Brief report
Report of two events of nosocomial outbreak and pseudo-outbreak due to contamination with Achromobacter spp.
Comunicación de 2 eventos de brote y seudobrote nosocomial debido a contaminación con Achromobacter spp
Liliana Claraa,b, María Ines Stanelonia,b, Estela Salazara, Graciela Grecoc, Mariangeles Visusc, Alicia Lizzib, Valeria Alexanderc, Gabriel Gutkindd,e, Marcela Radiced,e,
, Mariana Papaliad,e
Corresponding author
a Hospital Italiano de Buenos Aires, Sección Infectología, Servicio de Clínica Médica, Pres. Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, C1199, Argentina
b Hospital Italiano de Buenos Aires, Comité de Control de Infecciones, Pres. Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, C1199, Argentina
c Hospital Italiano de Buenos Aires, Sección Bacteriología Laboratorio Central, Pres. Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, C1199, Argentina
d Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, IBaViM, Laboratorio de Resistencia Bacteriana, Junín 956, 8vo. Piso, Ciudad Autónoma de Buenos Aires, CP 1113, Argentina
e Consejo Nacional de Investigaciones Científicas y Técnicas de Argentina (CONICET), Ciudad Autónoma de Buenos Aires, Argentina
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(A) Zoosporas germinadas en ausencia del extracto. (B) Tubo germinativo anormal. (C) Zoosporas sin geminación (enquistadas). (D y E) Las paredes de la zoospora de <span class="elsevierStyleItalic">P. capsici</span> se lisaron al momento del contacto con el extracto crudo que contenía los lipopéptidos producidos por <span class="elsevierStyleItalic">B. amyloliquefaciens</span> KX953161.1. Las imágenes fueron tomadas bajo microscopio, con objetivo de 40× en campo claro.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nancy Ley-López, José Basilio Heredia, Cesar San Martín-Hernández, J. Ramón Ibarra-Rodríguez, Miguel Ángel Angulo-Escalante, Raymundo Saúl García-Estrada" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Nancy" "apellidos" => "Ley-López" ] 1 => array:2 [ "nombre" => "José" "apellidos" => "Basilio Heredia" ] 2 => array:2 [ "nombre" => "Cesar" "apellidos" => "San Martín-Hernández" ] 3 => array:2 [ "nombre" => "J. 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Groups of eight animals were inoculated intragastrically with two different doses of <span class="elsevierStyleItalic">Salmonella</span> biofilm or planktonic lifestyle: (A) 10<span class="elsevierStyleSup">3</span> and (B) 10<span class="elsevierStyleSup">4</span> CFU per mouse. Clinical conditions were assessed for 10 days, following a double-blinded protocol, and clinical scores were calculated as described in “Materials and methods” section. <span class="elsevierStyleSup">#</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.1; *<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05; **<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01; ***<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001. Mann–Whitney <span class="elsevierStyleItalic">U</span> test.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mónica N. Giacomodonato, Sebastián H. Sarnacki, María del Rosario Aya Castañeda, Ailín N. Garófalo, Diana M. Betancourt, María C. Cerquetti, Mariángeles Noto Llana" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Mónica N." "apellidos" => "Giacomodonato" ] 1 => array:2 [ "nombre" => "Sebastián H." "apellidos" => "Sarnacki" ] 2 => array:2 [ "nombre" => "María del Rosario" "apellidos" => "Aya Castañeda" ] 3 => array:2 [ "nombre" => "Ailín N." "apellidos" => "Garófalo" ] 4 => array:2 [ "nombre" => "Diana M." "apellidos" => "Betancourt" ] 5 => array:2 [ "nombre" => "María C." "apellidos" => "Cerquetti" ] 6 => array:2 [ "nombre" => "Mariángeles" "apellidos" => "Noto Llana" ] ] ] ] "resumen" => array:1 [ 0 => array:3 [ "titulo" => "Highlights" "clase" => "author-highlights" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S.</span> Enteritidis 5694 biofilm lifestyle is less virulent than planktonic cells.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S.</span> Enteritidis 5694 biofilm shows an impaired invasiveness of no phagocytic cells.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S.</span> Enteritidis 5694 biofilm induces a diminished inflammatory response.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S.</span> Enteritidis 5694–host interaction varies with the bacterial lifestyle.