Scientific Letter
Implication of a national outbreak of Serratia marcescens associated with a contaminated solution of chlorhexidine in a paediatric hospital
Implicación de un brote nacional de infección por Serratia marcescens asociado a clorhexidina contaminada en un hospital pediátrico
Áurea Morilloa,
, María José Torresb, María Teresa Alonso Salasc, Manuel Condea, Javier Aznara,b,d
Corresponding author
a Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b Departamento de Microbiología, Universidad de Sevilla, Sevilla, Spain
c Unidad Clínica de Cuidados Críticos y Urgencias Pediátricas, Hospital Universitario Virgen del Rocío, Sevilla, Spain
d Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, CSIC Universidad de Sevilla, Sevilla, Spain
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"cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Implication of a national outbreak of <span class="elsevierStyleItalic">Serratia marcescens</span> associated with a contaminated solution of chlorhexidine in a paediatric hospital" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "171" "paginaFinal" => "172" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Áurea Morillo, María José Torres, María Teresa Alonso Salas, Manuel Conde, Javier Aznar" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Áurea" "apellidos" => "Morillo" "email" => array:1 [ 0 => "aurea.morillo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María José" "apellidos" => "Torres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "María Teresa" "apellidos" => "Alonso Salas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Manuel" "apellidos" => "Conde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Javier" "apellidos" => "Aznar" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Microbiología, Universidad de Sevilla, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad Clínica de Cuidados Críticos y Urgencias Pediátricas, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, CSIC Universidad de Sevilla, Sevilla, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Implicación de un brote nacional de infección por <span class="elsevierStyleItalic">Serratia marcescens</span> asociado a clorhexidina contaminada en un hospital pediátrico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3211 "Ancho" => 1650 "Tamanyo" => 339539 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulsed-field gel electrophoresis patterns of the strains involved in the outbreak.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Due to its ubiquity and its ability to survive in humid environments and to colonise the gastrointestinal and/or respiratory tracts, <span class="elsevierStyleItalic">Serratia marcescens</span> is responsible for multiple nosocomial outbreaks,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> especially in paediatric patients and specifically in newborns, who suffer the direst consequences.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> In some instances, it is possible to identify the source of infection, which is of particular relevance in outbreaks involving antiseptic solutions on account of their impact.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In this letter, we describe our experience in a children's hospital in the context of a nationwide <span class="elsevierStyleItalic">S. marcescens</span> outbreak associated with the use of contaminated chlorhexidine (CHX) antiseptic solution<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> that occurred between August 2014 and January 2015 and comprised 148 cases (86 confirmed) in 10 Autonomous regions. Although most of the affected patients were aged more than 65 years, 8 children were affected in our hospital, between November 22 and December 16, 2014. All developed bacteraemia and had favourable outcomes, except 1 infant who died within 24<span class="elsevierStyleHsp" style=""></span>h from diagnosis (mortality of 12.5%).