title: Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak.
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.
  
  
  CONCLUSIONS
  Recommended reprocessing guidelines are not sufficient.
authors.affiliation: 1Epidemic Intelligence Service,Centers for Disease Control and Prevention,Atlanta,Georgia.
authors.forename: Kristen A
authors.initials: KA
authors.lastname: Wendorf
authors.affiliation: 2Division of Communicable Diseases and Immunizations,Public Health-Seattle and King County,Seattle,Washington.
authors.forename: Meagan
authors.initials: M
authors.lastname: Kay
authors.affiliation: 3Infectious Diseases and Infection Control,Virginia Mason Medical Center,Seattle,Washington.
authors.forename: Christopher
authors.initials: C
authors.lastname: Baliga
authors.affiliation: 4Center for Global Infectious Disease Research,Seattle Children's Research Institute,Seattle,Washington.
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Weissman
authors.affiliation: 5Department of Gastroenterology,Virginia Mason Medical Center,Seattle,Washington.
authors.forename: Michael
authors.initials: M
authors.lastname: Gluck
authors.affiliation: 6Department of Microbiology,Virginia Mason Medical Center,Seattle,Washington.
authors.forename: Punam
authors.initials: P
authors.lastname: Verma
authors.affiliation: 7Washington State Department of Health,Shoreline,Washington.
authors.forename: Marisa
authors.initials: M
authors.lastname: D'Angeli
authors.affiliation: 7Washington State Department of Health,Shoreline,Washington.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Swoveland
authors.affiliation: 7Washington State Department of Health,Shoreline,Washington.
authors.forename: Mi-Gyeong
authors.initials: MG
authors.lastname: Kang
authors.affiliation: 7Washington State Department of Health,Shoreline,Washington.
authors.forename: Kaye
authors.initials: K
authors.lastname: Eckmann
authors.affiliation: 5Department of Gastroenterology,Virginia Mason Medical Center,Seattle,Washington.
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Ross
authors.affiliation: 2Division of Communicable Diseases and Immunizations,Public Health-Seattle and King County,Seattle,Washington.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Duchin
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D015780:Carbapenems / Q000494:pharmacology*; D018550:Cephalosporin Resistance / Q000235:genetics; D002511:Cephalosporins / Q000494:pharmacology*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods; D004196:Disease Outbreaks / Q000517:prevention & control*; D020698:Duodenoscopes / Q000382:microbiology*; D004866:Equipment Contamination / Q000517:prevention & control*; D004926:Escherichia coli / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000453:epidemiology / Q000517:prevention & control; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods / Q000592:standards; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D001618:beta-Lactamases / Q000235:genetics
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems; D002511:Cephalosporins; C103022:beta-lactamase CMY-2; D001618:beta-Lactamases