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Endoscopic Retrograde Cholangiopancreatography–Associated AmpC Escherichia coli Outbreak

  • Kristen A. Wendorf (a1) (a2), Meagan Kay (a2), Christopher Baliga (a3), Scott J. Weissman (a4), Michael Gluck (a5), Punam Verma (a6), Marisa D’Angeli (a7), Jennifer Swoveland (a7), Mi-Gyeong Kang (a7), Kaye Eckmann (a7), Andrew S. Ross (a5) and Jeffrey Duchin (a2) (a8)...

Abstract

BACKGROUND

We identified an outbreak of AmpC–producing Escherichia coli infections resistant to third-generation cephalosporins and carbapenems (CR) among 7 patients who had undergone endoscopic retrograde cholangiopancreatography at hospital A during November 2012–August 2013. Gene sequencing revealed a shared novel mutation in a bla CMY gene and a distinctive fumC/ fimH typing profile.

OBJECTIVE

To determine the extent and epidemiologic characteristics of the outbreak, identify potential sources of transmission, design and implement infection control measures, and determine the association between the CR E. coli and AmpC E. coli circulating at hospital A.

METHODS

We reviewed laboratory, medical, and endoscopy reports, and endoscope reprocessing procedures. We obtained cultures from endoscopes after reprocessing as well as environmental samples and conducted pulsed-field gel electrophoresis and gene sequencing on phenotypic AmpC isolates from patients and endoscopes. Cases were those infected with phenotypic AmpC isolates (both carbapenem-susceptible and CR) and identical bla CMY-2, fumC, and fimH alleles or related pulsed-field gel electrophoresis patterns.

RESULTS

Thirty-five of 49 AmpC E. coli tested met the case definition, including all CR isolates. All cases had complicated biliary disease and had undergone at least 1 endoscopic retrograde cholangiopancreatography at hospital A. Mortality at 30 days was 16% for all patients and 56% for CR patients. Two of 8 reprocessed endoscopic retrograde cholangiopancreatography scopes harbored AmpC that matched case isolates by pulsed-field gel electrophoresis. Environmental cultures were negative. No breaches in infection control were identified. Endoscopic reprocessing exceeded manufacturer’s recommended cleaning guidelines.

CONCLUSION

Recommended reprocessing guidelines are not sufficient.

Infect Control Hosp Epidemiol 2015;00(0): 1–9

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Copyright

Corresponding author

Address correspondence to Kristen Wendorf, MD, MS, Public Health–Seattle and King County, Division of Communicable Disease and Immunizations, 401 5th Ave, 9th Fl, Seattle, WA 98104 (xea0@cdc.gov).

Footnotes

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Presented in part: IDWeek; Philadelphia, Pennsylvania. October 11, 2014.

