title: New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes.
abstract: OBJECTIVE
  Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georg.
authors.forename: Lauren
authors.initials: L
authors.lastname: Epstein
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georg.
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Hunter
authors.affiliation: Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia3Illinois Department of Public Health, Chicago, Illinois.
authors.forename: M Allison
authors.initials: MA
authors.lastname: Arwady
authors.affiliation: Illinois Department of Public Health, Chicago, Illinois.
authors.forename: Victoria
authors.initials: V
authors.lastname: Tsai
authors.affiliation: Advocate Lutheran General Hospital, Park Ridge, Illinois.
authors.forename: Linda
authors.initials: L
authors.lastname: Stein
authors.affiliation: Advocate Lutheran General Hospital, Park Ridge, Illinois.
authors.forename: Marguerite
authors.initials: M
authors.lastname: Gribogiannis
authors.affiliation: Cook County Department of Public Health, Oak Forest, Illinois.
authors.forename: Mabel
authors.initials: M
authors.lastname: Frias
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alice Y
authors.initials: AY
authors.lastname: Guh
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alison S
authors.initials: AS
authors.lastname: Laufer
authors.affiliation: Chicago Department of Public Health, Chicago, Illinois.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Black
authors.affiliation: Chicago Department of Public Health, Chicago, Illinois.
authors.forename: Massimo
authors.initials: M
authors.lastname: Pacilli
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Heather
authors.initials: H
authors.lastname: Moulton-Meissner
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: J Kamile
authors.initials: JK
authors.lastname: Rasheed
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Johannetsy J
authors.initials: JJ
authors.lastname: Avillan
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Brandon
authors.initials: B
authors.lastname: Kitchel
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Brandi M
authors.initials: BM
authors.lastname: Limbago
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Duncan
authors.initials: D
authors.lastname: MacCannell
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: David
authors.initials: D
authors.lastname: Lonsway
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Judith
authors.initials: J
authors.lastname: Noble-Wang
authors.affiliation: Illinois Department of Public Health, Chicago, Illinois.
authors.forename: Judith
authors.initials: J
authors.lastname: Conway
authors.affiliation: Illinois Department of Public Health, Chicago, Illinois.
authors.forename: Craig
authors.initials: C
authors.lastname: Conover
authors.affiliation: Cook County Department of Public Health, Oak Forest, Illinois.
authors.forename: Michael
authors.initials: M
authors.lastname: Vernon
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Kallen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015780:Carbapenems / Q000494:pharmacology*; D016022:Case-Control Studies; D015331:Cohort Studies; D003428:Cross Infection / Q000453:epidemiology; D004196:Disease Outbreaks; D004203:Disinfection / Q000379:methods*; D024881:Drug Resistance, Bacterial; D020698:Duodenoscopes / Q000382:microbiology*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology / Q000209:etiology*; D004866:Equipment Contamination; D004926:Escherichia coli / Q000201:enzymology / Q000302:isolation & purification; D005260:Female; D006761:Hospitals; D006801:Humans; D007087:Illinois / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D001618:beta-Lactamases
chemical_list: D015780:Carbapenems; D001618:beta-Lactamases; C552864:beta-lactamase NDM-1