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Background:
We report a recurrent outbreak of postoperative infections with extended-spectrum β-lactamase (ESBL)-producing E. cloacae complex in cardiac surgery patients, describe the outbreak investigation and highlight the infection control measures.
Methods:
Cases were defined as cardiac surgery patients in Ghent University Hospital who were...
Contexts in source publication
Context 1
... cases were detected between May and July 2017. Table 1 shows the demographic and clinical characteristics of the cases, the treatment given and the outcome of the hospital stay. The case definition included both postoperatively colonized and clinically infected cardiac surgery patients, but all cases of the first outbreak episode had clinical signs of infection and received treatment with piperacillin-tazobactam (TZP) or meropenem (MEM). ...Context 2
... 3 shows a timeline of cases and key interventions performed to control the outbreak. The entire set of infection control measures is depicted in Additional file 1: Table S1. ...Context 3
... outbreak, however, unexpectedly recurred mid November 2017, with four new cases being identified over the course of 1 month (Fig. 1). All cases were symptomatic and three of them had an acute respiratory infection with ESBL-producing E. cloacae complex in the postoperative period (Table 1). These three cases were infants, whereas all patients of the first outbreak episode were adults, and one infant did not have traceable TEE examinations. ...Context 4
... new cluster of six cases occurred in January 2018 ( Fig. 1). All cases were adults, had undergone TEE examinations and had respiratory samples positive for ESBL-producing E. cloacae complex (Table 1). One case died from a non-infectious cause on the third postoperative day and probably did not have the time to develop pneumonia. ...Context 5
... of the TEE probe of CICU, which had been used in both patients, showed that a part of the silicone bead around the transducer lens was torn off (Fig. 2c). Measures taken to control the third outbreak episode included, among others, the obligatory use of a protective sheath to cover the TEE probe during cardiac surgery and the decision to switch from manual cleaning and disinfection using chlorine dioxide-generating wipes to automated reprocessing for the TEE probes of the operating rooms and CSICU (Fig. 3, Additional file 1: Table S1). The TEE probe of CICU and the TEE probe of the cardiology polyclinic, which also suffered from detachment of the silicone bead (Fig. 2d), were finally removed from service. ...Context 6
... surfaces have been described as sources of ESBL-producing Enterobacteriaceae in the ICU, providing an opportunity for both outbreak Abbreviations: ASA American Society of Anesthesiologists, BMI body mass index, CABG coronary artery bypass grafting, CI confidence interval, CICU cardiac intensive care unit, COPD chronic obstructive pulmonary disease, CSICU cardiac surgery intensive care unit, ECC extracorporeal circulation, ESBL extended-spectrum β-lactamase, ICU intensive care unit, IQR interquartile range, LVAD left ventricular assist device, MICU medical intensive care unit, SD standard deviation, SICU surgical intensive care unit, TEE transesophageal echocardiography Four patients required one or more revision operations for bleeding with imminent or manifest pericardial tamponade. Five of these revision operations occurred prior to infection with ESBL-producing E. cloacae complex (see Table 1). A fifth patient was reoperated because of postoperative mitral regurgitation with hemodynamic instability. ...Similar publications
The hospital environment has been reported as a source of transmission events and outbreaks of carbapenemase-producing Enterobacterales. Interconnected plumbing systems and the microbial diversity in these reservoirs pose a challenge for outbreak investigation and control. A total of 133 clinical and environmental OXA-48-producing Enterobacter cloa...
Citations
... After using a ready-to-use wipe with microbicidal, levurocidal, sporicidal, and virucidal effectiveness, representatives of vaginal, pharyngeal, and skin flora were detected on TVUS in 10.6% of samples [14]. Using the same 3-wipe system in a cardiology unit caused two outbreaks by the same clone and a third outbreak by a new clone of an extended-spectrum betalactamase-producing Enterobacter cloacae after transesophageal echocardiography [15]. After switching to automated reprocessing, the outbreak ended. ...
Objective
This study aims to provide additional support for the equipment needed in hospitals and medical practices for reprocessing transvaginal ultrasound probes (TVUS) through an economic analysis comparing manual and automated reprocessing methods. A questionnaire survey was also conducted in hospitals and medical practices to analyze the current practice of TVUS reprocessing.
