of coronavirus disease (COVID-19) in the European Union/European Economic Area and the United Kingdom World Health Organization. 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None.