</p></li></ul></p></span>" ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0325754121000997?idApp=UINPBA00004N" "url" => "/03257541/0000005400000003/v1_202209300808/S0325754121000997/v1_202209300808/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Report of two events of nosocomial outbreak and pseudo-outbreak due to contamination with <span 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] ] 7 => array:3 [ "nombre" => "Gabriel" "apellidos" => "Gutkind" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 8 => array:4 [ "nombre" => "Marcela" "apellidos" => "Radice" "email" => array:1 [ 0 => "mradice@ffyb.uba.ar" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 9 => array:3 [ "nombre" => "Mariana" "apellidos" => "Papalia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Hospital Italiano de Buenos Aires, Sección Infectología, Servicio de Clínica Médica, Pres. Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, C1199, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Italiano de Buenos Aires, Comité de Control de Infecciones, Pres. Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, C1199, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Italiano de Buenos Aires, Sección Bacteriología Laboratorio Central, Pres. Tte. Gral. Juan Domingo Perón 4190, Ciudad Autónoma de Buenos Aires, C1199, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, IBaViM, Laboratorio de Resistencia Bacteriana, Junín 956, 8vo. Piso, Ciudad Autónoma de Buenos Aires, CP 1113, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Consejo Nacional de Investigaciones Científicas y Técnicas de Argentina (CONICET), Ciudad Autónoma de Buenos Aires, Argentina" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comunicación de 2 eventos de brote y seudobrote nosocomial debido a contaminación con <span class="elsevierStyleItalic">Achromobacter</span> spp" ] ] "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" => 2749 "Ancho" => 3510 "Tamanyo" => 668995 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dendrogram based on Maximum Likelihood estimation conducted using MEGA 5.05 for <span class="elsevierStyleItalic">Achromobacter</span> spp. concatenated housekeeping genes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Achromobacter</span> spp. are aerobic, non-fermenting gram negative bacilli that are widely distributed in the environment. <span class="elsevierStyleItalic">Achromobacter xylosoxidans</span>, the first member of this genus, was first described by Yabuuchi and Oyama in 1971, then it was reclassified to the <span class="elsevierStyleItalic">Alcaligenes</span> genus, and later reassigned to the <span class="elsevierStyleItalic">Achromobacter</span> genus. Nowadays <span class="elsevierStyleItalic">Achromobacter</span> comprises 21 species, and some genogroups that have not been fully characterized yet<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a>. Phenotypic species identification, based on biochemical tests, usually renders incorrect or non-conclusive results; for that reason clinical isolates are mostly referred to as <span class="elsevierStyleItalic">A. xylosoxidans</span>. Accurate identification at species level can only be achieved using genotypic methods although these techniques are not used for routine identification<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Achromobacter</span> spp. have been usually associated with aquatic environments, and frequently colonize aqueous solutions in the hospital settings from where they may infect compromised patients<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a>. <span class="elsevierStyleItalic">Achromobacter</span> spp. are increasingly recognized as important emerging nosocomial pathogens, mainly in immunocompromised hosts, as well as in patients with cystic fibrosis<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,13</span></a>. Although increasingly reported, it is difficult to interpret their clinical significance.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Effective treatment of <span class="elsevierStyleItalic">Achromobacter</span> spp. infections can be challenging due to their natural and acquired multidrug resistance patterns<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,7</span></a>. Moreover, antiseptics and disinfectants are not always able to eliminate the source of <span class="elsevierStyleItalic">Achromobacter</span> spp. in the hospital environments<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,10</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Several outbreaks and pseudo-outbreaks caused by <span class="elsevierStyleItalic">Achromobacter</span> spp. have been reported, and many of them have contaminated fluids such as chlorhexidine as the epidemiological “common denominator”<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,3,10</span></a>. Both outbreaks and pseudo-outbreaks are negative as hospital quality indicators, as well as the inappropriate use of antibiotics. Institutional multidisciplinary management is required to prevent infections, outbreaks and pseudo-outbreaks, and the consequent inappropriate use of antibiotics, since antimicrobial stewardship constitutes another indicator of nosocomial quality.