Hidden transmissions of Pseudomonas aeruginosa ST111 -the importance of continuous molecular surveillance.

Background: A series of transmission of Pseudomonas aeruginosa ST111 bla, previously undetected by standard surveillance, was discovered in a tertiary care hospital in Northern Germany through molecular genetic monitoring. Hence, environmental sampling was initiated to find the source of infection.

Methods: First, routine epidemiological data ruled out patient-to-patient transmission and two initial diagnoses were assessed as externally acquired. After the discovery of the highly related cluster by whole genome sequencing, a more detailed epidemiological analysis was carried out, including previous hospitalizations. An environmental investigation was initiated due to a possible connection of transmissions with an intensive care unit.

Results: Between 2018 and 2023 16 clinical isolates of Pseudomonas aeruginosa ST111 bla were identified of which 12 isolates belonged to ST111 carrying an In59-like integron. Routine whole-genome sequencing of carbapenem resistant P. aeruginosa identified a highly related cluster (maximum of three allelic differences) of high-risk ST111 isolates in ICU patients over five years, confirming sink-to-patient transmission associated to sink drains in two ICU rooms. In initial routine epidemiological categorization of these highly related isolates four isolates were categorized as possible nosocomial acquisition without direct epidemiological link to other patients, whereas two isolates were categorized as 'externally acquired'.

Conclusions: This finding highlights the ability of high-risk clone ST111 to persist in hospital environments and emphasizes the importance of integrating molecular surveillance with routine epidemiology to uncover hidden transmissions. In this case, the frequent detection of the ST111 high-risk clone led to targeted environmental sampling, uncovering a prolonged outbreak that had gone unnoticed by conventional surveillance. The clone was eliminated from the ward during a reconstruction project.