title: Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices.
abstract: OBJECTIVE
  To determine the cause and mode of transmission of a cluster of infections due to Enterobacter cloacae.
  
  
  METHODS
  Retrospective cohort study in a neonatal intensive-care unit (NICU) from December 1996 to January 1997; environmental and laboratory investigations.
  
  
  METHODS
  60 infants hospitalized in the NICU during the outbreak period.
  
  
  METHODS
  Odds ratios (OR) linking E. cloacae colonization or infection and various exposures. All available E. cloacae isolates were typed and characterized by contour-clamped homogenous electric-field electrophoresis to confirm possible cross-transmission.
  
  
  RESULTS
  Of eight case-patients, two had bacteremia; one, pneumonia; one, soft-tissue infection; and four, respiratory colonization. Infants weighing <2,000 g and born before week 33 of gestation were more likely to become cases (P<.001). Multivariate analysis indicated that the use of multidose vials was independently associated with E. cloacae carriage (OR, 16.3; 95% confidence interval [CI95], 1.8-infinity; P=.011). Molecular studies demonstrated three epidemic clones. Cross-transmission was facilitated by understaffing and overcrowding (up to 25 neonates in a unit designed for 15), with an increased risk of E. cloacae carriage during the outbreak compared to periods without understaffing and overcrowding (relative risk, 5.97; CI95 2.2-16.4). Concurrent observation of healthcare worker (HCW) handwashing practices indicated poor compliance. The outbreak was terminated after decrease of work load, increase of hand antisepsis, and reinforcement of single-dose medication.
  
  
  CONCLUSIONS
  Several factors caused and aggravated this outbreak: (1) introduction of E. cloacae into the NICU, likely by two previously colonized infants; (2) further transmission by HCWs' hands, facilitated by substantial overcrowding and understaffing in the unit; (3) possible contamination of multidose vials with E. cloacae. Overcrowding and understaffing in periods of increased work load may result in outbreaks of nosocomial infections and should be avoided.
authors.affiliation: Infection Control Program, University Hospitals of Geneva, Switzerland.
authors.forename: S
authors.initials: S
authors.lastname: Harbarth
authors.forename: P
authors.initials: P
authors.lastname: Sudre
authors.forename: S
authors.initials: S
authors.lastname: Dharan
authors.forename: M
authors.initials: M
authors.lastname: Cadenas
authors.forename: D
authors.initials: D
authors.lastname: Pittet
mesh_terms: D003428:Cross Infection / Q000453:epidemiology*; D003441:Crowding; D004196:Disease Outbreaks; D016972:Enterobacter cloacae / Q000145:classification / Q000302:isolation & purification*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000635:transmission; D004866:Equipment Contamination; D005260:Female; D005865:Gestational Age; D006801:Humans; D006920:Hygiene; D015994:Incidence; D007231:Infant, Newborn; D017053:Infection Control / Q000379:methods; D007363:Intensive Care Units, Neonatal; D016015:Logistic Models; D008297:Male; D010564:Personnel, Hospital; D012189:Retrospective Studies; D012307:Risk Factors; D013557:Switzerland / Q000453:epidemiology