Outbreak Of Enterobacter Cloacae Research Articles

Direct-PCR from rectal swabs and environmental reservoirs: A fast and efficient alternative to detect blaOXA-48 carbapenemase genes in an Enterobacter cloacae outbreak setting

Carbapenemase-producing bacteria are a risk factor in clinical settings worldwide. The aim of the study was to accelerate the time to results during an outbreak situation with blaOXA-48-positive Enterobacter cloacae by using a real-time multiplex quantitative PCR (qPCR) directly on rectal swab specimens and on wastewater samples to detect carbapenemase-producing bacteria. Thus, we analyzed 681 rectal swabs and 947 environmental samples during a five-month period by qPCR and compared the results to culture screening. The qPCR showed a sensitivity of 100% by testing directly from rectal swabs and was in ten cases more sensitive than the culture-based methods. Environmental screening for blaOXA-48-carbapenemase genes by qPCR revealed reservoirs of different carbapenemase genes that are potential sources of transmission and might lead to new outbreaks. The rapid identification of patients colonized with those isolates and screening of the hospital environment is essential for earlier patient treatment and eliminating potential sources of nosocomial infections.

Enterobacter cloacae colonisation and infection in a neonatal intensive care unit: retrospective investigation of preventive measures implemented after a multiclonal outbreak

BackgroundEnterobacter cloacae species is responsible for nosocomial outbreaks in vulnerable patients in neonatal intensive care units (NICU). The environment can constitute the reservoir and source of infection in NICUs. Herein we report the impact of preventive measures implemented after an Enterobacter cloacae outbreak inside a NICU.MethodsThis retrospective study was conducted in one level 3 NICU in Lyon, France, over a 6 year-period (2012–2018). After an outbreak of Enterobacter cloacae infections in hospitalized neonates in 2013, several measures were implemented including intensive biocleaning and education of medical staff. Clinical and microbiological characteristics of infected patients and evolution of colonization/infection with Enterobacter spp. in this NICU were retrieved. Moreover, whole genome sequencing was performed on 6 outbreak strains.ResultsEnterobacter spp. was isolated in 469 patients and 30 patients developed an infection including 2 meningitis and 12 fatal cases. Preventive measures and education of medical staff were not associated with a significant decrease in patient colonisation but led to a persistent decreased use of cephalosporin in the NICU. Infection strains were genetically diverse, supporting the hypothesis of multiple hygiene defects rather than the diffusion of a single clone.ConclusionsGrouped cases of infections inside one setting are not necessarily related to a single-clone outbreak and could reveal other environmental and organisational problematics. The fight against implementation and transmission of Enterobacter spp. in NICUs remains a major challenge.

Alteration of antibiotic regimen as an additional control measure in suspected multi-drug-resistant Enterobacter cloacae outbreak in a neonatal intensive care unit

Increased occurrence of a particular species of Gram-negative bacteria (GNB), especially when multi-drug-resistant (MDR), in routine screening surveillance in neonatal intensive care units (NICUs) can be evoked by selection pressure. To evaluate adaptation of the empiric antibiotic regimen for its usefulness as a control measure in suspected outbreaks in the NICU. In a retrospective outbreak analysis, cases between 1st December 2017 and 31st March 2018 were identified through microbiology and hygiene surveillance records. Furthermore, risk factors for MDR-GNB colonization were collected. Whole-genome sequencing (WGS) was performed on all isolates. Control measure documentations and interviews were employed to define interventions. As well as infection control measures, administration of third-generation cephalosporins was avoided and replaced whenever clinically acceptable as part of the intervention bundle. In total, nine patients were found to have rectal colonization with third-generation cephalosporin-resistant Enterobacter cloacae in routine screening surveillance in the pre-intervention period. After implementation of an infection control bundle, the incidence declined rapidly. WGS analysis revealed that two MDR E.cloacae were transmitted, and the majority were new cases. The incidence density of MDR-GNB colonization was 7.94/1000 patient-days (PD) before the intervention and 1.68/1000 PD during the altered antibiotic regimen. No infections with MDR-GNB occurred during the study. Altering the antibiotic regimen with regard to selection pressure may be considered as part of an intervention bundle to rapidly control the emergence of MDR-GNB in suspected outbreak situations in the NICU.

Overestimation of an Outbreak of Enterobacter cloacae in a Neonatal Intensive Care Unit in Germany, 2015.

