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A recurrent and transesophageal echocardiography-associated outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae complex in cardiac surgery patients

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Abstract
Background: We report a recurrent outbreak of postoperative infections with extended-spectrum beta-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 not known preoperatively to carry ESBL-producing E. cloacae complex and who postoperatively had a positive culture for this multiresistant organism between May 2017 and January 2018. An epidemiological investigation, including a case-control study, and environmental investigation were conducted to identify the source of the outbreak. Clonal relatedness of ESBL-producing E. cloacae complex isolates collected from case patients was assessed using whole-genome sequencing-based studies. Results: Three separate outbreak episodes occurred over the course of 9 months. A total of 8, 4 and 6 patients met the case definition, respectively. All but one patients developed a clinical infection with ESBL-producing E. cloacae complex, most typically postoperative pneumonia. Overall mortality was 22% (4/18). Environmental cultures were negative, but epidemiological investigation pointed to transesophageal echocardiography (TEE) as the outbreak source. Of note, four TEE probes showed a similar pattern of damage, which very likely impeded adequate disinfection. The first and second outbreak episode were caused by the same clone, whereas a different strain was responsible for the third episode. Conclusions: Health professionals caring for cardiac surgery patients and infection control specialists should be aware of TEE as possible infection source. Caution must be exercised to prevent and detect damage of TEE probes.
Keywords
Outbreak, Cardiac surgery, Enterobacter cloacae complex, Extended-spectrumβ-lactamase, Transesophageal echocardiography

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MLA
Van Maerken, Tom, et al. “A Recurrent and Transesophageal Echocardiography-Associated Outbreak of Extended-Spectrum β-Lactamase-Producing Enterobacter Cloacae Complex in Cardiac Surgery Patients.” ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL, vol. 8, no. 1, 2019, doi:10.1186/s13756-019-0605-4.
APA
Van Maerken, T., De Brabandere, E., Noël, A., Coorevits, L., De Waegemaeker, P., Ablorh, R., … Leroux-Roels, I. (2019). A recurrent and transesophageal echocardiography-associated outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae complex in cardiac surgery patients. ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL, 8(1). https://doi.org/10.1186/s13756-019-0605-4
Chicago author-date
Van Maerken, Tom, Els De Brabandere, Audrey Noël, Liselotte Coorevits, Pascal De Waegemaeker, Raina Ablorh, Stefaan Bouchez, et al. 2019. “A Recurrent and Transesophageal Echocardiography-Associated Outbreak of Extended-Spectrum β-Lactamase-Producing Enterobacter Cloacae Complex in Cardiac Surgery Patients.” ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL 8 (1). https://doi.org/10.1186/s13756-019-0605-4.
Chicago author-date (all authors)
Van Maerken, Tom, Els De Brabandere, Audrey Noël, Liselotte Coorevits, Pascal De Waegemaeker, Raina Ablorh, Stefaan Bouchez, Ingrid Herck, Harlinde Peperstraete, Pierre Bogaerts, Bruno Verhasselt, Youri Glupczynski, Jerina Boelens, and Isabel Leroux-Roels. 2019. “A Recurrent and Transesophageal Echocardiography-Associated Outbreak of Extended-Spectrum β-Lactamase-Producing Enterobacter Cloacae Complex in Cardiac Surgery Patients.” ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL 8 (1). doi:10.1186/s13756-019-0605-4.
Vancouver
1.
Van Maerken T, De Brabandere E, Noël A, Coorevits L, De Waegemaeker P, Ablorh R, et al. A recurrent and transesophageal echocardiography-associated outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae complex in cardiac surgery patients. ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL. 2019;8(1).
IEEE
[1]
T. Van Maerken et al., “A recurrent and transesophageal echocardiography-associated outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae complex in cardiac surgery patients,” ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL, vol. 8, no. 1, 2019.
@article{8630186,
  abstract     = {{Background: We report a recurrent outbreak of postoperative infections with extended-spectrum beta-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 not known preoperatively to carry ESBL-producing E. cloacae complex and who postoperatively had a positive culture for this multiresistant organism between May 2017 and January 2018. An epidemiological investigation, including a case-control study, and environmental investigation were conducted to identify the source of the outbreak. Clonal relatedness of ESBL-producing E. cloacae complex isolates collected from case patients was assessed using whole-genome sequencing-based studies.
Results: Three separate outbreak episodes occurred over the course of 9 months. A total of 8, 4 and 6 patients met the case definition, respectively. All but one patients developed a clinical infection with ESBL-producing E. cloacae complex, most typically postoperative pneumonia. Overall mortality was 22% (4/18). Environmental cultures were negative, but epidemiological investigation pointed to transesophageal echocardiography (TEE) as the outbreak source. Of note, four TEE probes showed a similar pattern of damage, which very likely impeded adequate disinfection. The first and second outbreak episode were caused by the same clone, whereas a different strain was responsible for the third episode.
Conclusions: Health professionals caring for cardiac surgery patients and infection control specialists should be aware of TEE as possible infection source. Caution must be exercised to prevent and detect damage of TEE probes.}},
  articleno    = {{152}},
  author       = {{Van Maerken, Tom and De Brabandere, Els and Noël, Audrey and Coorevits, Liselotte and De Waegemaeker, Pascal and Ablorh, Raina and Bouchez, Stefaan and Herck, Ingrid and Peperstraete, Harlinde and Bogaerts, Pierre and Verhasselt, Bruno and Glupczynski, Youri and Boelens, Jerina and Leroux-Roels, Isabel}},
  issn         = {{2047-2994}},
  journal      = {{ANTIMICROBIAL RESISTANCE AND INFECTION CONTROL}},
  keywords     = {{Outbreak,Cardiac surgery,Enterobacter cloacae complex,Extended-spectrumβ-lactamase,Transesophageal echocardiography}},
  language     = {{eng}},
  number       = {{1}},
  pages        = {{14}},
  title        = {{A recurrent and transesophageal echocardiography-associated outbreak of extended-spectrum β-lactamase-producing Enterobacter cloacae complex in cardiac surgery patients}},
  url          = {{http://dx.doi.org/10.1186/s13756-019-0605-4}},
  volume       = {{8}},
  year         = {{2019}},
}

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