Abstract
BackgroundDespite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias.Case presentationWe describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients’ blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences.ConclusionThis case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored.
Highlights
Duodenoscope-associated infections (DAI) are infections caused by microorganisms transmitted from contaminated duodenoscopes into patients undergoing an endoscopic retrograde cholangiopancreaticography (ERCP)
This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae
Transmission of susceptible E. cloacae was highly suspected from amplified fragment length polymorphism (AFLP) and multi-locus sequence typing (MLST) results; by whole genome sequencing (WGS), 93 allelic differences were found which proves closely related strains
Summary
This report shows that DAIs by susceptible microorganisms can occur unnoticed and more research is required to estimate its prevalence. Epidemiologic information, bacterial identification, susceptibility testing and AFLP point to a link between the contaminated duodenoscope and the infection in the patient. The WGS results cast doubt on this conclusion. Notwithstanding the WGS results, we feel that this case points to a possible role of duodenoscopes as routes of transmission
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