title: Healthcare-associated prosthetic heart valve, aortic vascular graft, and disseminated Mycobacterium chimaera infections subsequent to open heart surgery.
abstract: OBJECTIVE
  We identified 10 patients with disseminated Mycobacterium chimaera infections subsequent to open-heart surgery at three European Hospitals. Infections originated from the heater-cooler unit of the heart-lung machine. Here we describe clinical aspects and treatment course of this novel clinical entity.
  
  
  RESULTS
  Interdisciplinary care and follow-up of all patients was documented by the study team. Patients' characteristics, clinical manifestations, microbiological findings, and therapeutic measures including surgical reinterventions were reviewed and treatment outcomes are described. The 10 patients comprise a 1-year-old child and nine adults with a median age of 61 years (range 36-76 years). The median duration from cardiac surgery to diagnosis was 21 (range 5-40) months. All patients had prosthetic material-associated infections with either prosthetic valve endocarditis, aortic graft infection, myocarditis, or infection of the prosthetic material following banding of the pulmonary artery. Extracardiac manifestations preceded cardiovascular disease in some cases. Despite targeted antimicrobial therapy, M. chimaera infection required cardiosurgical reinterventions in eight patients. Six out of 10 patients experienced breakthrough infections, of which four were fatal. Three patients are in a post-treatment monitoring period.
  
  
  CONCLUSIONS
  Healthcare-associated infections due to M. chimaera occurred in patients subsequent to cardiac surgery with extracorporeal circulation and implantation of prosthetic material. Infections became clinically apparent after a time lag of months to years. Mycobacterium chimaera infections are easily missed by routine bacterial diagnostics and outcome is poor despite long-term antimycobacterial therapy, probably because biofilm formation hinders eradication of pathogens.
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Kohler
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Stefan P
authors.initials: SP
authors.lastname: Kuster
authors.affiliation: Institute of Medical Microbiology, University of Zurich, Gloriastrasse 30/32, Zurich 8006, Switzerland.
authors.forename: Guido
authors.initials: G
authors.lastname: Bloemberg
authors.affiliation: Institute of Medical Microbiology, University of Zurich, Gloriastrasse 30/32, Zurich 8006, Switzerland National Reference Center for Mycobacteria, University of Zurich, Gloriastrasse 30/32, Zurich 8006, Switzerland.
authors.forename: Bettina
authors.initials: B
authors.lastname: Schulthess
authors.affiliation: Department of Cardiology, Cardiovascular Center, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Michelle
authors.initials: M
authors.lastname: Frank
authors.affiliation: Department of Cardiology, Cardiovascular Center, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Felix C
authors.initials: FC
authors.lastname: Tanner
authors.affiliation: Institute of Surgical Pathology, University Hospital Zurich, University of Zurich, Schmelzbergstrasse 12, Zurich 8091, Switzerland.
authors.forename: Matthias
authors.initials: M
authors.lastname: Rössle
authors.affiliation: Department of Ophthalmology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Christian
authors.initials: C
authors.lastname: Böni
authors.affiliation: Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland Deutsches Herzzentrum Berlin, Augustenburger Platz 1, Berlin 13353, Germany.
authors.forename: Volkmar
authors.initials: V
authors.lastname: Falk
authors.affiliation: Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Markus J
authors.initials: MJ
authors.lastname: Wilhelm
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Rami
authors.initials: R
authors.lastname: Sommerstein
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Achermann
authors.affiliation: Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Jaap
authors.initials: J
authors.lastname: Ten Oever
authors.affiliation: Laboratory of Medical Microbiology and Infectious Diseases, Isala Clinics, Zwolle, The Netherlands.
authors.forename: Sylvia B
authors.initials: SB
authors.lastname: Debast
authors.affiliation: Laboratory of Medical Microbiology and Infectious Diseases, Isala Clinics, Zwolle, The Netherlands.
authors.forename: Maurice J H M
authors.initials: MJ
authors.lastname: Wolfhagen
authors.affiliation: Department of Cardiothoracic Surgery, Isala Clinics, Zwolle, The Netherlands.
authors.forename: George J
authors.initials: GJ
authors.lastname: Brandon Bravo Bruinsma
authors.affiliation: Medical Microbiology and infectious Diseases, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Margreet C
authors.initials: MC
authors.lastname: Vos
authors.affiliation: Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Ad
authors.initials: A
authors.lastname: Bogers
authors.affiliation: Centre for Microbiology and Hygiene, University Hospital of Freiburg, Freiburg i.Br, Germany.
authors.forename: Annerose
authors.initials: A
authors.lastname: Serr
authors.affiliation: Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg i.Br, Germany.
authors.forename: Friedhelm
authors.initials: F
authors.lastname: Beyersdorf
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Hugo
authors.initials: H
authors.lastname: Sax
authors.affiliation: Institute of Medical Microbiology, University of Zurich, Gloriastrasse 30/32, Zurich 8006, Switzerland National Reference Center for Mycobacteria, University of Zurich, Gloriastrasse 30/32, Zurich 8006, Switzerland.
authors.forename: Erik C
authors.initials: EC
authors.lastname: Böttger
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland.
authors.forename: Rainer
authors.initials: R
authors.lastname: Weber
authors.affiliation: Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Jakko
authors.initials: J
authors.lastname: van Ingen
authors.affiliation: Department of Medicine, Center for Infectious Diseases and Travel Medicine and Center for Chronic Immunodeficiency, University Medical Center, Freiburg i.Br, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Wagner
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, Zurich 8091, Switzerland barbara.hasse@usz.ch b.hasse@gmx.ch.
authors.forename: Barbara
authors.initials: B
authors.lastname: Hasse
mesh_terms: D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000601:surgery; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003428:Cross Infection / Q000209:etiology*; D004697:Endocarditis, Bacterial / Q000209:etiology*; D004866:Equipment Contamination; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009165:Mycobacterium Infections, Nontuberculous / Q000209:etiology*; D016459:Prosthesis-Related Infections / Q000209:etiology*
keywords: Aortic graft infection; Cardiac surgery; Health-care associated infection; Mycobacterium chimaera; Myocarditis; Prosthetic valve endocarditis