A recurrent and transesophageal echocardiography–associated outbreak of extended-spectrum β-lactamase–producing Enterobacter cloacae complex in cardiac surgery patients

Van Maerken, Tom; De Brabandere, Els; Noël, Audrey; Coorevits, Liselotte; De Waegemaeker, Pascal; Ablorh, Raina; Bouchez, Stefaan; Herck, Ingrid; Peperstraete, Harlinde; Bogaerts, Pierre; Verhasselt, Bruno; Glupczynski, Youri; Boelens, Jerina; Leroux-Roels, Isabel

doi:10.1186/s13756-019-0605-4

Antimicrobial Resistance & Infection Control

Table 1 Demographic characteristics, clinical features, treatment and outcome of case patients

From: A recurrent and transesophageal echocardiography–associated outbreak of extended-spectrum β-lactamase–producing Enterobacter cloacae complex in cardiac surgery patients

Case No.^a	Age (yrs)	Sex	Type of surgery	Need for revision^b	Type of infection	Postoperative days to infection^c	Sample types^d	Treatment^e	Outcome^f
1	42	M	LVAD implantation	No	Pneumonia	28	Sputum, oropharynx, chest tube insertion site, stool, sacral decubitus ulcer	TZP	Discharge
2	55	M	Aortic dissection repair	Yes	Pneumonia	2 (1)	Endotracheal aspirate, sputum, oropharynx, stool	TZP, MEM	Discharge
3	75	F	Aortic valve replacement	Yes	Pneumonia	2 (2)	Sputum, endotracheal aspirate, stool	MEM	Discharge
4	53	M	LVAD implantation, tricuspid annuloplasty	Yes (twice)	CRBSI	12 (7; 6)	Blood, CVC tip, oropharynx, stool	TZP, MEM, CVC removal	Death
5	80	M	CABG	No	Sternal wound infection, mediastinitis	5	Sternal wound fluid, sternal and mediastinal debridement samples	MEM, sternal and mediastinal debridement	Discharge^g
6	72	F	Mitral valve replacement, tricuspid annuloplasty, maze procedure, PFO closure, LAA exclusion	No	Pneumonia	3	Endotracheal aspirate, oropharynx, BAL fluid, stool	TZP	Discharge
7	78	F	CABG, aortic valve replacement	No	Pneumonia, CRBSI	3	Endotracheal aspirate, blood, CVC tip, AC insertion site, stool	TZP, MEM, CVC removal	Death
8	86	F	Aortic dissection repair	Yes	Pneumonia	2 (1)	Oropharynx, sputum, stool	MEM	Discharge
9	<.1	F	Aortic coarctation repair, pulmonary artery banding	Yes	Tracheo-bronchitis	14 (14)	Oropharynx, endotracheal aspirate	TZP	Discharge
10	.3	M	ASD closure, mitral valvuloplasty	No	Pneumonia	4	Oropharynx, endotracheal aspirate, stool, urine	TZP	Discharge
11	33	M	Heart transplantation	No	Inguinal wound infection^h	41	Stool, inguinal wound fluid	Local wound care	Discharge
12	<.1	M	Blalock-Taussig shunt placement	No	Pneumonia	7	Oropharynx	TZP, MEM	Discharge
13	83	F	Mitral valve replacement	Yes	Pneumonia, sepsis	2 (1)	Oropharynx, endotracheal aspirate, blood, stool	MEM	Death
14	60	M	CABG, mitral annuloplasty	No	Colonizationⁱ	–	Oropharynx, endotracheal aspirate	–	Death
15	46	F	Bilateral pulmonary embolectomy	Yes	Pneumonia, UTI	3 (2)	Oropharynx, endotracheal aspirate, stool, urine	TZP, MEM, nitrofurantoin^j	Discharge
16	62	F	Aortic valve replacement	No	Infectious exacerbation of COPD	2	Sputum, stool	MEM	Discharge
17	64	M	Aortic valve replacement, mitral annuloplasty	No	Pneumonia, sepsis, sternal wound infection	1	Oropharynx, blood, sternal wound fluid	MEM, moxifloxacin, local wound care^k	Discharge
18	75	M	Aortic valve bioprosthesis replacement, ascending aorta replacement	Yes	Pneumonia	16 (16)^l	Oropharynx, stool	MEM	Discharge

Abbreviations: AC arterial catheter, ASD atrial septal defect, BAL bronchoalveolar lavage, CABG coronary artery bypass grafting, COPD chronic obstructive pulmonary disease, CRBSI catheter-related bloodstream infection, CVC central venous catheter, ESBL extended-spectrum β-lactamase, LAA left atrial appendage, LVAD left ventricular assist device, MEM meropenem, PFO patent foramen ovale, TZP piperacillin–tazobactam, UTI urinary tract infection
^aCases are numbered in chronological order of occurrence. Dashed lines separate the different outbreak episodes
^bPostoperative need for urgent reoperation because of bleeding with imminent or manifest pericardial tamponade or because of severe ventricular dysfunction
^cNumber of days between cardiac surgery and collection of the first clinical sample positive for ESBL-producing E. cloacae complex. In case of cardiac surgery followed by revision operation(s), values between brackets indicate days between revision operation and infection
^dAll types of clinical and screening specimens from which ESBL-producing E. cloacae complex was isolated
^eWhen both TZP and MEM are listed, TZP was given first and was later replaced by MEM because of antimicrobial susceptibility testing results or treatment failure
^fOutcome of the hospital stay. Deaths reflect overall mortality (see text for details on attributable mortality)
^gCase #5 had to be readmitted after discharge because of relapse of the sternal and mediastinal infection. Retreatment consisted of operative interventions and a prolonged course of high-dose MEM followed by a course of oral trimethoprim–sulfamethoxazole. Full recovery was achieved at the end of the second admission
^hCase #11 developed postoperative pneumonia caused by an E. cloacae complex strain that did not produce ESBL according to double disk synergy testing. An inguinal wound infection following percutaneous femoral vein catheterization occurred later in the postoperative period. An ESBL-producing E. cloacae complex strain was cultured from rectal swabs and inguinal wound fluid on postoperative day 19 and day 41, respectively
ⁱCase #14 died from low cardiac output and peripheral arterial disease on the third postoperative day, a few hours after the collection of two respiratory samples that turned out to be positive for ESBL-producing E. cloacae complex. The available time for developing an overt infection was limited in this patient. We classify this case as being colonized, but a beginning pneumonia cannot be excluded
^jCase #15 was first treated for pneumonia. TZP was given for 4 days and then switched to MEM for 10 days. The patient developed a UTI caused by ESBL-producing E. cloacae complex 2 weeks after MEM had been stopped, for which a course of nitrofurantoin was given
^kThe pneumonia and sepsis in case #17 were treated with MEM. This intravenous therapy was switched to oral moxifloxacin after 10 days, as prolonged treatment was needed for streptococcal endocarditis. Two superficial sternal wounds were primarily treated with local wound care, but the ESBL-producing E. cloacae complex in these wounds may also have responded well to moxifloxacin
^lCase #18 was treated postoperatively with TZP and linezolid for aortic valve bioprosthesis endocarditis. The TZP treatment may have delayed the development of full-blown pneumonia

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