Methods
The economic analysis compared four manual reprocessing methods using disinfection wipes and one automated device-based disinfection method using hydrogen peroxide vapor. The working times were measured with a stopwatch and complemented by passive working time (disinfection exposure time or machine cycle duration). The personnel costs for the working time were calculated and combined with the calculated acquisition and material costs to determine the total process costs.
Results
The economic analysis revealed that machine disinfection is not only time-saving but also more cost-effective per reprocessing cycle compared to two manual methods using wipes for cleaning and disinfection, where the disinfectant is applied to the wipe before use. However, two methods using ready-to-use (rtu) disinfection wipes from a container were more cost-effective. It is important to note that all wipe disinfection methods would incur additional costs due to the lack of validation. The additional costs for validation could not be calculated due to a lack of experience, making a final cost assessment for wipe disinfection methods currently impossible.
Despite extensive efforts to send the survey to hospitals and medical practices through three professional societies and attempts to acquire participants via a publication, only 35 institutions participated. Except for one case, all reprocessed manually. The survey revealed a deficit in knowledge regarding TVUS reprocessing. Manual reprocessing had not been validated despite national legal requirements existing since 2002.
Conclusion
As long as manual reprocessing is not validated in all steps, only machine reprocessing is ethically acceptable for patient safety. Even if manual wipe disinfection is validated, machine reprocessing offers higher patient safety, since deviations from the validated SOP cannot be excluded during manual execution. Machine reprocessing should always be preferred for occupational safety reasons.
Since the process costs for methods involving the application of the disinfectant to the wipe before disinfection were higher than for the machine method, the latter is preferred in this comparison. It is not possible to determine whether the overall process is economically superior to machine reprocessing because the cost calculation for rtu disinfection wipes does not include the entire process of reprocessing, including the legally required validation. Due to the better standardization of the machine reprocessing process, along with increased procedural, worker, and patient safety, machine reprocessing should be preferred regardless of process costs, especially if the economic difference is not significant. Additionally, avoiding disposable wipes is beneficial in terms of sustainability.
The lack of knowledge regarding national legal requirements and recommendations for TVUS reprocessing is a reason why the principles of reprocessing were not adhered to in several practices. Therefore, it is necessary to convey the basic knowledge of reprocessing during medical studies, followed by further training during specialization. Persons tasked with reprocessing must have the required education or participate in specialized training to demonstrate current knowledge (§ 8 Sect. 7 Medical Device Regulation).
... are not readily transferable between strains and do not pose the same infection prevention and control risk [20]. The carbapenemresistant mechanisms in Enterobacter Cloacae (CR-ECL) mechanisms began when the microbe commenced gaining plasmid-encoded carbapenemase genes and the overexpression of efflux pumps and integral overexpression of AmpC and extended-spectrum βlactamase (ESBL) production, combined with disrupted membrane outer membrane protein loss [21]. Furthermore, acquiring plasmid-mediated ESBL genes, including blaTEM, blaSHV, and blaCTX-M, can make Enterobacter cloacae resistant to most β-lactam drugs, thereby making the clinical treatment difficult [22]. ...
The sudden increase in the predominance and clinical impact of infection caused by carbapenem resistance Enterobacter cloacae (CR-ECL) is a global health concern. CR-ECL is notably problematic when identified in the clinical microbiology laboratory. Due to CR-ECL's intrinsic resistance to most cephalosporin and carbapenem and their ability to spread and colonize patients in healthcare settings, identifying and preventing the transmission of these organisms is a significant public health initiative, and coordinated international efforts are needed. Following established antibiotic susceptibility algorithms ensures a systematic and comprehensive assessment of bacterial resistance patterns. This approach helps identify potential resistance mechanisms and guide effective treatment strategies. The algorithm approach considers clinical factors such as patient history, site of infection, and local resistance patterns, enhancing the relevance and applicability of susceptibility testing results to individual patient management. Importantly, continuously monitoring CR-ECL antibiotic resistance patterns and surveillance of emerging resistance mechanisms is essential to adapting and refining antibiotic susceptibility algorithms to evolving clinical needs. This review highlights our current understanding of CR-ECL, emphasizing their epidemiology, detection, treatment, and control.
