title: Outbreak of ertapenem-resistant Enterobacter cloacae urinary tract infections due to a contaminated ureteroscope.
abstract: BACKGROUND
  Outbreaks of urinary tract infections (UTIs) due to contaminated ureteroscopes have been rarely reported.
  
  
  OBJECTIVE
  To report such an outbreak at a regional teaching hospital in southern Taiwan.
  
  
  METHODS
  From October to December 2010, ertapenem-resistant Enterobacter cloacae were identified from urine cultures of 15 patients who had undergone ureteroscopy prior to the infection. Three batches of surveillance cultures were obtained from the environmental objects and healthcare workers related to the procedures. Pulsed-field gel electrophoresis (PFGE) was used for bacterial typing. Antimicrobial susceptibility was assessed by disc diffusion and E-test methods. Polymerase chain reaction and sequencing were used to analyse β-lactamase genes.
  
  
  RESULTS
  A total of 70 specimens were obtained during the first surveillance operation. One ertapenem-resistant E. cloacae was isolated from a ureteroscope. Although the disinfection protocols for ureteroscopes were revised and implemented, seven additional UTI cases were identified thereafter. The pathogen was identified from two subsequent surveillance cultures and was not eliminated until ethylene oxide sterilization was added to the disinfection protocol. PFGE revealed that all 15 isolates from the patients and the three isolates from the ureteroscope shared a common pattern with minor variance. Most isolates were resistant to gentamicin, levofloxacin, ceftriaxone, ceftazidime, and ertapenem. All isolates were susceptible to amikacin, imipenem, and meropenem. SHV-12 and IMP-8 genes were simultaneously identified in 16 of the 18 isolates.
  
  
  CONCLUSIONS
  The outbreak of ertapenem-resistant E. cloacae was caused by a contaminated ureteroscope and was terminated by the implementation of a revised disinfection protocol for ureteroscopes.
authors: Committee of Infection Control, Tainan Municipal Hospital, Tainan, Taiwan.
authors: C-L
authors: CL
authors: Chang
authors: L-H
authors: LH
authors: Su
authors: C-M
authors: CM
authors: Lu
authors: F-T
authors: FT
authors: Tai
authors: Y-C
authors: YC
authors: Huang
authors: K-K
authors: KK
authors: Chang
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D016000:Cluster Analysis; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology; D004196:Disease Outbreaks; D004203:Disinfection / Q000379:methods; D016521:Electrophoresis, Gel, Pulsed-Field; D016972:Enterobacter cloacae / Q000145:classification / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology; D000077727:Ertapenem; D005260:Female; D005798:Genes, Bacterial; D005838:Genotype; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D058889:Molecular Typing; D016133:Polymerase Chain Reaction; D017422:Sequence Analysis, DNA; D013624:Taiwan / Q000453:epidemiology; D020709:Ureteroscopes / Q000382:microbiology*; D014552:Urinary Tract Infections / Q000453:epidemiology* / Q000382:microbiology; D018440:beta-Lactam Resistance; D047090:beta-Lactams / Q000494:pharmacology*
chemical_list: D000900:Anti-Bacterial Agents; D047090:beta-Lactams; D000077727:Ertapenem
keywords: Contamination; Enterobacter cloacae; Medical devices; Outbreak; Ureteroscope; Urinary tract infection