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Initially, when we were still unaware of the national scope of the outbreak, we hypothesised that there must be a common source/reservoir of <span class="elsevierStyleItalic">S. marcescens</span>, a fluid medium somewhere in the surgical suite of the hospital, where the first 5 affected patients had been treated. Since culture of the CHX-based antiseptic solutions in the surgical suite was negative and <span class="elsevierStyleItalic">S</span>. <span class="elsevierStyleItalic">marcescens</span> was isolated from a bag of packed red blood cells in a patient that had received a transfusion in the paediatric ICU and not undergone surgery, we considered transfusion another potential route of infection, as all the affected patients had received transfusions prior to the diagnosis of bacteraemia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">With the investigation underway, when 7 of the 8 cases had been detected, the Spanish Agency of Medicines and Medical Devices issued a recall of skin antiseptic based on CHX in aqueous or alcohol solution that had been distributed in 2014 (lots <span class="elsevierStyleSmallCaps">I</span>-15, <span class="elsevierStyleSmallCaps">I</span>-11, <span class="elsevierStyleSmallCaps">I</span>-28, <span class="elsevierStyleSmallCaps">I</span>-29, <span class="elsevierStyleSmallCaps">I</span>-30, <span class="elsevierStyleSmallCaps">I</span>-33 and <span class="elsevierStyleSmallCaps">I</span>-35), while the Epidemiological Surveillance System of Andalusia (SVEA) of Andalusia warned us that the use of this antiseptic was probably the cause of the outbreak at our hospital. Having received this warning, we verified that the units affected by the outbreak had been using products from several of the lots included in the recall. Unlike other published studies regarding this outbreak,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> we performed pulsed-field gel electrophoresis for the molecular analysis of isolates from patient samples, those obtained from new samples of CHX solutions removed from use in the hospital (lots <span class="elsevierStyleSmallCaps">I</span>-33 and <span class="elsevierStyleSmallCaps">I</span>-35) and the strain provided by the laboratories that distributed the contaminated antiseptic, and found that all isolates were from a single clone (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The procedures that most likely contributed to the transmission of infection were those whose performance was preceded by the use of this antiseptic, such as disinfection of the skin prior to surgery or catheterisation, and disinfection of 3-way stopcocks before transfusion. This was consistent with the information received in the outbreak report, where the medical procedure associated with the use of the CHX solution was catheterisation in 70% of cases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The rapid identification and notification of the outbreak, the implementation of preventive measures and molecular testing allowed the control of an outbreak affecting the paediatric age group, a particularly vulnerable population. We ought to highlight that our study evinced the clonal relationship of all isolates from the outbreak with the original contaminant strain, and that cases were restricted to the paediatric population, including one death that could be attributed to infection by <span class="elsevierStyleItalic">S</span>. <span class="elsevierStyleItalic">marcescens</span> out of the 148 patients affected nationwide. It is essential that we improve the communication between Public Health Agencies and health care facilities, as the problem started in 2014 and the outbreak persisted through December of the same year.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morillo Á, Torres MJ, Alonso Salas MT, Conde M, Aznar J. Implicación de un brote nacional de infección por <span class="elsevierStyleItalic">Serratia marcescens</span> asociado a clorhexidina contaminada en un hospital pediátrico. An Pediatr (Barc). 2018;88:171–172.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3211 "Ancho" => 1650 "Tamanyo" => 339539 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulsed-field gel electrophoresis patterns of the strains involved in the outbreak.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A six-month <span class="elsevierStyleItalic">Serratia marcescens</span> outbreak in a neonatal intensive care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Morillo" 1 => "V. González" 2 => "J. Aguayo" 3 => "C. Carreño" 4 => "M.J. Torres" 5 => "D. Jarana" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2016.01.006" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2016" "volumen" => "34" "paginaInicial" => "645" "paginaFinal" => "651" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26900002" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outbreaks of <span class="elsevierStyleItalic">Serratia marcescens</span> in neonatal and pediatric intensive care units: clinical aspects, risk factors and management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Voelz" 1 => "A. Mu¿ller" 2 => "J. Gillen" 3 => "C. Le" 4 => "T. Dresbach" 5 => "S. 