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Background: Febrile neutropenia (FN) is a common complication of stem cell transplantation., Aim: To evaluate the frequency of sepsis in patients with FN colonized with resistant Gram-negative bacteria (extended-spectrum β-lactamase (ESBL)-positive, multidrug-resistant (MDR) Pseudomonas aeruginosa) and the choice of primary antibiotic in colonized patients., Methods: This retrospective study analysed data from patients undergoing haematopoietic stem cell transplantation from January 2018 to September 2022. Data were extracted from the hospital information system., Findings: Carbapenem as the primary antibiotic of choice was chosen in 10.9% of non-colonized +/-AmpC patients, 31.5% of ESBL + patients, and 0% of MDR P. aeruginosa patients. Patients with FN and MDR P. aeruginosa colonization had a high prevalence of sepsis (namely 100%, P = 0.0197). The spectrum of sepsis appeared to be different, with Gram-negative bacilli predominating in the ESBL + group (OR: 5.39; 95% CI: 1.55-18.76; P = 0.0123). Colonizer sepsis was present in 100% of sepsis with MDR P. aeruginosa colonization (P = 0.002), all in allogeneic transplantation (P = 0.0003), with a mortality rate of 33.3% (P = 0.0384). The incidence of sepsis in patients with ESBL + colonization was 25.9% (P = 0.0197), with colonizer sepsis in 50% of sepsis cases (P = 0.0002), most in allogeneic transplantation (P = 0.0003)., Conclusion: The results show a significant risk of sepsis in FN with MDR P. aeruginosa colonization, a condition almost exclusively caused by the colonizer. At the same time, a higher risk of Gram-negative sepsis has been demonstrated in patients colonized with ESBL + bacteria., (Copyright © 2024 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Healthcare-associated infections (HAIs) are a major problem in intensive care units (ICUs). The hospital water environment is a potential reservoir for Gram-negative bacteria (GNB), and it has been shown that contaminated sinks contribute to the spread of GNB in outbreak and non-outbreak settings. This study aimed to investigate which sink interventions may reduce GNB infection and colonization rates in the ICU., Methods: A database search (MEDLINE via PubMed, EMBASE via Ovid and ClinicalTrials.gov) was undertaken without restrictions on language or date of publication. Studies of any design were included if they described an intervention on the water fixtures in patient rooms, and presented data about HAI or colonization rates in non-outbreak settings. Acquisition (infection and/or colonization) rates of GNB and Pseudomonas aeruginosa were analysed as outcomes., Results: In total, 4404 records were identified. Eleven articles were included in the final analysis. No randomized controlled trials were included in the analysis, and all studies were reported to have moderate to serious risk of bias. Removing sinks and applying filters on taps had a significant impact on GNB acquisition, but there was high heterogeneity among reported outcomes and sample size among the studies., Conclusion: Few studies have investigated the association of sinks in patient rooms with healthcare-associated acquisition of GNB in non-outbreak settings. Heterogeneity in study design made it impossible to generalize the results. Prospective trials are needed to further investigate whether removing sinks from patient rooms can reduce the endemic rate of HAIs in the ICU., (Copyright © 2023 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: The development of carbapenem-resistant Gram-negative bacilli (CR-GNB) is largely favoured by indiscriminate and prolonged carbapenem use, which is a significant contributing factor., Aim: To evaluate the impact of two carbapenem antibiotic stewardship programme interventions on both carbapenem prescriptions and the clinical isolation rates of CR-GNBs, using interrupted time-series analysis., Methods: A time-series analysis was performed using data for carbapenem usage from a tertiary hospital in South Korea from January 2017 to July 2022. Two carbapenem antibiotic stewardship programme interventions were implemented sequentially: (i) a prospective audit and feedback (PAF) from November 2018 to April 2020 (intervention 1), and (ii) preauthorization from May 2020 to August 2020 (intervention 2). Monthly carbapenem usage and incidence of CR-GNB before and after each intervention were compared using an autoregressive integrated moving average model., Findings: Implementation of PAF resulted in a significant reduction in carbapenem consumption, followed by an additional decrease after the preauthorization was implemented. The incidence of carbapenem-resistant Escherichia coli and Klebsiella pneumoniae increased after intervention 1, but there was a significant change from an increasing trend to a stationary trend after intervention 2. The incidence of carbapenem-resistant Pseudomonas aeruginosa, which had increased during the baseline period, became stationary after intervention 1. A significant decrease was observed in the incidence of carbapenem-resistant Acinetobacter baumannii during the implementation of intervention 1 and 2., Conclusion: This study emphasizes the importance of adopting comprehensive antibiotic management and rigorous infection control to prevent infections caused by antibiotic-resistant bacteria., (Copyright © 2023 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Multi-drug-resistant (MDR) Gram-negative bacterial (GNB) infection remains a significant cause of morbidity and mortality among surgical patients. The objective of this study was to recognize the risk factors for MDR GNB infection in patients following abdominal surgery, and determine the predictors independently associated with death., Methods: From 2010 to 2017, a retrospective cohort study was conducted among patients with abdominal surgery admitted to the surgical intensive care unit (ICU). Patients with GNB infection were included for analyses., Results: In total, 364 patients experienced GNB infection following abdominal surgery. Of these, 117 (32.1%) were MDR GNB infection. Of 133 MDR GNB isolates, the most common isolate was Escherichia coli (45.1%). Patients with MDR GNB infection had significantly longer ventilator-days and hospital stay, as well as higher 30-day and in-hospital mortality compared with non-MDR GNB patients. Multi-variable analysis showed that longer length of pre-ICU stay, surgical re-exploration, receipt of group 2 carbapenems (e.g. imipenem, meropenem and doripenem) and fluoroquinolones, and higher total bilirubin were independent risk factors for the acquisition of MDR GNB infection. Predictors for 30-day mortality among patients with MDR GNB infection were chronic kidney disease, receipt of group 2 carbapenems and inappropriate empirical antimicrobial therapy., Conclusions: This study provides important information about the risk factors for MDR GNB infection and 30-day mortality among patients following abdominal surgery., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI)., Aim: To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort., Methods: Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases., Findings: Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S. aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population., Conclusion: Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable., (Copyright © 2021 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: We investigated the clinical characteristics and risk factors for the isolation of multi-drug-resistant (MDR) Gram-negative bacteria (GNB) from critically ill COVID-19 patients., Methods: We retrospectively matched (1:2) critical COVID-19 patients with one or more MDR GNB from any clinical specimen (cases), with those with no MDR GNB isolates (controls)., Results: Seventy-eight cases were identified (4.5 per 1000 intensive care unit (ICU) days, 95% confidence interval (CI) 3.6-5.7). Of 98 MDR GNB isolates, the most frequent species were Stenotrophomonas maltophilia (24, 24.5%), and Klebsiella pneumoniae (23, 23.5%). Two (8.7%) K. pneumoniae, and six (85.7%) Pseudomonas aeruginosa isolates were carbapenem resistant. A total of 24 (24.5%) isolates were not considered to be associated with active infection. Those with active infection received appropriate antimicrobial agents within a median of one day. The case group had significantly longer median central venous line days, mechanical ventilation days, and hospital length of stay (P<0.001 for each). All-cause mortality at 28 days was not significantly different between the two groups (P=0.19). Mechanical ventilation days (adjusted odds ratio 1.062, 95% CI 1.012-1.114; P=0.015), but not receipt of corticosteroids or tocilizumab, was independently associated with the isolation of MDR GNB. There was no association between MDR GNB and 28-day all-cause mortality (adjusted odds ratio 2.426, 95% CI 0.833-7.069; P= 0.104)., Conclusion: In critically ill COVID-19 patients, prevention of MDR GNB colonization and infections requires minimizing the use of invasive devices, and to remove them as soon as their presence is no longer necessary., (Copyright © 2021 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Introduction: Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) and other multi-drug-resistant Gram-negative bacteria (MDR-GNB) have disseminated globally since their discovery in the late 20 th century. Various infection prevention and control measures are in place to prevent nosocomial transmission of these organisms, but their efficacy remains disputed. New literature has emerged in recent years providing further evidence which can be used to formulate effective strategies to tackle this issue in the future., Methods: A systematic review was performed to characterize the prevalence of colonization of multi-drug-resistant organisms and subsequent acquisition of these organisms within hospital settings. A meta-analysis was performed to characterize the prevalence and acquisition of ESBL-E in Europe and North America., Results: Twenty-eight studies fulfilled the inclusion criteria. Escherichia coli formed the main burden of MDR-GNB colonization worldwide. Patient-to-patient transmission of ESBL-E was found to be rare, but increased transmissibility of Klebsiella pneumoniae was described over E. coli. Within European and North American healthcare settings, a meta-analysis of eight studies identified a pooled prevalence of ESBL-E on admission to hospital of 7.91% and an acquisition rate of 3.73%., Discussion: Low prevalence at the point of hospital admission and insufficient evidence of patient-to-patient transmission suggests that infection prevention and control measures such as universal surveillance screening and single-room isolation are unlikely to be practical or effective interventions in reducing the overall burden of ESBL-E in hospitals, in line with current European guidelines. Instead, it is argued that efforts should be placed on controlling the spread of these organisms and other MDR-GNB in the community, predominantly long-term care facilities., (Copyright © 2020 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Neonatal sepsis remains a leading cause of neonatal mortality. Maternal bacterial colonization plays a major role in transmission to the infant, with potential for subsequent development of neonatal sepsis with maternally derived strains., Aim: To review the molecular evidence supporting transmission of multidrug-resistant Gram-negative bacteria (MDR-GNB) from colonized mothers to their infants and the risk factors for MDR-GNB transmission., Methods: PubMed and Scopus were searched for studies investigating the mechanisms, risk factors for and/or scale of transmission of MDR-GNB from colonized mothers to their infants. Random effects meta-analyses were performed to determine pooled proportions of MDR-GNB transmission and the neonatal outcomes of transmission., Findings: Eight studies were included in the narrative description and six in the meta-analysis. Five studies used pulsed-field gel electrophoresis to assess relatedness of isolates from colonized mothers and their infants. Pooled proportion of MDR-GNB transmission from colonized mothers to their infants was 27% (95% confidence interval (CI): 8-47%). Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae were the most frequently studied MDR-GNB pathogens transmitted between mother-infant pairs. Following mother-to-infant transmission of an MDR-GNB pathogen, the pooled proportion for the outcome of neonatal colonization was 19% (95% CI: 3-35%)., Conclusion: This systematic review strongly supports MDR and/or ESBL Enterobacteriaceae transmission from colonized mothers to their infants, with subsequent infant colonization. The risk factors contributing to transmission of MDR-GNB between colonized mothers and their infants warrants further research., (Copyright © 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Levofloxacin has been considered as an alternative treatment for Stenotrophomonas maltophilia infection. However, levofloxacin-resistant S. maltophilia (LRSM) are emerging worldwide., Aim: To investigate LRSM risk factors in hospitalized patients and to determine antibiotic susceptibility patterns of LRSM isolates., Methods: In a retrospective matched case-control-control study, LRSM patients (the case group) were compared with two control groups: levofloxacin-susceptible S. maltophilia (LSSM) patients (control group A) and non-S. maltophilia-infected patients (control group B). Conditional logistic regression was used to analyse risk factors for LRSM occurrence. Tigecycline, ceftazidime, colistin, and trimethoprim/sulfamethoxazole (TMP/SMX) susceptibilities in collected LRSM clinical isolates were determined., Findings: A total of 105 LRSM, 105 LSSM, and 105 non-S. maltophilia-infected patients were analysed. The first multivariate analysis (cases vs group A) revealed that previous fluoroquinolones use was significantly associated with LRSM occurrence, and the second multivariate analysis (cases vs group B) revealed that previous fluoroquinolone use, previous intensive care unit stay, and the number of previous exposures to different classes of antibiotics were significantly associated with LRSM occurrence. Of all the LRSM isolates tested for antibiotic susceptibility, ceftazidime, TMP/SMX, tigecycline, and colistin resistance rates were 42.0, 99.0, 78.0, and 40.0%, respectively., Conclusion: LRSM antibiotic susceptibility patterns revealed multiple-drug resistance, which further limits treatment options for clinicians. To reduce LRSM occurrence, proper use of antibiotics, especially fluoroquinolones, is mandatory., (Copyright © 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Over the last decade there has been a rapid, worldwide increase in carbapenem resistance, which is of growing concern. The main protagonists, the carbapenemases Klebsiella pneumoniae carbapenemase (KPC), oxacillinase β-lactamase 48 (OXA-48), imipenemase metallo-β-lactamase (IMP), Verona integron-borne metallo-β-lactamase (VIM), and New Delhi metallo-β-lactamase (NDM) have also been reported across the UK. However, these reports are derived from a combination of reactive screening, outbreak control, inpatient surveillance, and diagnostic samples. Therefore, the true community prevalence is unknown., Aim: To determine the community prevalence of carbapenemase-producing organisms (CPOs) in the area served by Barts Health NHS Trust., Methods: Active screening of 200 non-duplicate community stool samples was performed. Patient demographics and foreign travel history were extracted from the laboratory information management system to identify potential risk factors for carriage of CPOs., Findings: Patients in this study were aged from one to 93 years and were evenly distributed between male and female. Foreign travel in the last year was listed for 46 out of 200 (23%) patients, with the most commonly visited countries including Bangladesh (4%), India (2.5%), Morocco (2%), and Turkey (1.5%). However, only one patient tested positive for a CPO, an NDM-producing Pseudomonas aeruginosa, and this patient had travelled to the Caribbean., Conclusion: To date, there have been no studies investigating the prevalence of CPOs in the UK community. Given the high-risk patient population served by Barts Health NHS Trust, it is reassuring that the prevalence observed here was low. However, it should be highlighted that travel to countries not previously categorized as high risk may also pose a threat., (Copyright © 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Antimicrobial-resistant Gram-negative bacteria are a major cause of morbidity and mortality in hospitalized neonates in South and South-East Asia. This study aimed to determine the dynamics of colonization with antimicrobial-resistant Gram-negative bacteria amongst patients in a neonatal intensive care unit (NICU) in Thailand. From 97 enrolled patients, 52% were colonized by an extended-spectrum β-lactamase (ESBL) organism at some point during their stay and 64% were colonized by a carbapenem-resistant organism. Rapid acquisition of ESBL-positive and carbapenem-resistant organisms was found. Once colonized with an antibiotic-resistant organism, patients remained colonized for the remainder of their NICU stay., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: An electronic reporting system (ERS) for the enhanced surveillance of carbapenemase-producing Gram-negative bacteria (CPGNB) was launched by Public Health England in May 2015., Aim: This evaluation aimed to assess uptake, timeliness and completeness of data provided and explore potential barriers and facilitators to adopting the system., Methods: The evaluation comprised a retrospective analysis of surveillance data and semi-structured interviews with ERS users., Findings: The proportion of organisms referred for investigation of carbapenem resistance via ERS increased over the first 12 months post-implementation from 35% to 73%; uptake varied widely across regions of England. Completeness of enhanced data fields was poor in 78% of submitted isolates. The median number of days to report confirmatory test results via ERS was 1 