To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae(CRE) and their related superbugs during gastrointestinal(GI) endoscopy. Reports of outbreaks linked to GI endoscopes contami-nated with d...To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae(CRE) and their related superbugs during gastrointestinal(GI) endoscopy. Reports of outbreaks linked to GI endoscopes contami-nated with different types of infectious agents, includ-ing CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE's emergence, these reports were obtained by searching the peer-reviewed medical literature(via the United States National Library of Medicine's "MEDLINE" database); the Food and Drug Administration's Manu-facturer and User Facility Device Experience database, or "MAUDE"; and the Internet(via Google's search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at "Hospital X" located in the sub-urbs of Chicago(IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital's patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Con-trol and Prevention(CDC), which published a report about this outbreak in Morbidity and Mortality WeeklyReport(MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X's in-fection control practices following this CRE outbreak, were also reviewed. While this article focuses primar-ily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infec-tious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently as-sociated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospi-tal X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer's labeling, supplemented as needed with professional organizations' published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including broncho-scopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endos-copy. Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind andnear the forceps elevator located at the distal end othe ERCP endoscope, are recommended. If the ERCPendoscope features a narrow and exposed channel thathouses a wire connecting the GI endoscope's controhead to this forceps elevator, then this channel's com-plete reprocessing, including its flushing with a deter-gent using a procedure validated for effectiveness, is also emphasized.展开更多
Sepsis is one of the major challenges of today. Although gram-positive bacteria related infections are more prevalent in hospital setting, the highest mortality rate is associated with gram-negative microorganisms esp...Sepsis is one of the major challenges of today. Although gram-positive bacteria related infections are more prevalent in hospital setting, the highest mortality rate is associated with gram-negative microorganisms especially Enterobacteriaceae. Enterobacteriaceae, including Escherichia coli, Klebsiella spp., Proteus spp., Enterobacter spp. and Serratia spp. Resistance to β-lactams in Enterobacteriaceae is primarily attributed to the production of B-lactamase enzymes with subsequent antibiotic hydrolysis and to a lesser extent by alteration of efflux pump or porins expression. Carbapenem resistant Enterobacteriaceae(CRE) and Acinetobacter baumannii are the most notorious pathogens due to the high incidence of morbidity and mortality especially in the immunocompromised patients in the intensive care unit. The most appropriate antimicrobial therapy to treat CRE is still controversial. Combination therapy is preferred over monotherapy due to its broad-spectrum coverage of micro-organisms, due to its synergetic effect and to prevent development of further resistance. Current suggested therapies for CRE resistance as well as promising antibiotics that are currently under investigation for winning the war against the emerging CRE resistance are reviewed and discussed.展开更多
Background Identification of hospitalized carbapenem-resistant Enterobacteriaceae （CRE）-positive patient is important in preventing nosocomial transmission.The objective of this study was to illustrate the implement...Background Identification of hospitalized carbapenem-resistant Enterobacteriaceae （CRE）-positive patient is important in preventing nosocomial transmission.The objective of this study was to illustrate the implementation of proactive infection control measures in preventing nosocomial transmission of CRE in a healthcare region of over 3200 beds in Hong Kong between October 1,2010 and December 31,2011.Methods The program included active surveillance culture in patients with history of medical tourism with hospitalization and surgical operation outside Hong Kong within 12 months before admission,and ＂added test＂ as an opportunistic CRE screening in all fecal specimens submitted to the laboratory.Outbreak investigation and contact tracing were conducted for CRE-positive patients.Serial quantitative culture was performed on CRE-positive patients and the duration of fecal carriage of CRE was analyzed.Results During the study period,a total of 6533 patients were screened for CRE,of which 76 patients were positive （10 from active surveillance culture,65 from ＂added test＂,and 1 secondary case from contact tracing of 223 patients with no nosocomial outbreak）,resulting in an overall rate of CRE fecal carriage of 1.2％.The median time of fecal carriage of CRE was 43 days （range,13-119 days）.Beta-lactam-beta-lactamase-inhibitors,cephalosporins,and fluoroquinolones were associated significantly with high fecal bacterial load when used 90 days before CRE detection,while use of cephalosporins,carbapenems,and fiuoroquinolones after CRE detection are significantly associated with longer duration of carriage.The duration of fecal carriage of CRE also correlates significantly with the initial fecal bacterial load （Pearson correlation：0.53; P=0.02）.Conclusion Proactive infection control measures by enhanced surveillance program identify CRE-positive patients and data obtained are useful for the planning of and resource allocation for CRE control.展开更多