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Starting 2013 an increased presence of <span class="elsevierStyleItalic">Achromobacter</span> spp. in blood cultures and clinical samples was observed in a tertiary hospital in Buenos Aires city, leading to this epidemiological study.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Event report 1</span><p id="par0055" class="elsevierStylePara elsevierViewall">A descriptive study of <span class="elsevierStyleItalic">Achromobacter</span> spp. positive blood samples, recovered between 2013 and 2016, was carried out retrospectively, in order to characterize a possible outbreak and identify probable sources of contamination.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The incidence of <span class="elsevierStyleItalic">Achromobacter</span> spp. contaminated blood cultures, with respect to the total blood samples, was 51/36<span class="elsevierStyleHsp" style=""></span>286 (0.14%) in 2013, 91/40<span class="elsevierStyleHsp" style=""></span>285 (0.22%) in 2014 and 79/43<span class="elsevierStyleHsp" style=""></span>450 (0.18%) in 2015. True bloodstream infections were confirmed by clinical evaluation and a second positive blood culture<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,16</span></a>. Many of these contaminated samples came from emergency wards (61.5%), and in some cases, other unusual non-fermenting gram negative bacilli were also present.</p><p id="par0065" class="elsevierStylePara elsevierViewall">From June to October 2015, the probable sources of contamination were investigated, including heparin tubes, povidone-iodine solutions, and EDTA and sodium citrate lab tubes. Out of a total of 48 analyzed samples, 4 sodium citrate tubes were positive for <span class="elsevierStyleItalic">Achromobacter</span> spp.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Species identification of the isolates recovered from blood samples (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6) and blood collection test tubes (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4) was achieved using genotypic approaches. The <span class="elsevierStyleItalic">nrdA</span> sequences were determined according to Spilker et al., and compared with databases (<a href="https://pubmlst.org/achromobacter/"><span class="elsevierStyleUnderline">https://pubmlst.org/achromobacter/</span></a>)<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a>. The presence of species-specific markers, <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">OXA-114</span>, <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">OXA-258</span>, <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">OXA-364</span> and <span class="elsevierStyleItalic">bla</span><span class="elsevierStyleInf">OXA-243</span>, intrinsic for <span class="elsevierStyleItalic">A. xylosoxidans</span>, <span class="elsevierStyleItalic">Achromobacter ruhlandii</span>, <span class="elsevierStyleItalic">Achromobacter dolens</span>, and <span class="elsevierStyleItalic">Achromobacter insuavis</span>, respectively, were investigated according to Traglia et al. and Papalia et al.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11,14</span></a>. All these bacterial isolates were identified as <span class="elsevierStyleItalic">A. insuavis.</span></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Xba</span>I-pulsed-field gel electrophoresis (PFGE) was performed to compare the isolates recovered from sodium citrate tubes among them, and with those recovered from blood cultures<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a>. A single pulsotype indicative of the presence of the same strain in all samples was observed (<a class="elsevierStyleCrossRef" href="#sec0035">Suppl. Fig. S1</a>). Based on these results, it was assumed that these pseudo-bacteremias were originated by the use of contaminated sodium citrate tubes and the subsequent incorrect technique of loading the blood culture bottles, <span class="elsevierStyleItalic">i.e.</span>, first inoculating the blood collection test tubes that were contaminated with <span class="elsevierStyleItalic">A. insuavis</span> followed by the inoculation of the blood culture bottles with the same needle generating false positive blood cultures. In order to avoid these pseudo-outbreaks, personnel retraining regarding the correct sample loading technique was conducted and institutional guidelines were designed <span class="elsevierStyleItalic">ad hoc.