day for the regional service and nine days for the national reference laboratory, which additionally conducts phenotypic testing to confirm carbapenemase negativity. Hindrances to ERS utility included: a lack of designated, ongoing resource for system maintenance, technical support and development; uncertainty about how and when to use ERS and workload. Incomplete data prevented gaining a better understanding of important risk factors and transmission routes of CPGNB in England., Conclusion: The ERS is the only surveillance system in England with the potential to gather intelligence on important risk factors for CPGNB to inform public health measures to control their spread. Although the ERS captures more information on CPGNB than other surveillance systems, timeliness and completeness of the enhanced data require substantial improvements in order to deliver the desired health benefits., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: Gram-negative complicated urinary tract infections (cUTIs) can have serious consequences for patients and hospitals., Aim: To examine the clinical and economic burden attributable to Gram-negative carbapenem-non-susceptible (C-NS; resistant/intermediate) infections compared with carbapenem-susceptible (C-S) infections in 78 US hospitals., Methods: All non-duplicate C-NS and C-S urine source isolates were analysed. A subset had principal diagnosis ICD-9-CM codes denoting cUTI. Collection time (<3 vs ≥3 days after admission) determined isolate classification as community or hospital onset. Mortality, 30-day re-admissions, length of stay (LOS), hospital cost and net gain/loss in US dollars were determined for C-NS and C-S cases, with the C-NS-attributable burden estimated through propensity score matching. Three subgroups with adequate patient numbers were analysed: cUTI principal diagnosis, community onset; other principal diagnosis, community onset; and other principal diagnosis, hospital onset., Findings: The C-NS-attributable mortality risk was significantly higher (58%) for the other principal diagnosis, hospital-onset subgroup alone (odds ratio 1.58, 95% confidence interval 1.14-2.20; P < 0.01). The C-NS-attributable risk for 30-day re-admission ranged from 29% to 55% (all P < 0.05). The average attributable economic impact of C-NS was 1.1-3.9 additional days LOS (all P < 0.05), US$1512-10,403 additional total cost (all P < 0.001) and US$1582-11,848 net loss (all P < 0.01); overall burden and C-NS-attributable burden were greatest in the other principal diagnosis, hospital-onset subgroup., Conclusion: Greater clinical and economic burden was observed in propensity-score-matched patients with C-NS infections compared with C-S infections, regardless of whether cUTI was the principal diagnosis, and this burden was most severe in hospital-onset infections., (Copyright © 2018 Merck Sharp & Dohme Corp. and The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Recent studies reported seasonality in healthcare-associated infections (HCAI). The association of this phenomenon with other risk factors for HCAI is not clear., Aim: To analyse the interplay of season, weather and usual predictors of healthcare-associated bloodstream infections caused by Gram-negative bacilli (GNB-BSI)., Methods: A case-only study was conducted in a teaching hospital in Brazil. The study enrolled 446 subjects with GNB-BSI diagnosed from July 2012 to June 2016. Demographic data, comorbidities, invasive procedures and use of antimicrobials were reviewed in medical charts. The season in which GNB-BSI occurred, and weather parameters on the day of diagnosis were recorded. Factors associated with occurrence of GNB-BSI in different seasons (reference category: winter) and caused by different GNB (reference category: Escherichia coli) were analysed. Uni- and multi-variable models of multi-nomial logistic regression were used for analysis., Findings: GNB-BSI diagnosed in summer was more likely to be caused by Klebsiella spp. [odds ratio (OR) 5.33; 95% confidence interval (CI) 2.04-13.96] or Acinetobacter baumannii (OR 2.69; 95% CI 1.04-6.96), and there was an association between Klebsiella spp. and spring (OR 2.86; 95% CI 1.14-7.18). Average temperature on the day of diagnosis was associated with Klebsiella spp. (OR 1.19; 95% CI 1.07-1.33) and A. baumannii (OR 1.20; 95% CI 1.07-1.34)., Conclusion: Warm seasons and daily temperature impact on the aetiology of GNB-BSI, even in models adjusted for usual risk factors. One possible explanation for these findings is that seasonality of healthcare-associated pathogens is intrinsic to micro-organisms, and not associated with comorbidities, procedures or use of antimicrobials., (Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Bevacizumab, a recombinant humanized monoclonal antibody to inhibit tumour angiogenesis, is available for off-label use for treating choroidal neovascularization. Outbreaks have been reported after use of this drug, either because of contamination during manufacturing or the practice of multiple doses being administered from a single vial to different patients. In our institute we investigated one endophthalmitis outbreak following intravitreal injection of bevacizumab, rapidly identified the Stenotrophomonas maltophilia as the causative agent, and established the contaminated bevacizumab vial as the source using matrix-assisted laser desorption/ionization mass spectrometry (MALDI-TOF-MS) typing. The study emphasizes the need for early diagnosis of the source and pathogen for appropriate control measures., (Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Gram-negative bacteria are increasingly the cause of catheter-related bloodstream infection (CRBSI), and the prevalence of multi-drug-resistant strains is rising rapidly. This study evaluated the impact of delayed central venous catheter (CVC) removal on clinical outcomes in patients with Gram-negative CRBSI., Methods: Between January 2007 and December 2016, patients with Gram-negative bacteraemia and CVC placement, from two tertiary care hospitals, were included retrospectively. Cases