Extensively Drug-Resistant <i>Pseudomonas aeruginosa</i> Outbreak Associated With Artificial Tears
Marissa K. Grossman, Danielle A. Rankin, Meghan Maloney, Richard A. Stanton, Paige Gable, Valerie Stevens, Thomas Ewing, Katharine Saunders, Sarah Kogut, Elizabeth Nazarian, Sandeep Bhaurla, Jehan Mephors, Joshua Mongillo, Susan Stonehocker, Jeanette Prignano, Nickolas Valencia, Argentina Charles, Kiara McNamara, William A Fritsch, Shannon B. Ruelle, Carrie Ann Plucinski, Lynn Sosa, Belinda Ostrowsky, D. Cal Ham, Maroya Spalding Walters, for the Multistate Pseudomonas Outbreak Investigation Group, Homero Aguilar, Amir Hossein Alavi, Rocío Balbuena, Jasna Braut-Taormina, Hollianne Bruce, Wiley Chambers, Kai-Shun Chen, Kristen Clancy, M. Cockrell, Karlos Crayton, Michael Cyrus, Marisa D’Angeli, Maria Carmen G. Diaz, Jan Dollete, Samuel Eskenazi, Lorene Fong, Rosalie Giardina, Jennifer M. Gogley, William Greendyke, Susan Hadman, Hollis Houston, Catherine Huck, Philip F Istafanos, Amber Jean-Louis, Deborah L. Jones, M Kratz, Thao Kwan, Sammie P. La, Susan E. Lance, Megan Lasure, Cynthia Longo, María José Machado, Gillian McAllister, Sherri McGarry, Susannah L. McKay, Derek L Miller, M. Musk, Kelsey OYong, Elvis Patel, Arthur Pightling, Allison Rodriguez, Jeffery C. Rogers, H Romero, Mona Satyam, Matthew Silverman, Gail Skolek, Amanda Smith, Anna Stahl, Luis Torres, Kavita K. Trivedi, N. Wilmott
Abstract
BACKGROUND: Carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) are extensively drug-resistant bacteria. We investigated the source of a multistate CP-CRPA outbreak. METHODS: Cases were defined as a US patient's first isolation of P. aeruginosa sequence type 1203 with carbapenemase gene blaVIM-80 and cephalosporinase gene blaGES-9 from any specimen source collected and reported to the Centers for Disease Control and Prevention during 1 January 2022-15 May 2023. We conducted a 1:1 matched case-control study at the post-acute care facility with the most cases, assessed exposures associated with case status for all case-patients, and tested products for bacterial contamination. RESULTS: We identified 81 case-patients from 18 states, 27 of whom were identified through surveillance cultures. Four (7%) of 54 case-patients with clinical cultures died within 30 days of culture collection, and 4 (22%) of 18 with eye infections underwent enucleation. In the case-control study, case-patients had increased odds of receiving artificial tears versus controls (crude matched OR, 5.0; 95% CI, 1.1-22.8). Overall, artificial tears use was reported by 61 (87%) of 70 case-patients with information; 43 (77%) of 56 case-patients with brand information reported use of Brand A, an imported, preservative-free, over-the-counter (OTC) product. Bacteria isolated from opened and unopened bottles of Brand A were genetically related to patient isolates. Food and Drug Administration inspection of the manufacturing plant identified likely sources of contamination. CONCLUSIONS: A manufactured medical product serving as the vehicle for carbapenemase-producing organisms is unprecedented in the United States. The clinical impacts from this outbreak underscore the need for improved requirements for US OTC product importers.