</span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Event report 2</span><p id="par0080" class="elsevierStylePara elsevierViewall">A strikingly high number of <span class="elsevierStyleItalic">Achromobacter</span> spp. isolates in clinical specimens other than blood samples was also detected in our hospital, which led to an epidemiological study to characterize a possible outbreak and to identify a common denominator.</p><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 94 <span class="elsevierStyleItalic">Achromobacter</span> spp. positive samples, recovered from 59 patients from March 2014 to June 2016, were included in this study (<a class="elsevierStyleCrossRef" href="#sec0035">Suppl. Fig. 2</a>).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Each of these episodes was classified as <span class="elsevierStyleItalic">Achromobacter</span> spp. infection or colonization after reviewing the patients’ clinical histories. Patients with a positive culture and symptoms compatible with infection without any other apparent focus and with specific antibiotic treatment selected for these microorganisms were categorized as infected by <span class="elsevierStyleItalic">Achromobacter</span> spp., while patients with a positive culture for <span class="elsevierStyleItalic">Achromobacter</span> spp. without any clinical symptoms compatible with infection were categorized as colonized (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Twenty eight percent (28%) of the analyzed cases were interpreted as infections and the remaining 72% as <span class="elsevierStyleItalic">Achromobacter</span> spp. colonization. Mortality rate after 30 days was 1%, although it was unrelated to the presence of <span class="elsevierStyleItalic">Achromobacter</span> spp. in cultures. Ninety five percent (95%) of these cultures were recovered from patients that either were hospitalized for 48<span class="elsevierStyleHsp" style=""></span>h, or with previous hospitalization (less than 90 days), or that underwent surgery, thus categorized as hospital-acquired infections/colonizations. Clinical specimens are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Among <span class="elsevierStyleItalic">Achromobacter</span> spp. positive samples, a broad dominance was observed in those recovered from trauma surgeries and surgeries with anfractuous open wounds, performed at the orthopedic operating room (64/94). Twenty nine percent (29%) of the patients were assisted in clinical areas and 59% in critical care areas; in 23% previous washing with soapy chlorhexidine was recorded. Likewise, <span class="elsevierStyleItalic">Achromobacter</span> spp. were also recovered from other clinical samples, and other areas of the institution, suggesting a common source of extensive use throughout the hospital.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In April 2016, environmental, instrumental, antiseptic and disinfectant samples from 5 different operating rooms were analyzed. <span class="elsevierStyleItalic">Achromobacter</span> spp. was identified in 15/17 samples of 4% soapy chlorhexidine, recovered from all operating rooms, as well as in unopened containers stored in this center since 2014, indicating intrinsic contamination. Soapy chlorhexidine samples were removed from the spray bottle with pipettes to avoid touching the container. The soapy chlorhexidine samples were cultured in a PF Bact-Alert® flask (bioMérieux). Incubation was carried out for 5 days to rule out the possibility of a negative result. Prior to inoculation, a two-fold dilution of the sample was performed using sterile human plasma. The final inoculation volume was 5<span class="elsevierStyleHsp" style=""></span>ml (2.5<span class="elsevierStyleHsp" style=""></span>ml of antiseptic solution and 2.5<span class="elsevierStyleHsp" style=""></span>ml of human plasma).</p><p id="par0105" class="elsevierStylePara elsevierViewall">Twenty-five (25) isolates recovered from clinical specimens and from the chlorhexidine soap solution were identified by <span class="elsevierStyleItalic">nrd</span>A sequencing<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a>, corresponding to <span class="elsevierStyleItalic">A. xylosoxidans</span> (n: 1) and <span class="elsevierStyleItalic">Achromobacter</span> spp. (n: 24). A multilocus sequence-typing (MLST) scheme was conducted to identify those isolates which could not be unambiguously identified by <span class="elsevierStyleItalic">nrd</span>A sequencing. For this purpose, amplification and sequencing of inner fragments of seven housekeeping genes were conducted. Concatenate sequences (2254 nucleotides) of these seven fragments were obtained for those isolates included in this study and for 362 <span class="elsevierStyleItalic">Achromobacter</span> spp. available in the database (<a class="elsevierStyleCrossRef" href="#sec0035">Suppl. Table 1</a>). An