with CVC removal more than three days after onset of bacteraemia or without CVC removal were classified as having delayed CVC removal., Results: In total, 112 patients were included. Of these, 78 had CRBSI (43 definite and 35 probable) and 34 had Gram-negative bacteraemia from another source (non-CRBSI). Enterobacteriaceae were less common pathogens in patients with CRBSI than in patients with non-CRBSI (11.5% vs 41.3%; P<0.001). Delayed CVC removal was associated with increased 30-day mortality (40.5% vs 11.8%; P=0.01) in patients with Gram-negative CRBSI; this was not seen in patients with non-CRBSI (25.0% vs 14.3%; P>0.99). Delayed CVC removal [odds ratio (OR) 6.8], multi-drug-resistant (MDR) Gram-negative bacteraemia (OR 6.3) and chronic renal failure (OR 11.1) were associated with 30-day mortality in patients with CRBSI. The protective effect of early CVC removal on mortality was evident in the MDR group (48.3% vs 18.2%; P=0.03), but not in the non-MDR group (11.1% vs 0%; P=0.43)., Conclusion: CVCs should be removed early to improve clinical outcomes in patients with Gram-negative CRBSI, especially in settings where MDR isolates are prevalent., (Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Healthcare-associated infections in neonatal and paediatric populations are associated with poorer outcomes and healthcare costs, and surveillance is a necessary component of prevention programmes., Aim: To evaluate burden of illness, aetiology, and time-trends for central and peripheral line-associated bloodstream infection (CLABSI and PLABSI) in Australian neonatal and paediatric intensive care units (ICUs) between July 1 st , 2008 and December 31 st , 2016., Methods: Using National Healthcare Safety Network methods, surveillance in neonatal and paediatric units was performed by hospitals participating in the Victorian Healthcare Associated Infection Surveillance System. Mixed effects Poisson regression was used to model infections over time., Findings: Overall, 82 paediatric CLABSI events were reported during 37,125 CVC-days (2.21 per 1000 CVC-days), 203 neonatal CLABSI events were reported during 92,169 CVC-days (2.20 per 1000 CVC-days), and 95 neonatal PLABSI events were reported during 142,240 peripheral line-days (0.67 per 1000 peripheral line-days). Over time, a significant decrease in quarterly risk for neonatal CLABSI events was observed (risk ratio (RR): 0.98; 95% confidence interval: 0.97-0.99; P = 0.023) and this reduction was significant for the 751-1000 g birth weight cohort (RR: 0.97; P = 0.015). Most frequently, coagulase-negative Staphylococcus spp. (24.2%) and Staphylococcus aureus (16.1%) were responsible for CLABSI events. A significant reduction in Gram-negative neonatal infections was observed (annual RR: 0.85; P < 0.001)., Conclusion: CLABSI rates in neonatal and paediatric ICUs in our region are low, and neonatal infections have significantly diminished over time. Evaluation of infection prevention programmes is required to determine whether specific strategies can be implemented to further reduce infection risk., (Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Contaminated handwashing sinks have been identified as reservoirs that can facilitate colonization/infection of patients with multidrug-resistant (MDR) Gram-negative bacteria (GNB) in intensive care units (ICUs)., Aim: To assess the impact of removing patients' sinks and implementing other water-safe strategies on the annual rates of ICU-acquired MDR-GNB., Methods: This six-year quasi-experimental study was conducted from January 2011 to December 2016. The intervention was carried out in August 2014 in two adult ICU wards with 12 rooms each. To assess the changes in annual MDR-GNB rates before and after the intervention, we used segmented regression analysis of an interrupted time-series. Crude relative risk (RR) rates were also calculated., Findings: The incidence rates of MDR-GNB were 9.15 and 2.20 per 1000 patient-days in the pre- and post-intervention periods, respectively. This yielded a crude RR of acquiring MDR-GNB of 0.24 (95% confidence interval: 0.17-0.34). A significant change in level was observed between the MDR-GNB rate at the first point of the post-intervention period and the rate predicted by the pre-intervention time trend., Conclusion: The implementation of a new water-safe policy, which included the removal of sinks from all patient rooms, successfully improved the control of MDR-GNB spread in an ICU with endemic infection. Our results support the contribution of sink use with the incidence of MDR-GNB in endemic environments., (Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Stenotrophomona maltophilia has emerged as an important opportunistic pathogen that is highly antibiotic resistant. Analysis of antibiotic susceptibilities, drug-resistant gene profiles and molecular typing of S. maltophilia was undertaken in a university hospital of traditional Chinese medicine in East China. Resistance to sulphamethoxazole (SXT) was found to be an indicator of multi-drug resistance. SXT resistance was mediated by sul and dfrA genes in integrons, especially class 1. Some evidence of clonal dissemination was found, indicating the occurrence of cross-transmission of antibiotic-resistant strains within the hospital. This underscores the need for effective control and prevention measures in hospitals., (Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Stenotrophomonas maltophilia is an opportunistic multi-drug-resistant bacterium responsible for healthcare-associated infections. Strategies for in-hospital infection control and management of carriers and environmental reservoirs remain controversial., Aim: To determine the population structure of S. maltophilia strains in hospitalized infected patients and to identify putative highly pathogenic subpopulations that require upgraded infection control measures., Methods: Eighty-three diverse human strains of various clinical origins from 18 geographically distant hospitals were characterized phenotypically and genotypically using a multi-locus sequence