Simon Parks

Insidious risk of severe mycobacterium chimaera infection in cardiac surgery patients

Background. An urgent UK investigation was launched to assess risk of invasive Mycobacterium chimaera infection in cardiothoracic surgery and a possible association with cardiopulmonary bypass heater-cooler units following alerts in Switzerland and The Netherlands. Methods. Parallel investigations were pursued: (1) identification of cardiopulmonary bypass–associated M. chimaera infection through national laboratory and hospital admissions data linkage; (2) cohort study to assess patient risk; (3) microbiological and aerobiological investigations of heater-coolers in situ and under controlled laboratory conditions; and (4) whole-genome sequencing of clinical and environmental isolates. Results. Eighteen probable cases of cardiopulmonary bypass–associated M. chimaera infection were identified; all except one occurred in adults. Patients had undergone valve replacement in 11 hospitals between 2007 and 2015, a median of 19 months prior to onset (range, 3 months to 5 years). Risk to patients increased after 2010 from <0.2 to 1.65 per 10000 person-years in 2013, a 9-fold rise for infections within 2 years of surgery (rate ratio, 9.08 [95% CI, 1.81–87.76]). Endocarditis was the most common presentation (n = 11). To date, 9 patients have died. Investigations identified aerosol release through breaches in heater-cooler tanks. Mycobacterium chimaera and other pathogens were recovered from water and air samples. Phylogenetic analysis found close clustering of strains from probable cases. Conclusions. We identified low but escalating risk of severe M. chimaera infection associated with heater-coolers with cases in a quarter of cardiothoracic centers. Our investigations strengthen etiological evidence for the role of heater-coolers in transmission and raise the possibility of an ongoing, international point-source outbreak. Active management of heater-coolers and heightened clinical awareness are imperative given the consequences of infection.

Reaerosolization of Spores from Flooring Surfaces To Assess the Risk of Dissemination and Transmission of Infections

ABSTRACT The aim of this study was to quantify reaerosolization of microorganisms caused by walking on contaminated flooring to assess the risk to individuals accessing areas contaminated with pathogenic organisms, for example, spores of Bacillus anthracis. Industrial carpet and polyvinyl chloride (PVC) floor coverings were contaminated with aerosolized spores of Bacillus atrophaeus by using an artist airbrush to produce deposition of ∼103 to 104 CFU · cm−2. Microbiological air samplers were used to quantify the particle size distribution of the aerosol generated when a person walked over the floorings in an environmental chamber. Results were expressed as reaerosolization factors (percent per square centimeter per liter), to represent the ratio of air concentration to surface concentration generated. Walking on carpet generated a statistically significantly higher reaerosolization factor value than did walking on PVC (t = 20.42; P < 0.001). Heavier walking produced a statistically significantly higher reaerosolization factor value than did lighter walking (t = 12.421; P < 0.001). Height also had a statistically significant effect on the reaerosolization factor, with higher rates of recovery of B. atrophaeus at lower levels, demonstrating a height-dependent gradient of particle reaerosolization. Particles in the respirable size range were recovered in all sampling scenarios (mass mean diameters ranged from 2.6 to 4.1 μm). The results of this study can be used to produce a risk assessment of the potential aerosol exposure of a person accessing areas with contaminated flooring in order to inform the choice of appropriate respiratory protective equipment and may aid in the selection of the most suitable flooring types for use in health care environments, to reduce aerosol transmission in the event of contamination.

Biofilm formation in an experimental water distribution system: the contamination of non-touch sensor taps and the implication for healthcare

Hospital tap water is a recognised source of Pseudomonas aeruginosa. UK guidance documents recommend measures to control/minimise the risk of P. aeruginosa in augmented care units but these are based on limited scientific evidence. An experimental water distribution system was designed to investigate colonisation of hospital tap components. P. aeruginosa was injected into 27 individual tap ‘assemblies’. Taps were subsequently flushed twice daily and contamination levels monitored over two years. Tap assemblies were systematically dismantled and assessed microbiologically and the effect of removing potentially contaminated components was determined. P. aeruginosa was repeatedly recovered from the tap water at levels above the augmented care alert level. The organism was recovered from all dismantled solenoid valves with colonisation of the ethylene propylene diene monomer (EPDM) diaphragm confirmed by microscopy. Removing the solenoid valves reduced P. aeruginosa counts in the water to below detectable levels. This effect was immediate and sustained, implicating the solenoid diaphragm as the primary contamination source.