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Available from: <a id="intr0010" class="elsevierStyleInterRef" href="http://revista.isciii.es/index.php/bes/article/view/988/1211">http://revista.isciii.es/index.php/bes/article/view/988/1211</a> [accessed 01.03.17]" ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brote de <span class="elsevierStyleItalic">Serratia marcescens</span> producido por clorhexidina acuosa al 2% contaminada" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. De Frutos" 1 => "L. López-Urrutia" 2 => "M. Domínguez-Gil" 3 => "M. Arias" 4 => "J.L. Muñoz-Bellido" 5 => "J.M. Airosa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2016.06.016" "Revista" => array:2 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2016" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgments" "texto" => "<p id="par0030" class="elsevierStylePara elsevierViewall">We thank the Pediatric Critical Care and Emergency Unit, Department of Pediatrics and Department of Pediatric Surgery of the Pediatric University Hospital Virgen del Rocío, the Epidemiological Surveillance System of Andalusia and the Regional Blood transfusion center of Seville for their inestimable collaboration in managing the outbreak and their invaluable contributions.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008800000003/v1_201803020428/S2341287918300061/v1_201803020428/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008800000003/v1_201803020428/S2341287918300061/v1_201803020428/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918300061?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 9 | 18 |
| 2024 October | 50 | 43 | 93 |
| 2024 September | 54 | 25 | 79 |
| 2024 August | 73 | 63 | 136 |
| 2024 July | 55 | 31 | 86 |
| 2024 June | 76 | 46 | 122 |
| 2024 May | 57 | 32 | 89 |
| 2024 April | 73 | 33 | 106 |
| 2024 March | 53 | 21 | 74 |
| 2024 February | 49 | 32 | 81 |
| 2024 January | 29 | 16 | 45 |
| 2023 December | 41 | 18 | 59 |
| 2023 November | 36 | 29 | 65 |
| 2023 October | 31 | 23 | 54 |
| 2023 September | 21 | 26 | 47 |
| 2023 August | 38 | 20 | 58 |
| 2023 July | 52 | 24 | 76 |
| 2023 June | 37 | 27 | 64 |
| 2023 May | 70 | 25 | 95 |
| 2023 April | 32 | 14 | 46 |
| 2023 March | 50 | 21 | 71 |
| 2023 February | 43 | 15 | 58 |
| 2023 January | 16 | 12 | 28 |
| 2022 December | 47 | 33 | 80 |
| 2022 November | 86 | 27 | 113 |
| 2022 October | 66 | 42 | 108 |
| 2022 September | 53 | 30 | 83 |
| 2022 August | 45 | 54 | 99 |
| 2022 July | 37 | 36 | 73 |
| 2022 June | 39 | 36 | 75 |
| 2022 May | 47 | 41 | 88 |
| 2022 April | 40 | 42 | 82 |
| 2022 March | 78 | 54 | 132 |
| 2022 February | 38 | 17 | 55 |
| 2022 January | 63 | 43 | 106 |
| 2021 December | 34 | 39 | 73 |
| 2021 November | 38 | 41 | 79 |
| 2021 October | 102 | 65 | 167 |
| 2021 September | 29 | 36 | 65 |
| 2021 August | 27 | 38 | 65 |
| 2021 July | 31 | 25 | 56 |
| 2021 June | 24 | 26 | 50 |
| 2021 May | 50 | 55 | 105 |
| 2021 April | 163 | 77 | 240 |
| 2021 March | 58 | 39 | 97 |
| 2021 February | 55 | 23 | 78 |
| 2021 January | 70 | 26 | 96 |
| 2020 December | 33 | 25 | 58 |
| 2020 November | 54 | 28 | 82 |
| 2020 October | 53 | 27 | 80 |
| 2020 September | 63 | 37 | 100 |
| 2020 August | 79 | 28 | 107 |
| 2020 July | 67 | 19 | 86 |
| 2020 June | 67 | 15 | 82 |
| 2020 May | 93 | 30 | 123 |
| 2020 April | 39 | 24 | 63 |
| 2020 March | 56 | 33 | 89 |
| 2020 February | 84 | 41 | 125 |
| 2020 January | 34 | 15 | 49 |
| 2019 December | 51 | 21 | 72 |
| 2019 November | 70 | 24 | 94 |
| 2019 October | 48 | 19 | 67 |
| 2019 September | 46 | 22 | 68 |
| 2019 August | 45 | 25 | 70 |
| 2019 July | 47 | 27 | 74 |
| 2019 June | 70 | 31 | 101 |
| 2019 May | 166 | 30 | 196 |
| 2019 April | 90 | 28 | 118 |
| 2019 March | 37 | 17 | 54 |
| 2019 February | 37 | 11 | 48 |
| 2019 January | 43 | 18 | 61 |
| 2018 December | 32 | 19 | 51 |
| 2018 November | 71 | 25 | 96 |
| 2018 October | 109 | 15 | 124 |
| 2018 September | 58 | 18 | 76 |
| 2018 August | 8 | 0 | 8 |
| 2018 July | 4 | 0 | 4 |
| 2018 June | 5 | 0 | 5 |
| 2018 May | 10 | 0 | 10 |
| 2018 April | 44 | 0 | 44 |
| 2018 February | 0 | 17 | 17 |
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