typing (MLST) approach., Findings: Neither a predominant nor emerging sequence type (ST) was identified. Among the 80 typeable strains, only 29% corresponded to described STs, especially ST5 (N=6) and ST4/26/31 (N=2). The ST distribution and the phylogenic tree based on the concatenated MLST genes did not account for geographical, clinical origin or antimicrobial susceptibility clustering. A phylogenic tree that included 173 ST profiles from the MLST database and the 80 typeable strains confirmed the high genetic diversity of S. maltophilia, the previously reported genogroup organization and the predominance of genogroup 6, as it represented 41% (33/80) of the strains. Unexpectedly, genogroup 2 was the second most prevalent genogroup and included 16% (13/80) of the strains. These genogroups represented 57% (20/35) of the strains in respiratory patients and 75% (9/12) of the strains in patients with cystic fibrosis., Conclusion: Beyond MLST, the over-representation of some genogroups among strains responsible for healthcare-associated infections was confirmed. Genogrouping affiliation is recommended to implement infection control measures selectively for the most pathogenic strains isolated from patient or environmental reservoirs., (Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Multi-drug-resistant Gram-negative bacteria (MDRGNB) have become an important cause of nosocomial infection in intensive care units (ICUs)., Aims: To investigate the molecular epidemiology of MDRGNB isolated from medical personnel (MP) and non-medical personnel (NMP) at 69 ICUs in Tianjin, China., Methods: From April 2007 to October 2015, 2636 nasal and hand swab samples from 1185 MP and 133 NMP were cultured for GNB (including MDRGNB), meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The susceptibilities of GNB to 14 antimicrobial agents were determined, and 80 MDRGNB were characterized using pulsed-field gel electrophoresis (PFGE) and dendrogram analysis., Findings: In total, 301 GNB were identified in 269 MP, including 109 MDRGNB isolates in 104 MP. Forty-two GNB were isolated from 39 NMP, which included 20 NMP with MDRGNB. Overall, 8.8% of MP were colonized with MDRGNB, which greatly exceeded colonization rates with MRSA (0.9%) and VRE (0.1%). Three pairs of Klebsiella pneumoniae and one pair of Enterobacter aerogenes were indistinguishable from each other, but the majority of isolate tests had distinct PFGE profiles., Conclusions: The prevalence of MDRGNB was high among ICU MP in Tianjin, and greatly exceeded that of VRE and MRSA. There was no difference in the rates of nasal carriage of MDRGNB between MP and NMP, but NMP were significantly more likely to have hand colonization with MDRGNB. PFGE profiles showed that there was only limited sharing of strains of MDR E. aerogenes and K. pneumoniae between personnel., (Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

This article describes the prevalence of antibiotic resistance and predictors of mortality for healthcare-associated (HA) Gram-negative bloodstream infections (GN-BSI). In total, 831 cases of HA GN-BSI from 17 intensive care units in different centres in Turkey were included; the all-cause mortality rate was 44%. Carbapenem resistance in Klebsiella pneumoniae was 38%, and the colistin resistance rate was 6%. Multi-variate analysis showed that age >70 years [odds ratio (OR) 2, 95% confidence interval (CI) 1.22-3.51], central venous catheter use (OR 2.1, 95% CI 1.09-4.07), ventilator-associated pneumonia (OR 1.9, 95% CI 1.1-3.16), carbapenem resistance (OR 1.8, 95% CI 1.11-2.95) and APACHE II score (OR 1.1, 95% CI 1.07-1.13) were significantly associated with mortality., (Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: In June 2014, a cluster of identical S. maltophilia isolates was reported in an adult intensive care unit (ICU) at a district general hospital. An outbreak control team was convened to investigate the cluster and inform control measures., Aim: To identify potential risk factors for isolation of S. maltophilia in this setting., Methods: We conducted a cohort study of ICU patients for whom a bronchoalveolar lavage (BAL) specimen was submitted between October 2013 and October 2014. Cases were patients with S. maltophilia-positive BAL. We calculated the association between isolation of S. maltophilia and patient characteristics using risk ratios (RRs) with 95% confidence intervals (95% CIs) and univariate logistic regression. Chi-squared or Fisher's exact tests were used. BAL specimens were microbiologically typed using pulse-field gel electrophoresis (PFGE)., Findings: Eighteen patients met the case definition. Two patients had clinical presentations that warranted antibiotic treatment for S. maltophilia. All cases were exposed to bronchoscopy. PFGE typing revealed clusters of two strain types. We found statistically significant elevated risks of isolating BRISPOSM-4 in patients exposed to bronchoscope A (RR: 13.56; 95% CI: 1.82-100; P < 0.001) and BRISPOSM-3 in patients exposed to bronchoscope B (RR: 16.89; 95% CI: 2.14-133; P < 0.001). S. maltophilia type BRISPOSM-4 was isolated in water used to flush bronchoscope A after decontamination., Conclusion: Two pseudo-outbreaks occurred in which BAL specimens had been contaminated by reusable bronchoscopes. We cannot exclude the potential for colonization of the lower respiratory tract of exposed patients. Introduction of single-use bronchoscopes was an effective control measure., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Background: For all countries, information on pathogens causing healthcare-associated infections is important in order to develop proper strategies for preventing and treating nosocomial infections., Aim: To assess the change in frequencies and antimicrobial resistance of pathogens causing device-associated infections (DAIs) in intensive care units (ICUs) in South Korea between July 2006 and June 2014., Methods: Data from the Korean Nosocomial Infections Surveillance System (KONIS) were analysed, including three major DAI types in ICUs., Findings: The