title: Prolonged postprocedural outbreak of Mycobacterium massiliense infections associated with ultrasound transmission gel.
abstract: Postprocedural infections by Mycobacterium abscessus complex are increasing worldwide, and the source and route of transmission are infrequently identified. Here the extension of a previous clustering of paediatric patients with surgical site infections due to a single strain of the subspecies M. massiliense is reported. The investigation was conducted at a 2200-bed teaching hospital in Taiwan and included microbial surveillance of the environment (water, air, equipment and supplies) and a case-control study. We performed molecular identification and typing of the isolates by a trilocus sequencing scheme, confirmed by multilocus sequencing typing and pulsed-field gel electrophoresis. We investigated 40 patients who developed postprocedure soft tissue or bloodstream infections by M. massiliense (TPE101) during a 3-year period. Thirty-eight patients were identified at hospital A, and one newborn and her mother were identified at hospital B (185 km from hospital A). A case-control study identified the association of invasive procedures (adjusted odds ratio, 9.13) and ultrasonography (adjusted odds ratio, 2.97) (both p <0.05) with acquiring the outbreak strain. Isolates from the cases and unopened bottles of ultrasound transmission gel were all of strain ST48 and indistinguishable or closely related by pulsed-field gel electrophoresis. After replacement of contaminated gel, no new cases were detected during 18 months' follow-up. This investigation identified the use of contaminated gel as the common source causing an outbreak on a larger scale than had been recognized. Our findings halted production by the manufacturer and prompted revision of hospital guidelines.
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: A
authors.initials: A
authors.lastname: Cheng
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: W-H
authors.initials: WH
authors.lastname: Sheng
authors.affiliation: Department of Paediatrics, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Y-C
authors.initials: YC
authors.lastname: Huang
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: H-Y
authors.initials: HY
authors.lastname: Sun
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Y-T
authors.initials: YT
authors.lastname: Tsai
authors.affiliation: Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: M-L
authors.initials: ML
authors.lastname: Chen
authors.affiliation: Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Y-C
authors.initials: YC
authors.lastname: Liu
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Y-C
authors.initials: YC
authors.lastname: Chuang
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: S-C
authors.initials: SC
authors.lastname: Huang
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: C-I
authors.initials: CI
authors.lastname: Chang
authors.affiliation: Department of Paediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: L-Y
authors.initials: LY
authors.lastname: Chang
authors.affiliation: Department of Paediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: W-C
authors.initials: WC
authors.lastname: Huang
authors.affiliation: Department of Laboratory Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: P-R
authors.initials: PR
authors.lastname: Hsueh
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: C-C
authors.initials: CC
authors.lastname: Hung
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan. Electronic address: yeechunchen@gmail.com.
authors.forename: Y-C
authors.initials: YC
authors.lastname: Chen
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: S-C
authors.initials: SC
authors.lastname: Chang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D004196:Disease Outbreaks; D004340:Drug Contamination; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D005838:Genotype; D006784:Hospitals, Teaching; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D058885:Multilocus Sequence Typing; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology* / Q000382:microbiology; D009170:Nontuberculous Mycobacteria / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000382:microbiology; D013624:Taiwan / Q000453:epidemiology; D014463:Ultrasonography / Q000009:adverse effects*
keywords: Mycobacterium abscessus; Mycobacterium massiliense; outbreak; skin and soft tissue infections; ultrasonography gel