基金Supported by An educational grant provided by FUJIFILM Medical Systems,USA,Inc.,Endoscopy Division(Wayne,NJUnited States)
文摘To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae(CRE) and their related superbugs during gastrointestinal(GI) endoscopy. Reports of outbreaks linked to GI endoscopes contami-nated with different types of infectious agents, includ-ing CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE's emergence, these reports were obtained by searching the peer-reviewed medical literature(via the United States National Library of Medicine's "MEDLINE" database); the Food and Drug Administration's Manu-facturer and User Facility Device Experience database, or "MAUDE"; and the Internet(via Google's search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at "Hospital X" located in the sub-urbs of Chicago(IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital's patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Con-trol and Prevention(CDC), which published a report about this outbreak in Morbidity and Mortality WeeklyReport(MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X's in-fection control practices following this CRE outbreak, were also reviewed. While this article focuses primar-ily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infec-tious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently as-sociated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospi-tal X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer's labeling, supplemented as needed with professional organizations' published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including broncho-scopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endos-copy. Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind andnear the forceps elevator located at the distal end othe ERCP endoscope, are recommended. If the ERCPendoscope features a narrow and exposed channel thathouses a wire connecting the GI endoscope's controhead to this forceps elevator, then this channel's com-plete reprocessing, including its flushing with a deter-gent using a procedure validated for effectiveness, is also emphasized.
文摘Sepsis is one of the major challenges of today. Although gram-positive bacteria related infections are more prevalent in hospital setting, the highest mortality rate is associated with gram-negative microorganisms especially Enterobacteriaceae. Enterobacteriaceae, including Escherichia coli, Klebsiella spp., Proteus spp., Enterobacter spp. and Serratia spp. Resistance to β-lactams in Enterobacteriaceae is primarily attributed to the production of B-lactamase enzymes with subsequent antibiotic hydrolysis and to a lesser extent by alteration of efflux pump or porins expression. Carbapenem resistant Enterobacteriaceae(CRE) and Acinetobacter baumannii are the most notorious pathogens due to the high incidence of morbidity and mortality especially in the immunocompromised patients in the intensive care unit. The most appropriate antimicrobial therapy to treat CRE is still controversial. Combination therapy is preferred over monotherapy due to its broad-spectrum coverage of micro-organisms, due to its synergetic effect and to prevent development of further resistance. Current suggested therapies for CRE resistance as well as promising antibiotics that are currently under investigation for winning the war against the emerging CRE resistance are reviewed and discussed.
文摘Background Identification of hospitalized carbapenem-resistant Enterobacteriaceae （CRE）-positive patient is important in preventing nosocomial transmission.The objective of this study was to illustrate the implementation of proactive infection control measures in preventing nosocomial transmission of CRE in a healthcare region of over 3200 beds in Hong Kong between October 1,2010 and December 31,2011.Methods The program included active surveillance culture in patients with history of medical tourism with hospitalization and surgical operation outside Hong Kong within 12 months before admission,and ＂added test＂ as an opportunistic CRE screening in all fecal specimens submitted to the laboratory.Outbreak investigation and contact tracing were conducted for CRE-positive patients.Serial quantitative culture was performed on CRE-positive patients and the duration of fecal carriage of CRE was analyzed.Results During the study period,a total of 6533 patients were screened for CRE,of which 76 patients were positive （10 from active surveillance culture,65 from ＂added test＂,and 1 secondary case from contact tracing of 223 patients with no nosocomial outbreak）,resulting in an overall rate of CRE fecal carriage of 1.2％.The median time of fecal carriage of CRE was 43 days （range,13-119 days）.Beta-lactam-beta-lactamase-inhibitors,cephalosporins,and fluoroquinolones were associated significantly with high fecal bacterial load when used 90 days before CRE detection,while use of cephalosporins,carbapenems,and fiuoroquinolones after CRE detection are significantly associated with longer duration of carriage.The duration of fecal carriage of CRE also correlates significantly with the initial fecal bacterial load （Pearson correlation：0.53; P=0.02）.Conclusion Proactive infection control measures by enhanced surveillance program identify CRE-positive patients and data obtained are useful for the planning of and resource allocation for CRE control.