Footnotes

References

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1. Canton, R, Coque, TM, Baquero, F. Multi-resistant gram-negative bacilli: from epidemics to endemics. Curr Opin Infect Dis 2003;16:315325.
2. McGrath, EJ, Asmar, BI. Nosocomial infections and multidrug-resistant bacterial organisms in the pediatric intensive care unit. Indian J Pediatr 2011;78:176184.
3. Palmore, TN, Henderson, DK. Managing transmission of carbapenem-resistant Enterobacteriaceae in healthcare settings: a view from the trenches. Clin Infect Dis 2013;57:1159311599.
4. Kotsanas, D, Wijesooriya, WR, Korman, TM, et al. “Down the drain”: carbapenem-resistant bacteria in intensive care unit patients and handwashing sinks. Med J Aust 2013;198:267269.
5. Lerner, A, Adler, A, Abu-Hanna, J, Meitus, I, Navon-Venezia, S, Carmeli, Y. Environmental contamination by carbapenem-resistant Enterobacteriaceae. J Clin Microbiol 2013;51:177181.
6. Hornbeck, T, Naylor, D, Segre, AM, Thomas, G, Herman, T, Polgreen, PM. Using sensor networks to study the effect of peripatetic healthcare workers on the spread of hospital-associated infections. J Infect Dis 2012;206:15491557.
7. Pittet, D, Allegranzi, B, Boyce, J. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611622.
8. Hidron, AI, Edwards, JR, Patel, J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol 2008;29:9961011.
9. Emori, TG, Gaynes, RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev 1993;6:428442.
10. Wenzel, RP, Osterman, CA, Donowitz, LG, et al. Identification of procedure-related nosocomial infections in high-risk patients. Rev Infect Dis 1981;3:701707.
11. DiazGranados, CA, Jones, MY, Kongphet-Tran, T, et al. Outbreak of Pseudomonas aeruginosa infection associated with contamination of a flexible bronchoscope. Infect Control Hosp Epidemiol 2009;30:550555.
12. Gastmeier, P, Vonberg, RP. Klebsiella spp. in endoscopy-associated infections: we may only be seeing the tip of the iceberg. Infection 2014;42:1521.
13. Coelho-Prabhu, N, Shah, ND, Van Houten, H, Kamath, PS, Baron, TH. Endoscopic retrograde cholangiopancreatography: utilisation and outcomes in a 10-year population-based cohort. BMJ Open 2013;3:e002689.
14. Bilbao, MK, Dotter, CT, Lee, TG, Katon, RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP): a study of 10,000 cases. Gastroenterology 1976;70:314320.
15. Sauter, G, Grabein, B, Huber, G, Mannes, GA, Ruckdeschel, G, Sauerbruch, T. Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography: a randomized controlled study. Endoscopy 1990;22:164167.
16. Epstein, L, Hunter, JC, Arwady, MA, et al. New Delhi metallo-beta-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014;312:14471455.
17. Tenover, FC, Arbeit, RD, Goering, RV, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol 1995;33:22332239.
18. Struelens, MJ, Rost, F, Deplano, A, et al. Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis. Am J Med 1993;95:489498.
19. Fraser, TG, Reiner, S, Malczynski, M, Yarnold, PR, Warren, J, Noskin, GA. Multidrug-resistant Pseudomonas aeruginosa cholangitis after endoscopic retrograde cholangiopancreatography: failure of routine endoscope cultures to prevent an outbreak. Infect Control Hosp Epidemiol 2004;25:856859.
20. Kovaleva, J, Meessen, NE, Peters, FT, et al. Is bacteriologic surveillance in endoscope reprocessing stringent enough? Endoscopy 2009;41:913916.
21. Ranjan, P, Das, K, Ayyagiri, A, Saraswat, VA, Choudhuri, G. A report of post-ERCP Pseudomonas aeruginosa infection outbreak. Indian J Gastroenterol 2005;24:131132.
22. Classen, DC, Jacobsen, JA, Burke, JP, Jacobsen, JT, Evans, RS. Serious Pseudomonas infections associated with endoscopic retrograde cholangiopancreatography. Am J Med 1988;84:590596.
23. Siegman-Igra, Y, Isakov, A, Inbar, G, Cahaner, J. Pseudomonas aeruginosa septicemia following endoscopic retrograde cholangiopancreatography with a contaminated endoscope. Scand J Infect Dis 1987;19:527530.
24. Earnshaw, JJ, Clark, AW, Thom, BT. Outbreak of Pseudomonas aeruginosa following endoscopic retrograde cholangiopancreatography. J Hosp Infect 1985;6:9597.
25. Cryan, EM, Falkiner, FR, Mulvihill, TE, Keane, CT, Keeling, PW. Pseudomonas aeruginosa cross-infection following endoscopic retrograde cholangiopancreatography. J Hosp Infect 1984;5:371376.
26. Aumeran, C, Poincloux, L, Souweine, B, et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010;42:895899.
27. Alfa, MJ, Olson, N, DeGagne, P, Jackson, M. A survey of reprocessing methods, residual viable bioburden, and soil levels in patient-ready endoscopic retrograde choliangiopancreatography duodenoscopes used in Canadian centers. Infect Control Hosp Epidemiol 2002;23:198206.
28. Alfa, MJ, Olson, N, DeGagne, P, Simner, PJ. Development and validation of rapid use scope test strips to determine the efficacy of manual cleaning for flexible endoscope channels. Am J Infect Control 2012;40:860865.
29. Gupta, N, Limbago, BM, Patel, JB, Kallen, AJ. Carbapenem-resistant Enterobacteriaceae: epidemiology and prevention. Clin Infect Dis 2011;53:6067.
30. Kallen, A, Guh, A. United States Centers for Disease Control and Prevention issue updated guidance for tackling carbapenem-resistant Enterobacteriaceae. Euro Surveill 2012;17:20207.
31. Van Duin, D, Kaye, KS, Neuner, EA, Bonomo, RA. Carbapenem-resistant Enterobacteriaceae: a review of treatment and outcomes. Diagn Microbiol Infect Dis 2013;75:115120.
32. Ktari, S, Arlet, G, Verdet, C, et al. Molecular epidemiology and genetic environment of acquired bla ACC-1 in Salmonella enterica serotype Livingstone causing a large nosocomial outbreak in Tunisia. Microb Drug Resist 2009;15:279286.
33. Huang, IF, Chiu, CH, Wang, MH, Wu, CY, Hsieh, KS, Chiou, CC. Outbreak of dysentery associated with ceftriaxone-resistant Shigella sonnei: first report of plasmid-mediated CMY-2-type AmpC beta-lactamase resistance in S. sonnei . J Clin Microbiol 2005;43:26082612.
34. Ohana, S, Leflon, V, Ronco, E, et al. Spread of a Klebsiella pneumoniae strain producing a plasmid-mediated ACC-1 AmpC beta-lactamase in a teaching hospital admitting disabled patients. Antimicrob Agents Chemother 2005;49:20952097.
35. Arena, F, Giani, T, Becucci, E, et al. Large oligoclonal outbreak due to Klebsiella pneumoniae ST14 and ST26 producing the FOX-7 AmpC beta-lactamase in a neonatal intensive care unit. J Clin Microbiol 2013;51:40674072.
36. Fitzpatrick, M, Zembower, T, Malczynski, M, Qi, C, Bolon, MK. Outcomes of an enhanced surveillance program for carbapenem-resistant Enterobacteriaceae. Infect Control Hosp Epidemiol 2014;35:419422.

Endoscopic Retrograde Cholangiopancreatography–Associated AmpC Escherichia coli Outbreak

  • Kristen A. Wendorf (a1) (a2), Meagan Kay (a2), Christopher Baliga (a3), Scott J. Weissman (a4), Michael Gluck (a5), Punam Verma (a6), Marisa D’Angeli (a7), Jennifer Swoveland (a7), Mi-Gyeong Kang (a7), Kaye Eckmann (a7), Andrew S. Ross (a5) and Jeffrey Duchin (a2) (a8)...

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