In August 2015, 17 neonates with Enterobacter cloacae (E. cloacae) colonization were identified in a neonatal intensive care unit (NICU) in Germany. Two developed severe brain abscesses. Despite temporary NICU closure in September, another infant with E. cloacae colonization was detected in October 2015. We defined potential cases as inpatients treated in the NICU or any pediatric/maternity ward in 2015 with E. cloacae in any specimen before molecular typing. Cases were at first confirmed by arbitrarily-primed-polymerase-chain-reaction and later by XbaI-macrorestriction/pulsed-field gel electrophoresis and next-generation-sequencing. Enhanced barrier precautions and cohorting were implemented for all potential cases and microbiologic screening was extended from NICU to all pediatric/maternity wards. Of 41 potential cases (occurring between 08/04/2015 and 15/11/2015 in 4 wards), the isolates of 23 shared identical arbitrarily-primed-polymerase-chain-reaction patterns; 3 without plausible epidemiologic link. Pulsed-field gel electrophoresis analyses verified only 10 cases (all in the NICU); next-generation-sequencing analysis confirmed these results. In addition 6 cases without isolates available for genotyping were closely linked in place and time. Forty-one suspected patients were cohorted and the NICU was temporarily closed. Further analyses revealed that only 16 cases belonged to the outbreak. Only close interdisciplinary collaboration and highly discriminatory genotyping methods allowed to clearly differentiate between cases and noncases in this E. cloacae outbreak.

Genomic Investigation of a Putative Endoscope-Associated Carbapenem-Resistant Enterobacter cloacae Outbreak Reveals a Wide Diversity of Circulating Strains and Resistance Mutations.

A genomic epidemiologic investigation of a putative carbapenem-resistant Enterobacter cloacae outbreak revealed few plausible instances of nosocomial transmission, highlighting instead the frequent importation of E. cloacae into our hospital. Searching for genetic determinants of carbapenem resistance demonstrated that most resistance is due to convergent mutations in phylogenetically diverse E. cloacae.

An outbreak of neonatal septicaemia by Enterobacter cloacae

Objective To report an outbreak of Enterobacter cloacae ( E. cloacae) in a neonatal intensive care unit of a rural hospital in Karnataka and conduct a prospective study on neonatal septicaemia. Methods The diagnosis was based on culture, buffy coat smear examination and C-reactive protien test. Results E. cloacae was isolated from 18 neonates with septicaemic syndrome, of which 8 babies died. Source of infection was found to be the water used to bathe the babies. The strain was multidrug resistant, extended-spectrum beta-lactamase producer and was sensitive only to amikacin and flouroquinolones. Conclusions Clinical significance of E. cloacae as neonatal pathogen warrants attention of clinicians as well as microbiologists. Breaches in infection control measures should be avoided to prevent such outbreaks.

Investigation of an outbreak of Enterobacter cloacae in a neonatal unit and review of the literature

Enterobacter cloacae has emerged as an important pathogen in neonatal units, with several outbreaks of infection being reported. The aim of this study was to investigate an outbreak of sepsis due to E. cloacae in a neonatal unit and to review the literature. A retrospective cohort study was conducted in which cases were compared with all newborns hospitalised for more than 48h in the neonatal intensive care unit (NICU). Cohorting of infected patients and work reorganisation were implemented. Pulsed-field gel electrophoresis was performed. The retrospective cohort included the six cases and 13 control patients that had been in the NICU during April 2006. Univariate analysis showed that the use of dobutamine was significantly associated with infection (P=0.036) and that enteral feeding was a protective factor (P=0.02). Multivariate analysis did not find any independent risk factor. Bed occupancy rate in March 2006 was 109.6%, indicating overcrowding. PFGE identified indistinguishable patterns among isolates from all six newborns. PubMed and OVID was search from 1 January 1983 to 15 January 2008 for papers including the terms 'E. cloacae', 'outbreaks', 'clusters' in combination with 'neonate', 'newborn', and 'infant'. We found 26 reports of outbreaks due to E. cloacae in neonate patients: sixteen (52%) were bloodstream infection outbreaks, of which two (12.5%) were related to multiple-dose medications. The source for our outbreak was not identified. Reinforcement of hygiene practices, restrictions on new admissions and the establishment of single-dose medications helped to control the outbreak.

Multiresistant Enterobacter cloacae outbreak in an intensive care unit associated with therapeutic beds

We report a multiresistant Enterobacter cloacae outbreak in an intensive care unit, associated with mattresses and with antibacterial-treated and vapour-permeable polyurethane synthetic mattress covers of therapeutic beds.

