Elizabethkingia meningoseptica is a nosocomial-adapted, Gram negative bacillus with intrinsic resistance to most antibiotics. An outbreak investigation was commenced when five patients developed E. meningoseptica bacteraemia within a three week period in the Cardiothoracic Intensive Care Unit (CTICU) and Surgical ICU (SICU).

Analysis of laboratory data, case reviews, workflows within CTICU and extensive environmental sampling of surfaces and taps within four ICU wards, four general wards, two dialysis units and eight operating theatres were performed.

Upon review laboratory data revealed an unrecognized subtle increasing trend of E. meningoseptica clinical infections in all ICUs over the preceding 3 years. E. meningoseptica was cultured from aerators of 44% (35/79) taps. Taps in sinks frequently used for non-sanctioned practices were more likely to be contaminated (95% CI 1.2-2.3, p<0.003). Elizabethkingia was not cultured from any other surfaces within patient rooms. Investigation of ICU nursing practice revealed introduction of non-sanctioned practices regarding disposal of patient respiratory secretions and cleaning of patient equipment in designated hand hygiene sinks within patient rooms. An urgent education programme was instituted to change these practices. Rooms underwent terminal cleaning. Faucets were systematically cleaned and aerators were changed. No further cases occurred in SICU or CT-ICU over the following three months. One month after aerator change, new aerators remained free of E. meningoseptica.

Introduction of non-sanctioned practices due to suboptimal unit design may have unintended consequences for vulnerable patients. Nursing workflows must also be practical to ensure proper waste disposal and cleaning of medical equipment.

None declared.