... Infections with these pathogens are especially dangerous in immunocompromised patients, e.g., in solid organ transplant recipients on chronic immunosuppressive therapy [7] or in hemodialysis patients [8]. Enterobacter cloacae, the main representative of Enterobacter spp., colonizes the mucosa of the human intestine in a physiological state; however, it is also described as the source of many different disorders, including bacteremia [9,10], urinary tract infections (UTIs) [11,12], wound infections [13][14][15], osteoarticular infections [16][17][18], and pneumonia/lower respiratory tract infections [19][20][21]. These bacteria also commonly colonize in various hospital wards, including neonatal intensive care units, which may result in the development of life-threatening infections such as meningitidis [22]. ...
... A significant proportion of clinical bacterial isolates are extended-spectrum β-lactamase (ESBL)-producing strains. The principal described genes responsible for this mechanism of resistance to β-lactam antibiotics (penicillins, cephalosporins, and monobactams) include bla TEM , bla CTX-M , and bla SHV [20,24,25]. Broad-spectrum antibiotic resistance also includes resistance to carbapenems, known as last-resort antibiotics, and to colistin, which often causes a wide range of side effects [26,27]. ...
In an era of antibiotic therapy crisis caused by spreading antimicrobial resistance, and when recurrent urinary tract infections constitute a serious social and medical problem, the isolation and complex characterization of phages with a potential therapeutic application represents a promising solution. It is an inevitable, and even a necessary direction in the development of current phage research. In this paper, we present two newly isolated myoviruses that show lytic activity against multidrug-resistant clinical isolates of Enterobacter spp. (E. cloacae, E. hormaechei, and E. kobei), the genomes of which belong to a poorly represented phage group. Both phages were classified as part of the Tevenvirinae subfamily (Entb_43 was recognized as Karamvirus and Entb_45 as Kanagawavirus). Phage lytic spectra ranging from 40 to 60% were obtained. The most effective phage-to-bacteria ratios (MOI = 0.01 and MOI = 0.001) for both the phage amplification and their lytic activity against planktonic bacteria were also estimated. Complete adsorption to host cells were obtained after about 20 min for Entb_43 and 10 min for Entb_45. The phage lysates retained their initial titers even during six months of storage at both −70 °C and 4 °C, whereas storage at 37 °C caused a complete loss in their activity. We showed that phages retained their activity after incubation with solutions of silver and copper nanoparticles, which may indicate possible synergistic antibacterial activity. Moreover, a significant reduction in phage titers was observed after incubation with a disinfectant containing octenidinum dihydrochloridum and phenoxyethanol, as well as with 70% ethanol. The observed maintenance of phage activity during incubation in a urine sample, along with other described properties, may suggest a therapeutic potential of phages at the infection site after intravesical administration.
... Nosocomial pathogens can spread via multiple routes within a hospital setting. Besides acquisition of infections and colonization via contaminated products or involving health care workers, the environmental reservoir has been linked to long-term transmission events and outbreaks in the hospital setting (5,(8)(9)(10)(11). In particular, water systems in health care facilities have been reported as a source of nosocomial infection, especially among immunocompromised patients in critical care units (10,12,13). ...
The hospital environment has been reported as a source of transmission events and outbreaks of carbapenemase-producing Enterobacterales. Interconnected plumbing systems and the microbial diversity in these reservoirs pose a challenge for outbreak investigation and control. A total of 133 clinical and environmental OXA-48-producing Enterobacter cloacae isolates collected between 2015 and 2021 were characterized by whole-genome sequencing (WGS) to investigate a prolonged intermittent outbreak involving 41 patients in the hematological unit. A mock-shower experiment was performed to investigate the possible acquisition route. WGS indicated the hospital water environmental reservoir as the most likely source of the outbreak. The lack of diversity of the blaOXA-48-like harbouring plasmids was a challenge for data interpretation. The detection of blaOXA-48-like-harboring E. cloacae strains in the shower area after the mock-shower experiment provided strong evidence that showering is the most likely route of acquisition. Initially, in 20 out of 38 patient rooms, wastewater traps and drains were contaminated with OXA-48-positive E. cloacae. Continuous decontamination using 25% acetic acid three times weekly was effective in reducing the trap/drain positivity in monthly environmental screening but not in reducing new acquisitions. However, the installation of removable custom-made shower tubs did prevent new acquisitions over a subsequent 12-month observation period. In the present study, continuous decontamination was effective in reducing the bacterial burden in the nosocomial reservoirs but was not sufficient to prevent environment-to-patient transmission in the long term. Construction interventions may be necessary for successful infection prevention and control.