Quantification of Microbial Aerosol Generation during Standard Laboratory Procedures

Laboratory containment systems are designed to remove potentially infectious aerosolized particles from the workers environment. However, little evidence on the quantities of aerosol generated during common microbiological practices exists. This studys objective was to measure aerosol and splash contamination during the microbiology techniques of serial dilution and pipetting, undertaken by staff with a range of experience and training. High-titer suspensions of Bacillus atrophaeus were used, with sodium fluorescein added to the solutions to enable visualization of any splashes. Air samples were taken to measure the microbial aerosols produced during the study. The results showed a range of air and surface contamination produced during the tests, with a high variance among participants. More experienced personnel on average produced significantly lower amounts of aerosol (6.9 cfu) when performing serial dilutions compared to inexperienced personnel (13.6 cfu), whereas no significant difference between the two groups was noted for the plating out procedure. This trend was followed when examining the splash results. The average contamination from aerosols and splashes was also significantly reduced for those trained at containment level 3 (CL3) compared to those who were not CL3 trained. The study highlights that aerosol and splash contamination is produced by all users, even those highly trained and experienced, but that a correctly operating biological safety cabinet (BSC) will capture these aerosols. However, the contamination on the gloves and surfaces could potentially be spread within the laboratory and outside, indicating the need for effective personal protective equipment (PPE) and hygiene controls.

Scoping studies to establish the capability and utility of a real-time bioaerosol sensor to characterise emissions from environmental sources

A novel dual excitation wavelength based bioaerosol sensor with multiple fluorescence bands called Spectral Intensity Bioaerosol Sensor (SIBS) has been assessed across five contrasting outdoor environments. The mean concentrations of total and fluorescent particles across the sites were highly variable being the highest at the agricultural farm (2.6 cm-3 and 0.48 cm-3, respectively) and the composting site (2.32 cm-3 and 0.46 cm-3, respectively) and the lowest at the dairy farm (1.03 cm-3 and 0.24 cm-3, respectively) and the sewage treatment works (1.03 cm-3 and 0.25 cm-3, respectively). In contrast, the number-weighted fluorescent fraction was lowest at the agricultural site (0.18) in comparison to the other sites indicating high variability in nature and magnitude of emissions from environmental sources. The fluorescence emissions data demonstrated that the spectra at different sites were multimodal with intensity differences largely at wavelengths located in secondary emission peaks for λex 280 and λex 370. This finding suggests differences in the molecular composition of emissions at these sites which can help to identify distinct fluorescence signature of different environmental sources. Overall this study demonstrated that SIBS provides additional spectral information compared to existing instruments and capability to resolve spectrally integrated signals from relevant biological fluorophores could improve selectivity and thus enhance discrimination and classification strategies for real-time characterisation of bioaerosols from environmental sources. However, detailed lab-based measurements in conjunction with real-world studies and improved numerical methods are required to optimise and validate these highly resolved spectral signatures with respect to the diverse atmospherically relevant biological fluorophores.

Cabinet Decontamination Using Formaldehyde

Formaldehyde fumigation is the most widely used method for terminal decontamination of biosafety cabinets in the UK. International standards define volumes of Formalin and water to be used for an effective fumigation. However, no published information is available showing that these levels are appropriate or effective. Studies have been undertaken to optimize the volumes of fumigant required to achieve 6 log reductions of bacterial spores within 2 sizes of biosafety cabinet. The tests have shown effective cycles can be achieved using significantly lower levels of fumigant than are recommended within the European Standard for biosafety cabinets and UK guidance. There is clear evidence of stratification of the fumigant within the cabinets with the time taken to achieve a 6 log reduction depending on the position within the cabinet and the local relative humidity.