FP1.08 Failure to control a multidrug-resistant Enterobacter cloacae outbreak despite adequate implementation of recommended infection control measures

FP1.08 Failure to control a multidrug-resistant Enterobacter cloacae outbreak despite adequate implementation of recommended infection control measures

Management of an outbreak of Enterobacter cloacae in a neonatal unit using simple preventive measures

Enterobacter cloacae is becoming an increasingly important nosocomial pathogen. Outbreaks ofE. cloacae in intensive care units and burns units have been described frequently. In December 1999, a neonate with line sepsis was transferred from a university hospital to the neonatal unit of the Diakonessen Hospital. Blood culture yielded E. cloacae. An outbreak of E. cloacae was occurring in the university hospital at that time. In February 2000, a second neonate in our hospital developed line sepsis caused by E. cloacae. Direct measures taken included cohorting of infected children, disinfection of incubators, thermometers and wards, and screening patients. Of nine neonates, seven were colonized withE. cloacae . Despite these measures, the outbreak continued. Forty-one patients were screened; 15 were colonized. Environmental searches yielded E. cloacae in a sink and on two thermometers. Sixteen isolates were typed by arbitrarily primed PCR using four primers. All the patient isolates and the two isolates from thermometers were identical. The strain isolated from the sink was unrelated. Amplified fragment length polymorphism typing showed that the outbreak clone was identical to that in the university hospital. After the introduction of disposable thermometer covers, E. cloacae colonization slowly decreased.

Enterobacter cloacae outbreak in the NICU related to disinfected thermometers

In the first week of December 1997, an increasing incidence of neonates colonized with multi-drug resistant Enterobacter cloacae (MR- E. cloacae) was observed in the neonatal intensive care unit of our 950-bed university hospital. Initially, re-enforcement of infection control practices including hand disinfection and cohort isolation seemed to be sufficient to control the outbreak. Nevertheless, an increasing number of newly admitted patients was paralleled by another rise in the incidence of colonized neonates. Since E. cloacae was initially found in urine specimens of the patients, surveillance and environmental cultures were aimed at procedures and instruments that might colonize the gastro-intestinal and/or urinary tract. E. cloacae was isolated from a single cap of an electronic digital thermometer. Despite banning of this possible source, newly admitted neonates still became colonized. The unit was closed for further admissions and a second round of extensive screening was started; this time including all available thermometers and continuous rectal temperature probes. Ready-to-use ‘disinfected’ thermometers and probes were found to be colonized with MR- E. cloacae. Observation of disinfection procedures and a laboratory investigation revealed that ‘rushed’ disinfection with alcohol 80% led to a 1 in 10 chance of thermometers still being contaminated. Furthermore, alcoholic hand rub used for convenience disinfection failed to disinfect thermometers in 40% and 20% of the cases when done in a ‘rushed’ or ‘careful’ fashion, respectively. Adequate disinfection of the thermometers led to the control of the outbreak, with no new occurrence of MR- E. cloacae in the following months.

An outbreak of Enterobacter cloacae associated with contamination of a blood gas machine

Over a 3-month period, five cases of Enterobacter cloacae bacteraemia occurred on our neonatal unit. In at least three of these, isolation of the organism coincided with clinical deterioration and evidence of sepsis. In one case, the same strain was isolated from an abscess on the neonate's forearm. The isolates had identical sensitivity patterns being resistant to all beta-lactams tested except imipenem. The extended time course of the infections made cross-infection an unlikely explanation. Moreover, close questioning of the staff and observation of their practices with regard to blood culture collection, failed to reveal any likely mechanism for pseudobacteraemia. On extensive investigation of the environment to try to identify a potential source of the organism, a strain of Enterobacter cloacae, was isolated from the probe of the blood gas machine and the probe cover. No other environmental samples were found to harbour the organism. Subsequent typing procedures showed the blood gas isolate to be indistinguishable from the clinical isolates. Five neonates were successfully treated with imipenem and gentamicin. The exact mechanism whereby these bacteraemias occurred remains obscure. In one case, the baby had positive blood cultures within 2 h of being on the unit and contamination of the blood culture bottle by the doctor taking the culture was suspected. Most of the episodes, however, appeared clinically to be genuine septicaemias. When vigorous infection control procedures were instituted to prevent staff acquisition of the organism from the machine, cases on the unit ceased.