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culture at the time of hospital admission in both patients and was considered to represent asymptomatic bacteriuria. One month before identification of the first CRAB, the patients
overlapped at DHMC for 8 days on different units. Potential epi- demiologic links included radiology and wound care. Both patients had radiographs taken on the same day; one patient traveled to the radiology department, whereas the other had a portable radiograph. Observations of portable radiology technicians revealed consistent and adequate low-level disinfection of equipment and reliable hand hygiene. One wound-care nurse provided care to both patients on the same day. Observations of the wound-care team indicated opportunities to improve hand hygiene prior to donning and after doffing gloves; the use of single-use scissors on multiple patients; and inconsistent cleaning of a mobile device used to photograph open wounds. Discussion with the patients’ outpatient providers showed that their suprapubic and wound care supplies were obtained from different companies. Molecular analyses of the 2 patients’ isolates were indis- tinguishable by PFGE using the restriction enzymes AscI and ApaI. Antimicrobial susceptibility testing revealed that both iso- lates were susceptible to colistin and resistant to all carbapenems tested. Both harbored OXA-23–like genes according to a Research Use Only assay performed at CDC. While OXA-23-like enzymes are novel in Colorado, they were
first identified in Scotland in 1985 and are the most common carbapenemase enzyme detected worldwide, accounting for 63% of nosocomial CRAB in Argentina, 42%–100% in Brazil, 98% in Colombia, and 55%–80% in Saudi Arabia.4,6,7 OXA-23–like enzymes are almost exclusively found in Acinetobacter baumannii and can be encoded by genes located on either a chromosome or plasmid.2,5 OXA-23–like enzymes do not require the presence of other resistance mechanisms (eg, porin mutations or efflux pumps) to confer carbapenem resistance. However, when a bacterial strain also carries an efflux pump, the bacteria exhibit higher minimum inhibitory concentration (MIC) to carbapenems as well as resis- tance to multiple antibiotics, complicating the detection of the gene variant through phenotypic surveillance.5 We suspect that the organisms were transmitted during the overlapping hospital admission, although we could not determine where the organism originated or the route of transmission. On the facility level, opportunities to improve hand hygiene and low- level disinfection were identified and addressed. The charts were flagged to indicate that the patients harbored an MDR organism
Emília Carolina Oliveira de Souza et al
and would require contact precautions upon arrival. Infection preventionists notified clinics when upcoming outpatient appointments were detected. The clinics scheduled these patients to be the last of the clinic session when possible to allow for a thorough environmental cleaning after the clinic visit. On a regional level, CDPHE epidemiologists contacted other
healthcare facilities where these patients frequently sought care and encouraged these facilities to also electronically flag medical records and to ensure effective infection control measures. While no further cases of CRAB have been identified to date at DHMC, 1 additional OXA-23–producing CRAB case, without epidemio- logic links to the previous 2 patients, has been identified in Colorado since this cluster. The emergence of previously undetected carbapenemases in
Colorado is of great public health concern. Active collaboration and communication between public health and healthcare facilities is critical to halt transmission of novel regional pathogens.
Acknowledgments. Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References 1. Munoz-Price LS, Weinstein RA. Acinetobacter infection. N Engl J Med 2008;358:1271–1281.
2. Walsh TR. Clinically significant carbapenemases: an update. Curr Opin Infect Dis 2008;21:367–371.
3. Young LS, Sabel AL, Price CS. Epidemiologic, clinical, and economic evaluation of an outbreak of clonal multidrug-resistant Acinetobacter baumannii infection in a surgical intensive care unit. Infect Control Hosp Epidemiol 2007;28:1247–1254.
4. Paton R, Miles RS, Hood J, Amyes SG, Miles RS, Amyes SG. ARI 1: beta- lactamase-mediated imipenem resistance in Acinetobacter baumannii. Int J Antimicrob Agent 1993;2:81–87.
5. Evans BA, Amyes SG. OXA beta-lactamases. Clin Microbiol Rev 2014;27:241–263.
6. Labarca JA, Salles MJ, Seas C, Guzman-Blanco M. Carbapenem resistance in Pseudomonas aeruginosa and Acinetobacter baumannii in the nosoco- mial setting in Latin America. Crit Rev Microbiol 2016;42:276–292.
7. Yezli S, Shibl AM, Memish ZA. The molecular basis of beta-lactamase production in gram-negative bacteria from Saudi Arabia. J Med Microbiol 2015;64:127–136.
Post-discharge impact of healthcare-associated infections in a developing country: A cohort study
Emília Carolina Oliveira de Souza RN, Sebastião Pires Ferreira Filho MD, MSc, Kasys Meira Gervatauskas MD and
Carlos Magno Castelo Branco Fortaleza MD, PhD Department of Tropical Diseases, Botucatu Medical School, São Paulo State University (UNESP), City of Botucatu, São Paulo State, Brazil
Author for correspondence: Carlos Magno Castelo Branco Fortaleza, Departamento
de Doenças Tropicais, Faculdade de Medicina de Botucatu, Distrito de Rubião Júnior, S/N, City of Botucatu, São Paulo State Brazil 18618-970. E-mail:
cmfortaleza@uol.com.br Cite this article: de Souza ECO, et al. (2018). Post-discharge impact of healthcare-
associated infections in a developing country: A cohort study. Infection Control & Hospital Epidemiology 2018, 39, 1274–1276. doi: 10.1017/ice.2018.201
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
To the Editor —The impact of healthcare-associated infections (HCAIs) on in-hospital mortality, morbidity, length-of-stay, and costs has been extensively reported.1,2 However, few studies have focused on the follow-up of HCAI-affected subjects after
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