OBJECTIVE
To determine the cause and mode of transmission of a cluster of infections due to Enterobacter cloacae.


DESIGN AND SETTING
Retrospective cohort study in a neonatal intensive-care unit (NICU) from December 1996 to January 1997; environmental and laboratory investigations.


SUBJECTS
60 infants hospitalized in the NICU during the outbreak period.


MAIN OUTCOME MEASURES
Odds ratios (OR) linking E. cloacae colonization or infection and various exposures. All available E. cloacae isolates were typed and characterized by contour-clamped homogenous electric-field electrophoresis to confirm possible cross-transmission.


RESULTS
Of eight case-patients, two had bacteremia; one, pneumonia; one, soft-tissue infection; and four, respiratory colonization. Infants weighing <2,000 g and born before week 33 of gestation were more likely to become cases (P<.001). Multivariate analysis indicated that the use of multidose vials was independently associated with E. cloacae carriage (OR, 16.3; 95% confidence interval [CI95], 1.8-infinity; P=.011). Molecular studies demonstrated three epidemic clones. Cross-transmission was facilitated by understaffing and overcrowding (up to 25 neonates in a unit designed for 15), with an increased risk of E. cloacae carriage during the outbreak compared to periods without understaffing and overcrowding (relative risk, 5.97; CI95 2.2-16.4). Concurrent observation of healthcare worker (HCW) handwashing practices indicated poor compliance. The outbreak was terminated after decrease of work load, increase of hand antisepsis, and reinforcement of single-dose medication.


CONCLUSIONS
Several factors caused and aggravated this outbreak: (1) introduction of E. cloacae into the NICU, likely by two previously colonized infants; (2) further transmission by HCWs' hands, facilitated by substantial overcrowding and understaffing in the unit; (3) possible contamination of multidose vials with E. cloacae. Overcrowding and understaffing in periods of increased work load may result in outbreaks of nosocomial infections and should be avoided.

Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices [see comments]

Sepsis and septic shock are common life-threatening pathologies associated with high mortality and substantial costs for healthcare system. Clinical guidelines and bundles for the management of patients with sepsis have recently been updated. Herein, we review the history of sepsis and related conditions definitions from the first consensus conference in 1991 to nowadays, the epidemiologic data resulting from worldwide studies on incidence and mortality, the diagnostic approaches including the microbiological assessment of infection and the use of several prognostic and diagnostic biomarkers and finally we review the main therapeutic measures as the intravenous immunoglobulin therapy and the administration of appropriate antibiotic treatment to provide patients with sepsis a favourable outcome in the antibiotic-resistance era.

Sepsis and septic shock: New definitions, new diagnostic and therapeutic approaches.

We focused our attention on susceptibility profile of Acinetobacter spp., Pseudomonas spp., and Klebsiella spp. isolated from biological specimens at the University Hospital of Salerno between June 2011 and October 2012.Acinetobacter, with a prevalence of Acinetobacter baumannii (97%) presented a high range of resistance to the antimicrobials considered, excluding colistin (COL). Klebsiella spp. isolates, with a prevalence of Klebsiella pneumoniae (90%), presented a variable pattern of resistance [from 9·8% for COL to 50% for levofloxacin (LEV)]. Extended-spectrum beta-lactamases production was detected in 15% of isolates. Most Pseudomonas isolates were P. aeruginosa with a high rate of resistance (95% to amoxicillin/clavulanate and trimethoprim/sulfamethoxazole, and <50% to the other antibiotics). Colistin remained the most effective drug tested.This study provided useful information of the local bacterial epidemiology hopefully permitting to establish a more effective empirical therapy, preventi...

Epidemiology and antibiotic resistance in a large Italian teaching hospital

For the period 2002-2005 we verified and compared the data of the prevalence and resistance of Pseudomonas aeruginosa (PA) isolated in Mantova Hospital (Italy) with the data from the international database. From the first six-month period of 2004 a significant increase was found (9% vs 28.8%) in the prevalence of multi-drug resistant PA (MDR-PA). The principal wards involved were the Intensive Care Unit and the Department of Respiratory Diseases. A significant increase in resistance rates was observed for all antimicrobials tested, in particular for aztreonam, ceftazidime, ciprofloxacin, gentamycin and imipenem. The lowest dual resistance rates were observed between amikacina with piperacillin/tazobactam, while the highest were for those that included ciprofloxacin and beta-lactams (aztreonam, cefepime). In this study we confirm the importance of continuous surveillance of laboratory data and tightening local control measures for nosocomial infections in order to prevent the spread and selection of MDR-PA.

[Epidemiologic surveillance of multi-drug resistant Pseudomonas aeruginosa in Mantova Hospital (Italy)].

Nosocomial Infections are a serious problem, due to their continuous presence and resulting marked increase in health care system costs, as well as morbidity and mortality 1,2. In particular, in the past decade the rate of NI in Neonatal Intensive Care Unit (NICU) is rapidly rising (from 5% to 25%) 3. Despite advances in neonatal care, 10-20% of deaths among neonates are still caused by infections 4. Gram-negative bacilli are responsible for serious infections in specific hospital settings and for the emergence of resistance to antimicrobial drugs. Multiresistant Gram-negative bacterial rates have been reported in various surveillance studies; e.g. a 9-year surveillance study from Beth Israel Hospital in Boston Massachusetts reports an increase in the rate of MDR among Pseudomonas aeruginosa (1% to 16%), Klebsiella spp (0.5 to 17%) and Enterobacter spp (4% to 13%) 5. This letter focuses on Enterobacter cloacae, a member of the Enterobacteriaceae, that has emerged as an important nosocomial pathogen; nosocomial infections involving E. cloacae have been documented increasingly in NICUs in recent years; bacteremia due to E. cloacae accounts for approximately 1 episode per 1,000 admissions 6. Enterobacter spp, including E. cloacae, are common commensals of the human intestinal tract and account for 4 to 12% of all cases of bacteremia caused by Gram-negative bacteria and are associated Journal of Chemotherapy Vol. 18 n. 1 (110-111) 2006

Enterobacter cloacae in an Italian Neonatal Intensive Care Unit: pattern of drug resistance compared with an international database (SENTRY Antimicrobial Surveillance Program).

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[Epidemiologic surveillance of multi-drug resistant Pseudomonas aeruginosa in Mantova Hospital (Italy)].

Enterobacter cloacae in an Italian Neonatal Intensive Care Unit: pattern of drug resistance compared with an international database (SENTRY Antimicrobial Surveillance Program).