New Delhi metallo-ß-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes.

IMPORTANCE: Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-ß-lactamase (NDM) are rare in the United States, but have the potential to add to the increasing CRE burden. Previous NDM-producing CRE clusters have been attributed to person-to-person transmission in health care facilities. OBJECTIVE: To identify a source for, and interrupt transmission of, NDM-producing CRE in a northeastern Illinois hospital. DESIGN, SETTING, AND PARTICIPANTS: Outbreak investigation among 39 case patients at a tertiary care hospital in northeastern Illinois, including a case-control study, infection control assessment, and collection of environmental and device cultures; patient and environmental isolate relatedness was evaluated with pulsed-field gel electrophoresis (PFGE). Following identification of a likely source, targeted patient notification and CRE screening cultures were performed. MAIN OUTCOMES AND MEASURES: Association between exposure and acquisition of NDM-producing CRE; results of environmental cultures and organism typing. RESULTS: In total, 39 case patients were identified from January 2013 through December 2013, 35 with duodenoscope exposure in 1 hospital. No lapses in duodenoscope reprocessing were identified; however, NDM-producing Escherichia coli was recovered from a reprocessed duodenoscope and shared more than 92% similarity to all case patient isolates by PFGE. Based on the case-control study, case patients had significantly higher odds of being exposed to a duodenoscope (odds ratio [OR], 78 [95% CI, 6.0-1008], P < .001). After the hospital changed its reprocessing procedure from automated high-level disinfection with ortho-phthalaldehyde to gas sterilization with ethylene oxide, no additional case patients were identified. CONCLUSIONS AND RELEVANCE: In this investigation, exposure to duodenoscopes with bacterial contamination was associated with apparent transmission of NDM-producing E coli among patients at 1 hospital. Bacterial contamination of duodenoscopes appeared to persist despite the absence of recognized reprocessing lapses. Facilities should be aware of the potential for transmission of bacteria including antimicrobial-resistant organisms via this route and should conduct regular reviews of their duodenoscope reprocessing procedures to ensure optimal manual cleaning and disinfection.

Investigation and control of an outbreak of Achromobacter xylosoxidans bacteremia.

OBJECTIVE: To define the extent of an outbreak of Achromobacter xylosoxidans bacteremia, determine the source of the outbreak, and implement control measures. DESIGN: An outbreak investigation, including environmental and infection control assessment, and evaluation of hypotheses using the binomial distribution and case control studies. SETTING: A 50-bed medical surgical unit in a hospital in Illinois during the period January 1-July 15, 2006. INTERVENTIONS: Discontinuation of use of opioid delivery via patient-controlled analgesia (PCA) until the source of the outbreak was identified and implementation of new protocols to ensure more rigorous observation of PCA pump cartridge manipulations. RESULTS: Calculations based on the binomial distribution indicated the probability that all 9 patients with A. xylosoxidans bacteremia were PCA pump users by chance alone was <.001. A subsequent case control study identified PCA pump use for administration of morphine as a risk factor for A. xylosoxidans bacteremia (odds ratio, undefined; P < .001). Having a PCA pump cartridge with morphine started by nurse C was significantly associated with becoming a case-patient (odds ratio, 46; 95% confidence interval, 4.0-525.0; P < .001). CONCLUSIONS: We hypothesize that actions related to diversion of morphine by nurse C were the likely cause of the outbreak. An aggressive pain control program involving the use of opioid medication warrants an equally aggressive policy to prevent diversion of medication by staff.