Abstract
Purpose
Two endoscopy-associated nosocomial outbreaks caused by carbapenemase-producing Klebsiella pneumoniae (CPKP) were recently observed in two German hospitals. In this study, we performed a systematic search of the medical literature in order to elucidate the epidemiology of Klebsiella spp. in endoscopy-associated outbreaks.
Methods
Medline, the Outbreak Database (http://www.outbreak-database.com) and reference lists of articles extracted from these databases were screened for descriptions of endoscopy-associated nosocomial outbreaks. The data extracted and analysed were: (1) the type of medical department affected; (2) characterisation of pathogen to species and conspicuous resistance patterns (if applicable); (3) type of endoscope and the grade of its contamination; (4) number and the types of infections; (5) actual cause of the outbreak.
Results
A total of seven nosocomial outbreaks were identified, of which six were outbreaks of endoscopic retrograde cholangiopancreatography-related infections and caused by contaminated duodenoscopes. Including our own outbreaks in the analysis, we identified one extended-spectrum beta-lactamase-producing K. pneumoniae strain and six CPKP strains. Insufficient reprocessing after the use of the endoscope was the main reason for subsequent pathogen transmission.
Conclusions
There were only two reports of nosocomial outbreaks due to Klebsiella spp. in the first three decades of endoscopic procedures, but seven additional outbreaks of this kind have been reported within the last 4 years. It is very likely that many of such outbreaks have been missed in the past because this pathogen belongs to the physiological gut flora. However, with the emergence of highly resistant (carbapenemase-producing) strains, strict adherence to infection control guidelines is more important than ever.
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References
Srinivasan A. Epidemiology and prevention of infections related to endoscopy. Curr Infect Dis Rep. 2003;5:467–72.
Seoane-Vazquez E, Rodriguez-Monguio R. Endoscopy-related infection: relic of the past? Curr Opin Infect Dis. 2008;21:362–6.
Yigit H, Queenan AM, Anderson GJ, Domenech-Sanchez A, Biddle JW, Steward CD, Alberti S, Bush K, Tenover FC. Novel carbapenem-hydrolyzing beta-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae. Antimicrob Agents Chemother. 2001;45:1151–61.
Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneumoniae carbapenemase-producing bacteria. Lancet Infect Dis. 2009;9:228–36.
Rapp RP, Urban C. Klebsiella pneumoniae carbapenemases in Enterobacteriaceae: history, evolution, and microbiology concerns. Pharmacotherapy. 2012;32:399–407.
Lee GC, Burgess DS. Treatment of Klebsiella pneumoniae carbapenemase (KPC) infections: a review of published case series and case reports. Ann Clin Microbiol Antimicrob. 2012;11:32.
Kaase M. Carbapenemases in gram-negative bacteria. Current data and trends of resistance resulting from the work of national reference centres. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2012;55:1401–4.
Wendt C, Schutt S, Dalpke AH, Konrad M, Mieth M, Trierweiler-Hauke B, Weigand MA, Zimmermann S, Biehler K, Jonas D. First outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in Germany. Eur J Clin Microbiol Infect Dis. 2010;29:563–70.
Steinmann J, Kaase M, Gatermann S, Popp W, Steinmann E, Damman M, Paul A, Saner F, Buer J, Rath P. Outbreak due to a Klebsiella pneumoniae strain harbouring KPC-2 and VIM-1 in a German university hospital, July 2010 to January 2011. Euro Surveill. 2011;16:19944.
Becker-Rux D, Knaust A, Laudi S, Voelker MT, Busch T, Rodloff A, Kaisers UX. Large local outbreak of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (kpc-Kp) in Germany. Am J Respir Crit Care Med. 2012;185:A6077 [presented at the International Conference of the American Thoracic Society (ATS), May 18–23, San Francisco].
Vonberg RP, Weitzel-Kage D, Behnke M, Gastmeier P. Worldwide outbreak database: the largest collection of nosocomial outbreaks. Infection. 2011;39:29–34.
Kovaleva J, Peters FT, van der Mei HC, Degener JE. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev. 2013;26:231–54.
Orsi GB, Bencardino A, Vena A, Carattoli A, Venditti C, Falcone M, Giordano A, Venditti M. Patient risk factors for outer membrane permeability and KPC-producing carbapenem-resistant Klebsiella pneumoniae isolation: results of a double case-control study. Infection. 2013;41:61–7.
Lubowski DZ, Newstead GL. Rigid sigmoidoscopy: a potential hazard for cross-contamination. Surg Endosc. 2006;20:812–4.
Ribeiro MM, de Oliveira AC. Analysis of the air/water channels of gastrointestinal endoscopies as a risk factor for the transmission of microorganisms among patients. Am J Infect Control. 2012;40:913–6.
Kinney TP, Kozarek RA, Raltz S, Attia F. Contamination of single-use biopsy forceps: a prospective in vitro analysis. Gastrointest Endosc. 2002;56:209–12.
Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008. Available at: http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf. 2008. Accessed 20 Sep 2013.