... 3,10 Moreover, the acquisition of plasmid-mediated ESBL genes, such as bla TEM , bla SHV , bla CTX-M , and so forth, makes ECC resistant to most β-lactam drugs, thus increasing the difficulty in clinical treatment. [11][12][13][14][15] Two major categories of carbapenem enzymes, carbapenem-hydrolyzing serine β-lactamases and metallo-β-lactamases, such as KPC, NmcA, IMI, FRI, GES, OXA, VIM, IMP, and NDM, have been identified in carbapenem-resistant Enterobacteriaceae. 3 The most common description of KPC and NDM-1 was in ECC isolates. ...
Background
The emergence and spread of carbapenem-resistant Enterobacter cloacae complex (ECC) have posed a serious threat to human health worldwide. This study aimed to investigate the molecular mechanism of carbapenem resistance and its prevalence among ECC in China.
Methods
A total of 1314 ECC clinical isolates were collected from the First Affiliated Hospital of Wenzhou Medical University from 2004 to 2018. Sensitivity to antibiotics was determined using the agar dilution method. The production of carbapenemases and the prevalence of resistance-associated genes were investigated using PCR. The expression of outer membrane porin (OMP) genes (ompC/ompF) and cephalosporinase gene ampC was analyzed by quantitative real-time PCR. The effect of efflux pump mechanism on carbapenem resistance was tested. ECC was typed by multilocus sequence typing (MLST).
Results
In this study, 113 carbapenem-nonsusceptible ECC strains were identified. The prevalence rates of carbapenemase genes blaKPC-2 and blaNDM were 12.4% (14/113) and 17.7% (20/113), and that of the extended-spectrum β-lactamase (ESBL) genes blaCTX-M, blaTEM, and blaSHV were 28.3% (32/113), 27.4% (31/113), and 14.2% (16/113), respectively. Among 67 carbapenem-nonsusceptible ECC isolates producing non-carbapenemase, low expression of ompC/ompF and overexpression of ampC were found in 46 and 40 strains, respectively. In addition, the carbapenem resistance was related to the overexpression of the efflux pump in the study. Finally, the 113 carbapenem-nonsusceptible ECC strains were categorized into 39 different sequence types using MLST.
Conclusion
Carbapenem-nonsusceptible ECC strains producing non-carbapenemase were predominant. The low expression of OMP with the overexpression of cephalosporinase or production of ESBLs and overexpression of efflux pump might contribute to the resistance to carbapenem for carbapenem-nonsusceptible ECC strains producing non-carbapenemase. The blaNDM and blaKPC comprised the principal resistance mechanism of carbapenemase-producing ECC in the hospital, causing a threat to public health. Therefore, monitoring programs to prevent the emergence and further spread of antibiotic resistance are urgently needed.
Ultrasound technology has revolutionized point of care diagnostics, decision making, and guidance of interventional procedures in Anesthesiology and Perioperative Medicine. Recent literature has highlighted important infection control considerations when performing transesophageal or transthoracic echocardiography, point of care ultrasound, and ultrasound guided procedures. This narrative review focuses on operator precautions and disinfection methods, and summarizes key recommendations from international Echocardiography and Radiology Societies.
Commercially available bite blocks used for invasive imaging procedures have design limitations, including bulky profile, being made of hard plastic that may damage surrounding tissue, and tendency to dislodge. We designed a novel bite block to address these limitations and evaluated this bite block in 50 patients undergoing diagnostic or intraprocedural transesophageal echocardiography examinations. Nine of 11 (82%) imagers who used the redesigned bite block preferred it over the standard bite block used at our institution. The novel bite block is an alternative device to standard bite blocks that was redesigned to protect both the patient and probe.
Transesophageal echocardiography (TEE) is firmly established in cardiac surgery for diagnostics, hemodynamic monitoring and as a guiding tool. Dynamic and (patho)physiological processes of the heart can be immediately depicted. Ideally, therapeutic changes can be derived. For this reason, TEE is increasingly used in high-risk non-cardiac surgery interventions and in the interventional setting. In the first part of this advanced training series, general aspects regarding TEE examinations as well as indications and contraindications are presented. Clinical fields of application, where TEE can play a role in hemodynamic monitoring are outlined. The second part focusses on an emergency examination pathway and differential diagnoses, which can be made in the event of intraoperative hemodynamic instability or unexplained hypoxemia using TEE. The article concludes with an outlook on the use of computer-aided evaluation of TEE images.