frequency of Gram-negative bacteria gradually increased for central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP) (from 24.6% to 32.6% and from 52.8% to 73.5%, respectively). By contrast, the frequency of Gram-positive bacteria decreased from 58.6% to 49.2% for CLABSI, and from 44.3% to 23.8% for VAP (P < 0.001). Staphylococcus aureus was the most frequent causative pathogen in CLABSI throughout the surveillance period, but for VAP was replaced as the most frequent pathogen by Acinetobacter baumannii as of 2010. Candida albicans was the most frequent pathogen for catheter-associated urinary tract infection. The meticillin resistance rate in S. aureus decreased from 95% to 90.2% (P < 0.001); amikacin resistance in Klebsiella pneumoniae and Escherichia coli decreased from 43.8% to 14.7% and from 15.0% to 1.8%, respectively (P < 0.001); imipenem resistance in A. baumannii increased from 52.9% to 89.8% (P < 0.001)., Conclusion: The proportion of Gram-negative bacteria as nosocomial pathogens for CLABSI and VAP has increased. The prevalence of A. baumannii causing DAIs in Korean ICUs has increased rapidly, as has the rate of carbapenem resistance in these bacteria., (Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Multidrug-resistant Gram-negative bacilli are responsible for more than 50% of healthcare-associated infections. Colonization dynamics, characteristics, and risk factor data for CR-GNB are scarce in children., Aim: To examine the molecular characteristics of, and risk factors for nosocomial colonization with, carbapenem-resistant Gram-negative bacilli (CR-GNB) in hospitalized paediatric patients in a tertiary university hospital's paediatric units in Turkey., Methods: A prospective case-control study was performed at a university hospital in Istanbul, Turkey., Findings: A total of 1840 rectal swab specimens were collected from all 762 hospitalized children between March 2013 and October 2013. Among them, 176 (23%) patients were colonized with CR-GNB. Of these, 72 (9%) patients were colonized with carbapenem-resistant Enterobacteriaceae, 138 (18%) with CR-non-fermenter Gram-negative bacilli (CR-NF) and 34 (4%) with both. The median CR-GNB colonization time was 10 days (range: 1-116). The median duration of rectal colonization with CR-GNB was 8 days (range: 1-160). NDM (31%) was the second most frequent carbapenemase identified in Acinetobacter baumannii isolates, and has not previously been detected in Turkey. All of the 17 patients colonized with NDM-producing A. baumannii were newborns in the neonatal intensive care unit. Independent risk factors for CR-GNB colonization were: age <1 year, nasogastric tube placement, presence of underlying chronic diseases, ampicillin usage, surgical intervention, and carbapenem use., Conclusion: This is the first description of NDM in A. baumannii in newborn units in Turkey. Carbapenem usage is a common independent risk factor for both CRE and CR-NF colonization, which underscores the importance of antibiotic stewardship programmes., (Copyright © 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Global trade and mobility of people has increased rapidly over the last 20 years. This has had profound consequences for the evolution and the movement of antibiotic resistance genes. There is increasing exposure of populations all around the world to resistant bacteria arising in the emerging economies. Arguably the most important development of the last two decades in the field of antibiotic resistance is the emergence and spread of extended-spectrum β-lactamases (ESBLs) of the CTX-M group. A consequence of the very high rates of ESBL production among Enterobacteriaceae in Asian countries is that there is a substantial use of carbapenem antibiotics, resulting in the emergence of plasmid-mediated resistance to carbapenems. This article reviews the emergence and spread of multidrug-resistant Gram-negative bacteria, focuses on three particular carbapenemases--imipenem carbapenemases, Klebsiella pneumoniae carbapenemase, and New Delhi metallo-β-lactamase--and highlights the importance of control of antibiotic use., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Achromobacter spp. are Gram-negative bacilli from aqueous environments, occasionally involved in bacteraemia in immunocompromised hosts and in outbreaks., Aim: We describe the characteristics of an achromobacter bacteraemia outbreak in a paediatric onco-haematology department., Methods: Throughout a one-year period, 16 blood cultures from seven patients were positive for Achromobacter sp. All patients were immunocompromised, febrile, and central venous catheter (CVC) holders. A microbiological study was performed in patients' rooms, completed with an analysis of the disinfectant atomizers (didecyl diammonium chloride 0.25%, Surfanios, DMA). In total, 41 clinical and environmental strains were analysed by enterobacterial repetitive intergenic consensus (ERIC) polymerase chain reaction (PCR), repetitive PCR, and random amplified polymorphic DNA (RAPD)-PCR, and pulsed-field gel electrophoresis (PFGE). The bactericidal activity of DMA was studied on two Achromobacter sp. representative strains and one Pseudomonas aeruginosa reference strain, comparing biofilm and planktonic growth models., Findings: The seven patients, including two severe cases, were successfully treated by systemic antimicrobial therapy and/or catheter removal. The 25 environmental isolates were recovered with the following chronology: hospital filtered tap water, disinfectant atomizers, and patients' rooms. All environmental, patient, and atomizer strains had identical PCR and PFGE patterns. The disinfectant susceptibility assay revealed that the strain isolated from the atomizers had high survival abilities in biofilm conditions and remained resistant to DMA after short contact periods., Conclusion: The use of disinfectant atomizers associated with the survival of Achromobacter in the atomizer pipes may explain the contamination and colonization of the CVC. Control measures (non-atomizer containers and use of sterile water) allowed the