title: Outbreak of IMP-producing carbapenem-resistant Enterobacter gergoviae among kidney transplant recipients.
abstract: The objective of this study was to investigate a prolonged outbreak of carbapenem-resistant Enterobacter gergoviae (CREG) involving kidney transplant recipients (KTRs) between 2009 and 2014.
  
  
  
  A case-control study was undertaken. Controls (n = 52) were selected from CREG-negative KTRs. Surveillance cultures for CREG were collected weekly. Colonization was defined as isolation of CREG from surveillance samples or from clinical specimens, with no evidence of infection. We also investigated infection control practices at the facility.
  
  
  
  Of 26 identified cases, 13 had had no known contact with another CREG-positive patient before the first positive culture. Seven patients (27%) developed infection. The site most often colonized was the urinary tract. During the study period two clusters were identified, one in 2009 and another in 2013-14. DNA sequencing revealed blaIMP-1 in all CREG tested. No environmental or hand cultures tested positive for CREG. An audit of infection control practices detected flaws in the handling and cleaning of urinary tract devices. Multivariate analysis identified advanced age, ureteral stent use, retransplantation and male gender as risk factors for CREG acquisition.
  
  
  
  An outbreak among KTRs caused by an unusual species of MDR bacteria may have resulted from a common source of contamination related to urinary tract devices.
authors.affiliation: Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil maristelapf@uol.com.br.
authors.forename: Maristela Pinheiro
authors.initials: MP
authors.lastname: Freire
authors.affiliation: Bacteriology Centre, Adolfo Lutz Institute, São Paulo, Brazil.
authors.forename: Doroti
authors.initials: D
authors.lastname: de Oliveira Garcia
authors.affiliation: Microbiology Section, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Ana Paula
authors.initials: AP
authors.lastname: Cury
authors.affiliation: Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Fernanda
authors.initials: F
authors.lastname: Spadão
authors.affiliation: Division of Microbiology, DASA Medicina Diagnóstica, São Paulo, Brazil.
authors.forename: Thais S R
authors.initials: TS
authors.lastname: Di Gioia
authors.affiliation: Bacteriology Centre, Adolfo Lutz Institute, São Paulo, Brazil.
authors.forename: Gabriela Rodrigues
authors.initials: GR
authors.lastname: Francisco
authors.affiliation: Bacteriology Centre, Adolfo Lutz Institute, São Paulo, Brazil.
authors.forename: Maria Fernanda Campagnari
authors.initials: MF
authors.lastname: Bueno
authors.affiliation: Laboratory for Medical Research 54, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Mariama
authors.initials: M
authors.lastname: Tomaz
authors.affiliation: Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Flavio Jota
authors.initials: FJ
authors.lastname: de Paula
authors.affiliation: Division of Microbiology, DASA Medicina Diagnóstica, São Paulo, Brazil.
authors.forename: Lorena Brito
authors.initials: LB
authors.lastname: de Faro
authors.affiliation: Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Affonso C
authors.initials: AC
authors.lastname: Piovesan
authors.affiliation: Microbiology Section, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Flavia
authors.initials: F
authors.lastname: Rossi
authors.affiliation: Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil.
authors.forename: Anna Sara
authors.initials: AS
authors.lastname: Levin
authors.affiliation: Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: Elias
authors.initials: E
authors.lastname: David Neto
authors.affiliation: Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil.
authors.forename: William C
authors.initials: WC
authors.lastname: Nahas
authors.affiliation: Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil.
authors.forename: Ligia Camera
authors.initials: LC
authors.lastname: Pierrotti
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D015780:Carbapenems / Q000494:pharmacology*; D016022:Case-Control Studies; D004196:Disease Outbreaks; D004754:Enterobacter / Q000201:enzymology* / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D006801:Humans; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D017422:Sequence Analysis, DNA; D066027:Transplant Recipients; D014552:Urinary Tract Infections / Q000453:epidemiology / Q000382:microbiology; D055815:Young Adult; D018440:beta-Lactam Resistance; D001618:beta-Lactamases / Q000235:genetics / Q000378:metabolism*
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems; D001618:beta-Lactamases