alignment of all concatenates was performed using the program ClustalX 2.1. The statistical selection of best-fit model of nucleotide substitution was assessed by JModelTest. Maximum Likelihood estimation was conducted using MEGA 5.05. Bootstraps with 1000 re-sample matrices were executed to assess the statistical support for the identified groups. The dendrogram obtained with Maximum Likelihood is depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>, showing that these isolates grouped with <span class="elsevierStyleItalic">Achromobacter</span> genogroup 20. However, they could correspond to a new species of the genus <span class="elsevierStyleItalic">Achromobacter</span> (a long-term analysis out of the scope for the present study).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Xba</span>I-pulsed-field gel electrophoresis (PFGE) was performed to compare the <span class="elsevierStyleItalic">Achromobacter</span> genogroup 20 isolates, recovered both from clinical specimens and from the chlorhexidine soap solution; PFGE analysis showed 4 different pulsotypes (<a class="elsevierStyleCrossRef" href="#sec0035">Suppl. Fig. 3</a>).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Surgical wound lavage with chlorhexidine soap solution was interpreted as possibly responsible for the high colonization/infection rate in trauma surgeries, although this practice could only be confirmed in a low percentage of patients by surgery records. It should be mentioned that surgical wound lavage with sterile physiological solution is recommended in this institution.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The intrinsic contamination of the antiseptic soapy chlorhexidine solution prompted the following measures: removal of all 4% chlorhexidine soap solution bottles from the entire facility; notification to the supplier about the presence of <span class="elsevierStyleItalic">Achromobacter</span> spp. in unopened bottles of 4% chlorhexidine soap solution; and the complaint to the relevant health authorities, the National Administration for Drugs, Food and Medical Technology (<span class="elsevierStyleItalic">Administración Nacional de Medicamentos, Alimentos y Tecnología Médica</span> (ANMAT)).</p><p id="par0125" class="elsevierStylePara elsevierViewall">Since this antiseptic was removed, between May and June 2016, the presence of <span class="elsevierStyleItalic">Achromobacter</span> spp. was detected only once in the course of the next 18 months, corresponding to in a clinical sample from the orthopedic operating room in a post-intervention toilet, which was interpreted as contamination. The withdrawal of all the vials in the institution continued to be reinforced.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">In this study we describe two simultaneous events attributable to two different <span class="elsevierStyleItalic">Achromobacter</span> spp. contaminated sources, in addition to incorrect procedures that facilitated their dissemination. One event was related to an episode of pseudo-bacteremia due to sodium citrate blood collection tubes contaminated with <span class="elsevierStyleItalic">A. insuavis</span> added to a deficient technique in the loading of blood culture bottles, which caused their contamination. The other corresponded to <span class="elsevierStyleItalic">Achromobacter</span> genogroup 20 infections and colonizations caused by an intrinsically contaminated chlorhexidine soap solution, which was probably used in surgical wound healing and other clinical scenarios.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The undesirable effect of contaminated blood culture and their financial impact is well known, being independently associated with increased laboratory charges, hospitalization admission and inappropriate use of intravenous antibiotics<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The risk of antiseptic solution contamination, especially by gram negative bacilli, is well documented in the medical literature<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a>. Moreover, pseudo-bacteremia outbreaks have been already associated with <span class="elsevierStyleItalic">Achromobacter</span> spp. contaminated chlorhexidine aqueous solutions<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,10</span></a>. However, outbreaks with a predominance of clinical samples related to surgical wounds, such as the one described in this study, are infrequent. In other <span class="elsevierStyleItalic">Achromobacter</span> spp. pseudo-outbreaks, contamination of the chlorhexidine spray pipette has been described, although it was ruled out in this study by direct sampling of chlorhexidine with sterile pipettes avoiding the passage through the spray pipette of the container.