Bojer MS, Krogfelt KA, Struve C. The newly discovered ClpK protein strongly promotes survival of Klebsiella pneumoniae biofilm subjected to heat shock. J Med Microbiol. 2011;60:1559–61.
Johnson AP, Woodford N. Global spread of antibiotic resistance: the example of New Delhi metallo-beta-lactamase (NDM)-mediated carbapenem resistance. J Med Microbiol. 2013;62:499–513.
Correa L, Martino MD, Siqueira I, Pasternak J, Gales AC, Silva CV, Camargo TZ, Scherer PF, Marra AR. A hospital-based matched case-control study to identify clinical outcome and risk factors associated with carbapenem-resistant Klebsiella pneumoniae infection. BMC Infect Dis. 2013;13:80.
Struelens MJ, Rost F, Deplano A, Maas A, Schwam V, Serruys E, Cremer M. Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis. Am J Med. 1993;95:489–98.
Cetre JC, Nicolle MC, Salord H, Perol M, Tigaud S, David G, Bourjault M, Vanhems P. Outbreaks of contaminated broncho-alveolar lavage related to intrinsically defective bronchoscopes. J Hosp Infect. 2005;61:39–45.
Centers for Disease Control and Prevention (CDC). Notice to readers: Pseudomonas aeruginosa infections associated with defective bronchoscopes. MMWR. 2002;51:190.
Srinivasan A, Wolfenden LL, Song X, Mackie K, Hartsell TL, Jones HD, Diette GB, Orens JB, Yung RC, Ross TL, Merz W, Scheel PJ, Haponik EF, Perl TM. An outbreak of Pseudomonas aeruginosa infections associated with flexible bronchoscopes. N Engl J Med. 2003;348:221–7.
Kirschke DL, Jones TF, Craig AS, Chu PS, Mayernick GG, Patel JA, Schaffner W. Pseudomonas aeruginosa and Serratia marcescens contamination associated with a manufacturing defect in bronchoscopes. N Engl J Med. 2003;348:214–20.
Cetre JC, Salord H, Vanhems P. Outbreaks of infection associated with bronchoscopes. N Engl J Med. 2003;348:2039–40.
Aumeran C, Poincloux L, Souweine B, Robin F, Laurichesse H, Baud O, Bommelaer G, Traore O. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy. 2010;42:895–9.
Hennequin C, Aumeran C, Robin F, Traore O, Forestier C. Antibiotic resistance and plasmid transfer capacity in biofilm formed with a CTX-M-15-producing Klebsiella pneumoniae isolate. J Antimicrob Chemother. 2012;67:2123–30.
Alrabaa SF, Nguyen P, Sanderson R, Baluch A, Sandin RL, Kelker D, Karlapalem C, Thompson P, Sams K, Martin S, Montero J, Greene JN. Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment. Am J Infect Control. 2013;41:562–4.
Sanderson R, Braithwaite L, Ragan P, Eisenstein L. An outbreak of carbapenem-resistant Klebsiella pneumoniae infections associated with endoscopic retrograde cholangiopancreatography (ERCP) procedures at a hospital. Am J Infect Control. 2010;38:e141 [presented at the 37th annual educational conference & international meeting of the association for professionals in infection control and epidemiology (APIC), July 11th–15th, New Orleans].
Carbonne A, Thiolet JM, Fournier S, Fortineau N, Kassis-Chikhani N, Boytchev I, Aggoune M, Seguier JC, Senechal H, Tavolacci MP, Coignard B, Astagneau P, Jarlier V. Control of a multi-hospital outbreak of KPC-producing Klebsiella pneumoniae type 2 in France, September to October 2009. Euro Surveill. 2010;15:19734.
Naas T, Cuzon G, Babics A, Fortineau N, Boytchev I, Gayral F, Nordmann P. Endoscopy-associated transmission of carbapenem-resistant Klebsiella pneumoniae producing KPC-2 beta-lactamase. J Antimicrob Chemother. 2010;65:1305–6.
Kassis-Chikhani N, Decre D, Ichai P, Sengelin C, Geneste D, Mihaila L, Dussaix E, Arlet G. Outbreak of Klebsiella pneumoniae producing KPC-2 and SHV-12 in a French hospital. J Antimicrob Chemother. 2010;65:1539–40.
Koo VS, O’Neill P, Elves A. Multidrug-resistant NDM-1 Klebsiella outbreak and infection control in endoscopic urology. BJU Int. 2012;110:E922–6.
The Shrewsbury and Telford Hospital NHS Trust. Klebsiella: statement and information. Available at: http://www.sath.nhs.uk/media/news_archive/Klebsiella_Statement_July30.aspx (2010). Accessed 20 Sep 2013.
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Gastmeier, P., Vonberg, RP. Klebsiella spp. in endoscopy-associated infections: we may only be seeing the tip of the iceberg. Infection 42, 15–21 (2014). https://doi.org/10.1007/s15010-013-0544-6
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DOI: https://doi.org/10.1007/s15010-013-0544-6