Two patients who stayed in the same Idaho hospital intensive care unit room four months apart contracted the same drug-resistant bacteria, and an investigation by state officials and the CDC found the culprit to be a sink.
The first patient, a woman between 50 and 65 years old who was on ventilation for three to five weeks, occupied the room in September 2021, according to a case study published Aug. 3. The other patient was a woman older than 65 who was on ventilation for four weeks in January 2022.
Both were diagnosed with carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) infections from fifth and third, respectively, sputum specimens, which suggested a hospital-acquired infection. Between the two infected patients, 16 others stayed in the ICU room, and no other CP-CRPA specimens were found.
The second patient was discharged to a long-term care facility in late January. The first hospital contacted the next site about a precaution recommendation based on CP-CRPA detection, but this message was not given to the facility's infection preventionist. No CP-CRPA infections were found at the second location.
The cluster was likely because of a contaminated sink, the CDC said. The recommended measures included a drain biofilm disinfectant and screening future patients who stay in that room, such as the next 10.