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The investigation process of these events was cumbersome, in part due to the presence of two different species of the same genus that could not be identified by phenotypic tests in the routine laboratory, added to the great variety of sample types and different hospital areas involved. Molecular approaches were critical to achieving the accurate species identification and to assess the clonal relationship of the isolates. The importance of the multidisciplinary work of microbiologists, infectious disease specialists, epidemiologists and nurses in infection control should be emphasized, with great perseverance in elucidating this epidemiological situation.</p><p id="par0150" class="elsevierStylePara elsevierViewall">This study confirms, once more, the likelihood of aqueous chlorhexidine solution contamination by ubiquitous environmental hydrophilic microorganisms such as <span class="elsevierStyleItalic">Achromobacter</span> spp. with the hazard of related hospital outbreaks and pseudo-outbreaks. In addition, it highlights the importance of conducting outbreak investigations, persisting even with initial disappointing findings, implementing molecular studies, alerting against this type of deviations, and highlighting the need to reinforce microbiological controls (including long-term microbiological stability) in antiseptic production companies.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This work was partially supported by grants from <span class="elsevierStyleGrantSponsor" id="gs1">UBACyT</span> to M. Radice (<span class="elsevierStyleGrantNumber" refid="gs1">20020150100174BA</span>) and G. Gutkind (<span class="elsevierStyleGrantNumber" refid="gs1">20020130100432BA</span>) and by <span class="elsevierStyleGrantSponsor" id="gs2">ANPCYT</span><span class="elsevierStyleGrantNumber" refid="gs2">PICT-2017-3996</span> to Mariana Papalia.</p><p id="par0160" class="elsevierStylePara elsevierViewall">M. Radice, G. Gutkind, M. Papalia are members of Carrera del Investigador Científico (CONICET).</p><p id="par0165" class="elsevierStylePara elsevierViewall">Hospital Italiano – The funds correspond to the budget assigned to the infection committee.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1777031" "titulo" => "Highlights" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres1777032" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1560242" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1777030" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0015" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1560241" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Event report 1" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Event report 2" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-02-20" "fechaAceptado" => "2021-10-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1560242" "palabras" => array:9 [ 0 => "<span class="elsevierStyleItalic">Achromobacter insuavis</span>" 1 => "Achromobacter genogroup 20" 2 => "Genotyping" 3 => "Outbreaks" 4 => "Pseudo-outbreaks" 5 => "Pseudo-bacteremia" 6 => "Clorhexidine contamination" 7 => "Wound care" 8 => "Antibiotic stewardship" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1560241" "palabras" => array:9 [ 0 => "<span class="elsevierStyleItalic">Achromobacter insuavis</span>" 1 => "<span class="elsevierStyleItalic">Achromobacter</span> genogrupo 20" 2 => "Genotipificación" 3 => "Brote" 4 => "Seudobrote" 5 => "Seudobacteriemia" 6 => "Contaminación con clorhexidina" 7 => "Cuidado de heridas" 8 => "Uso apropiado de antibióticos" ] ] ] ] "tieneResumen" => true "highlights" => array:2 [ "titulo" => "Highlights" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0005" class="elsevierStylePara elsevierViewall">Description of two events of nosocomial <span class="elsevierStyleItalic">Achromobacter</span> spp. outbreak and pseudo-outbreak.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0010" class="elsevierStylePara elsevierViewall">Contamination of sodium citrate blood collection tubes with <span class="elsevierStyleItalic">Achromobacter insuavis.</span></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall">Chlorhexidine soap contaminated with <span class="elsevierStyleItalic">Achromobacter</span> spp. caused infections.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">Molecular approaches were critical to achieve the accurate species identification.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">The multidisciplinary work was essential to elucidate the epidemiological situation.