Extensively Drug-Resistant Pseudomonas aeruginosa Outbreak Associated With Artificial Tears
Authors: Grossman Marissa K , Rankin Danielle A , Maloney Meghan , Stanton Richard A , Gable Paige , Stevens Valerie A , Ewing Thomas , Saunders Katharine , Kogut Sarah , Nazarian Elizabeth , Bhaurla Sandeep , Mephors Jehan , Mongillo Joshua , Stonehocker Susan , Prignano Jeanette , Valencia Nickolas , Charles Argentina , McNamara Kiara , Fritsch William A , Ruelle Shannon , Plucinski Carrie Ann , Sosa Lynn E , Ostrowsky Belinda , Ham D Cal , Walters Maroya S ,   for the Multistate Pseudomonas Outbreak Investigation Group, Aguilar Homero , Alavi Amir , Balbuena Rocio , Braut-Taormina Jasna , Bruce Hollianne , Chambers Wiley , Chen Kai-Shun , Clancy Kristen , Cockrell Michelle , Crayton Karlos , Cyrus Michael , D'Angeli Marisa , Diaz Maria , Dollete Jan , Eskenazi Samuel , Fong Lorene , Giardina Rosalie , Gogley Jennifer , Greendyke William , Hadman Susan , Houston Hollis , Huck Catherine , Istafanos Philip , Jean-Louis Amber , Jones Deborah , Kratz Molly , Kwan Thao , La Sammie , Lance Susan , Lasure Megan , Longo Cynthia , Machado Maria , McAllister Gillian , McGarry Sherri , McKay Susannah , Miller Derek L , Musk Marissa , O'Yong Kelsey , Patel Elvis , Pightling Arthur , Rodriguez Allison , Rogers Jeffery , Romero Haydee , Satyam Mona , Silverman Matthew , Skolek Gail , Smith Amanda J , Stahl Anna , Torres Luis , Trivedi Kavita K , Wilmott Nadine 
Published: February 2024

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.