• Lauren Epstein, Jennifer C Hunter, M Allison Arwady, Victoria Tsai, Linda Stein, Marguerite Gribogiannis, Mabel Frias, Alice Y Guh, Alison S Laufer, Stephanie Black, Massimo Pacilli, Heather Moulton-Meissner, J Kamile Rasheed, Johannetsy J Avillan, Brandon Kitchel, Brandi M Limbago, Duncan MacCannell, David Lonsway, Judith Noble-Wang, Judith Conway, Craig Conover, Michael Vernon, and Alexander J Kallen.
• Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georg.
• JAMA. 2014 Oct 8; 312 (14): 144714551447-55.

ImportanceCarbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-lactamase (NDM) are rare in the United States, but have the potential to add to the increasing CRE burden. Previous NDM-producing CRE clusters have been attributed to person-to-person transmission in health care facilities.ObjectiveTo identify a source for, and interrupt transmission of, NDM-producing CRE in a northeastern Illinois hospital.Design, Setting, And ParticipantsOutbreak investigation among 39 case patients at a tertiary care hospital in northeastern Illinois, including a case-control study, infection control assessment, and collection of environmental and device cultures; patient and environmental isolate relatedness was evaluated with pulsed-field gel electrophoresis (PFGE). Following identification of a likely source, targeted patient notification and CRE screening cultures were performed.Main Outcomes And MeasuresAssociation between exposure and acquisition of NDM-producing CRE; results of environmental cultures and organism typing.ResultsIn total, 39 case patients were identified from January 2013 through December 2013, 35 with duodenoscope exposure in 1 hospital. No lapses in duodenoscope reprocessing were identified; however, NDM-producing Escherichia coli was recovered from a reprocessed duodenoscope and shared more than 92% similarity to all case patient isolates by PFGE. Based on the case-control study, case patients had significantly higher odds of being exposed to a duodenoscope (odds ratio [OR], 78 [95% CI, 6.0-1008], P < .001). After the hospital changed its reprocessing procedure from automated high-level disinfection with ortho-phthalaldehyde to gas sterilization with ethylene oxide, no additional case patients were identified.Conclusions And RelevanceIn this investigation, exposure to duodenoscopes with bacterial contamination was associated with apparent transmission of NDM-producing E coli among patients at 1 hospital. Bacterial contamination of duodenoscopes appeared to persist despite the absence of recognized reprocessing lapses. Facilities should be aware of the potential for transmission of bacteria including antimicrobial-resistant organisms via this route and should conduct regular reviews of their duodenoscope reprocessing procedures to ensure optimal manual cleaning and disinfection.

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