</p></li></ul></p></span>" ] "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Achromobacter</span> spp. are increasingly recognized as emerging pathogens in immunocompromised patients or suffering cystic fibrosis, but unusual in immunocompetent hosts or individuals that underwent surgery. In this study we describe two simultaneous events attributable to two different <span class="elsevierStyleItalic">Achromobacter</span> spp. contaminated sources. One event was related to an episode of pseudo-bacteremia due to sodium citrate blood collection tubes contaminated with <span class="elsevierStyleItalic">Achromobacter insuavis</span> and the other to <span class="elsevierStyleItalic">Achromobacter</span> genogroup 20 infection and colonization caused by an intrinsically contaminated chlorhexidine soap solution. Both threatened the appropriate use of antimicrobials. Molecular approaches were critical to achieving the accurate species identification and to assess the clonal relationship, strengthening the need for dedicated, multidisciplinary and collaborative work of microbiologists, specialists in infectious diseases, epidemiologists and nurses in the control of infections to clarify these epidemiological situations.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Achromobacter</span> spp. son reconocidas con mayor frecuencia como patógenos emergentes en pacientes con fibrosis quística e inmunodeprimidos, pero son inusuales en hospedadores inmunocompetentes o quirúrgicos. En este estudio describimos 2 eventos simultáneos atribuibles a 2 fuentes contaminadas con <span class="elsevierStyleItalic">Achromobacter</span> spp. Uno correspondió a un episodio de seudobacteriemia por tubos de citrato de sodio contaminados con <span class="elsevierStyleItalic">Achromobacter insuavis</span> y el otro a infecciones y colonizaciones debidas al uso de solución jabonosa de clorhexidina intrínsecamente contaminada con <span class="elsevierStyleItalic">Achromobacter</span> genogrupo 20. Ambos episodios pusieron en peligro el uso apropiado de antimicrobianos. Los enfoques moleculares fueron fundamentales para lograr la identificación precisa de las especies y evaluar la relación clonal de los aislamientos, lo que refuerza la necesidad del trabajo perseverante y multidisciplinario de microbiólogos, especialistas en enfermedades infecciosas, epidemiólogos y enfermeras en el control de infecciones para el esclarecimiento de estas situaciones epidemiológicas.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0180" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2749 "Ancho" => 3510 "Tamanyo" => 668995 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dendrogram based on Maximum Likelihood estimation conducted using MEGA 5.05 for <span class="elsevierStyleItalic">Achromobacter</span> spp. concatenated housekeeping genes.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient information (n: 59) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 years (average) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 female/38 male \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Underlying disease</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immunocompromised patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Solid organ and bone marrow transplantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Solid tumor surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (6 bone tumors) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Other comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hepatic failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Peripheral cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neurological disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic respiratory disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Orthopedics and traumatology patients</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (6 bone tumors) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">In-patients in internal medicine</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">In-patients in critical units</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Surgery patients</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Achromobacter</span> spp. infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Achromobacter</span> spp. colonization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30-Day mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (unrelated death) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Characteristics of patients with microbiological samples (not blood cultures) positive for <span class="elsevierStyleItalic">Achromobacter</span> spp.