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<jats:title>ABSTRACT</jats:title> <jats:p>Carbapenem-resistant <jats:named-content content-type="genus-species">Enterobacteriaceae</jats:named-content> (CRE) represent a health threat, but effective control interventions remain unclear. Hospital wastewater sites are increasingly being highlighted as important potential reservoirs. We investigated a large <jats:named-content content-type="genus-species">Klebsiella pneumoniae</jats:named-content> carbapenemase (KPC)-producing <jats:named-content content-type="genus-species">Escherichia coli</jats:named-content> outbreak and wider CRE incidence trends in the Central Manchester University Hospital NHS Foundation Trust (CMFT) (United Kingdom) over 8 years, to determine the impact of infection prevention and control measures. Bacteriology and patient administration data (2009 to 2017) were linked, and a subset of CMFT or regional hospital KPC-producing <jats:named-content content-type="genus-species">E. coli</jats:named-content> isolates (<jats:italic>n</jats:italic> = 268) were sequenced. Control interventions followed international guidelines and included cohorting, rectal screening (<jats:italic>n</jats:italic> = 184,539 screens), environmental sampling, enhanced cleaning, and ward closure and plumbing replacement. Segmented regression of time trends for CRE detections was used to evaluate the impact of interventions on CRE incidence. Genomic analysis (<jats:italic>n</jats:italic> = 268 isolates) identified the spread of a KPC-producing <jats:named-content content-type="genus-species">E. coli</jats:named-content> outbreak clone (strain A, sequence type 216 [ST216]; <jats:italic>n</jats:italic> = 125) among patients and in the environment, particularly on 2 cardiac wards (wards 3 and 4), despite control measures. ST216 strain A had caused an antecedent outbreak and shared its KPC plasmids with other <jats:named-content content-type="genus-species">E. coli</jats:named-content> lineages and <jats:named-content content-type="genus-species">Enterobacteriaceae</jats:named-content> species. CRE acquisition incidence declined after closure of wards 3 and 4 and plumbing replacement, suggesting an environmental contribution. However, ward 3/ward 4 wastewater sites were rapidly recolonized with CRE and patient CRE acquisitions recurred, albeit at lower rates. Patient relocation and plumbing replacement were associated with control of a clonal KPC-producing <jats:named-content content-type="genus-species">E. coli</jats:named-content> outbreak; however, environmental contamination with CRE and patient CRE acquisitions recurred rapidly following this intervention. The large numbers of cases and the persistence of <jats:italic>bla</jats:italic><jats:sub>KPC</jats:sub> in <jats:named-content content-type="genus-species">E. coli</jats:named-content>, including pathogenic lineages, are of concern.</jats:p>

Original publication




Journal article


Antimicrobial Agents and Chemotherapy


American Society for Microbiology

Publication Date