Healthcare-associated links in transmission of nontuberculous mycobacteria among people with cystic fibrosis (HALT NTM) study: Rationale and study design

Jane E Gross, Silvia Caceres, Katie Poch, Nabeeh A Hasan, Rebecca M Davidson, L Elaine Epperson, Ettie Lipner, Charmie Vang, Jennifer R Honda, Matthew Strand, Michael Strong, Lisa Saiman, D Rebecca Prevots, Kenneth N Olivier, Jerry A Nick, Jane E Gross, Silvia Caceres, Katie Poch, Nabeeh A Hasan, Rebecca M Davidson, L Elaine Epperson, Ettie Lipner, Charmie Vang, Jennifer R Honda, Matthew Strand, Michael Strong, Lisa Saiman, D Rebecca Prevots, Kenneth N Olivier, Jerry A Nick

Abstract

Background: Healthcare-associated transmission of nontuberculous mycobacteria (NTM) among people with cystic fibrosis (pwCF) has been reported and is of increasing concern. No standardized epidemiologic investigation tool has been published for healthcare-associated NTM outbreak investigations. This report describes the design of an ongoing observational study to standardize the approach to NTM outbreak investigation among pwCF.

Methods: This is a parallel multi-site study of pwCF within a single Center who have respiratory NTM isolates identified as being highly-similar. Participants have a history of positive airway cultures for NTM, receive care within a single Center, and have been identified as part of a possible outbreak based on genomic analysis of NTM isolates. Participants are enrolled in the study over a 3-year period. Primary endpoints are identification of a shared healthcare-associated encounter(s) among patients in a Center and identification of environmental isolates that are genetically highly-similar to respiratory isolates recovered from pwCF. Secondary endpoints include characterization of potential transmission modes and settings, as well as incidence and prevalence of healthcare-associated environmental NTM species/subspecies by geographical region.

Discussion: We hypothesize that genetically highly-similar strains of NTM among pwCF cared for at the same Center may arise from healthcare sources including patient-to-patient transmission and/or acquisition from environmental sources. This novel study design will establish a standardized, evidence-based epidemiologic investigation tool for healthcare-associated NTM outbreak investigation within CF Care Centers, will broaden the scope of independent outbreak investigations and demonstrate the frequency and nature of healthcare-associated NTM transmission in CF Care Centers nationwide. Furthermore, it will provide valuable insights into modeling risk factors associated with healthcare-associated NTM transmission and better inform future infection prevention and control guidelines. This study will systematically characterize clinically-relevant NTM isolates of CF healthcare environmental dust and water biofilms and set the stage to describe the most common environmental sources within the healthcare setting harboring clinically-relevant NTM isolates.

Trial registration: ClinicalTrials.gov NCT04024423. Date of registry July 18, 2019.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Schematic showing an overview of…
Fig 1. Schematic showing an overview of the healthcare-associated links in transmission of nontuberculous mycobacteria among people with cystic fibrosis (HALT NTM) study.
Fig 2. Schematic showing an overview of…
Fig 2. Schematic showing an overview of the parallel multi-site study design.

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