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical specimens (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>94) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2014 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2015 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>54) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2016 (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>27) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory samples: tracheal aspirate, bronchoalveolar lavage, sputum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-orthopedic surgery samples: bone, soft tissue, wound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other samples: breast, wound, gastric fluid, duodenum, catheter tip, urine, skin, hematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Distribution of <span class="elsevierStyleItalic">Achromobacter</span> spp. positive clinical specimens.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.zip" "ficheroTamanyo" => 1925545 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Detection of <span class="elsevierStyleItalic">Achromobacter xylosoxidans</span> in hospital, domestic, and outdoor environmental samples and comparison with human clinical isolates" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:10 [ 0 => "L. Amoureux" 1 => "J. Bador" 2 => "S. Fardeheb" 3 => "C. Mabille" 4 => "C. Couchot" 5 => "C. Massip" 6 => "A.L. Salignon" 7 => "G. Berlie" 8 => "V. Varin" 9 => "C. Neuwirth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/AEM.02293-13" "Revista" => array:6 [ "tituloSerie" => "Appl Environ Microbiol" "fecha" => "2013" "volumen" => "79" "paginaInicial" => "7142" "paginaFinal" => "7149" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24038696" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0090" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Investigation and control of an outbreak of <span class="elsevierStyleItalic">Achromobacter xylosoxidans</span> bacteremia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Behrens-Muller" 1 => "J. Conway" 2 => "J. Yoder" 3 => "C.S. Conover" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/663710" "Revista" => array:6 [ "tituloSerie" => "Infect Control Hosp Epidemiol" "fecha" => "2012" "volumen" => "33" "paginaInicial" => "180" "paginaFinal" => "184" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22227988" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0095" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brote hospitalario de <span class="elsevierStyleItalic">Achromobacter denitrificans</span> relacionado con el uso de clorhexidina contaminada" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L.M. Echeverri" 1 => "S. Atehortúa" 2 => "M. Tamayo" 3 => "D.M. Restrepo" 4 => "N. Valencia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0123-9392(12)70064-4" "Revista" => array:5 [ "tituloSerie" => "Infectio" "fecha" => "2012" "volumen" => "16" "paginaInicial" => "112" "paginaFinal" => "116" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0100" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Updated review of blood culture contamination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.K. Hall" 1 => "J.A. Lyman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/CMR.00062-05" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Rev" "fecha" => "2006" "volumen" => "19" "paginaInicial" => "788" "paginaFinal" => "802" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17041144" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0105" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "False-positive blood cultures association with nonsterile blood collection tubes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.C. Hoffman" 1 => "P.M. Arnow" 2 => "D.A. Goldmann" 3 => "P.L. Parrott" 4 => "W.E. Stamm" 5 => "J.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 21 | 6 | 27 |
| 2024 September | 35 | 5 | 40 |
| 2024 August | 19 | 5 | 24 |
| 2024 July | 20 | 6 | 26 |
| 2024 June | 14 | 6 | 20 |
| 2024 May | 20 | 3 | 23 |
| 2024 April | 13 | 4 | 17 |
| 2024 March | 23 | 11 | 34 |
| 2024 February | 13 | 13 | 26 |
| 2024 January | 16 | 7 | 23 |
| 2023 December | 13 | 14 | 27 |
| 2023 November | 16 | 9 | 25 |
| 2023 October | 30 | 10 | 40 |
| 2023 September | 20 | 6 | 26 |
| 2023 August | 16 | 41 | 57 |
| 2023 July | 13 | 21 | 34 |
| 2023 June | 26 | 20 | 46 |
| 2023 May | 55 | 31 | 86 |
| 2023 April | 36 | 12 | 48 |
| 2023 March | 20 | 26 | 46 |
| 2023 February | 12 | 17 | 29 |
| 2023 January | 18 | 22 | 40 |
| 2022 December | 43 | 36 | 79 |
| 2022 November | 45 | 32 | 77 |
| 2022 October | 30 | 23 | 53 |
| 2022 September | 17 | 20 | 37 |
| 2022 August | 9 | 8 | 17 |
| 2022 July | 11 | 15 | 26 |
| 2022 June | 8 | 21 | 29 |
| 2022 May | 13 | 11 | 24 |
| 2022 April | 15 | 21 | 36 |
| 2022 March | 10 | 12 | 22 |
| 2022 February | 9 | 11 | 20 |
| 2022 January | 10 | 7 | 17 |
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