eradication of the source and the outbreak control., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Stenotrophomonas maltophilia causes opportunistic infections and remains a problem pathogen on intensive care unit (ICU) due to its multidrug resistance., Aim: An outbreak of S. maltophilia on ICU is described in order to highlight the risk from contaminated devices for supply of drinking water., Methods: The outbreak was investigated by a combination of epidemiology, environmental sampling and molecular typing., Findings: From 2009 to 2011 isolates of S. maltophilia from 23 patients were found to belong to only two genotypes by contrast with isolates from 52 other patients during this period, which represented distinct strains. The monthly incidence for all S. maltophilia strains ranged from 0 to 11% and for the two outbreak strains from 0 to 9%. Admission and weekly pharyngeal screening on ICU showed that the outbreak strains were acquired on ICU (range: 3-90 days). The majority of isolates (74%) were from the respiratory tract. Only two of 12 (17%) colonized intubated patients developed pneumonia. Environmental sampling found the two outbreak strains in two sinks and in the drinking water of the cooling unit in the ICU kitchen. S. maltophilia had formed a biofilm in the flexible tube from the carbon filter to the chiller and from the latter to the tap at the kitchen sink. This cooled water was used for providing drinking water and mouth care to ICU patients. The outbreak strains disappeared after removal of the water-cooler and the monthly incidence fell to <2% of ICU admissions., Conclusion: This outbreak report highlights the risk from biofilms in devices that supply drinking water for ICU patients., (Copyright © 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

From 2008 to 2010, patients with microbiologically confirmed Gram-negative catheter-related bloodstream infection (GN-CRBSI) were each compared with two randomly selected controls. We included 81 cases (17% of all CRBSI) and 162 controls with CRBSI caused by other pathogens. Incidence of GN-CRBSI was 0.53 episodes per 1000 admissions. Cases were more likely to have underlying neurological disease or gastrointestinal conditions, previous antimicrobial therapy and a shorter time to blood culture positivity. Surgery in the present admission (odds ratio: 3.5), P. aeruginosa (3.6) and a complicated bacteraemia (4.1) were related to a higher mortality rate. GN-CRBSI accounts for 17% of all CRBSI and should be taken into consideration in the empirical therapy of patients with the characteristics mentioned above., (Copyright © 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Postoperative endophthalmitis often progresses to significant visual impairment. This paper describes an outbreak of Ochrobactrum anthropi endophthalmitis following cataract surgery, and propose a new sterilization protocol to minimize the risk of further cases. Medical records of patients with O. anthropi endophthalmitis or with suggestive clinical findings during the outbreak were reviewed. Seven cases of O. anthropi pseudophakic endophthalmitis were confirmed between 24 July and 10 November 2010. The most probable cause of the outbreak of Ochrobactrum anthropi endophthalmitis was contamination of the tubing of the phaco-emulsification machine. Following introduction of a new sterilization protocol, no further cases occurred in over 1000 subsequent procedures., (Copyright © 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Nosocomial infections (NIs) have become a matter of major concern and an important cause of morbidity and mortality in neonatal intensive care units (NICUs)., Aim: The objective of this study was to determine the incidence, anatomical sites and causative organisms of NI in an Egyptian NICU, and to assess the impact of NI on length of stay and mortality., Methods: This was a descriptive hospital-based study carried out for 12 months in the NICU of the Mansoura University Children's Hospital. NI rates were calculated using different denominators (overall nosocomial infection rate, nosocomial infection incidence density, device-specific infection rates and device-days infection rates)., Findings: Of the 238 neonates evaluated, 49 developed 51 nosocomial infective episodes, equating to an incidence rate of 21.4% or 13.8 infections per 1000 bed-days. Pneumonia was the most frequently occurring infection (11.3%) followed by bloodstream infection (8.8%). The most frequently isolated organisms were Klebsiella spp. (33.3%) followed by Escherichia coli (21.6%). NIs were associated with prolonged hospital stay., Conclusion: NI is a significant problem in the Mansoura University Children's Hospital NICU. Gram-negative bacteria, especially Klebsiella spp., were the predominant causes of neonatal NI, as has been described in other studies from developing countries., (Copyright © 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Stenotrophomonas maltophilia is a significant nosocomial pathogen, responsible for an increasing number of infections, particularly in immunocompromised patients., Aim: This study describes the clinical and microbiological characteristics of patients with Stenotrophomonas maltophilia bacteraemia., Methods: We reviewed the charts of 102 patients with Stenotrophomonas maltophilia bacteraemia over a seven-year period from 2001 to 2007 in two tertiary care centres in New York, USA., Findings: There were 79 episodes (77.5%) related to nosocomial acquisition, 21 (20.6%) were healthcare-associated and two episodes (2%) were community-acquired. The most common source of bacteraemia was an infected central catheter in 44 patients (43.1%); 17 (16.6%) were related to neutropenic sepsis; nine (8.8%) were from an abdominal source; six (5.9%) were from a respiratory source, and the source of the bacteraemia was unclear in 26 cases (25.5%). The majority (94.1%) of the patients had central venous access devices. Intensive care unit stay, intubation, septic shock, neutropenia at the time of bacteraemia or carbapenem antibiotic use within 30 days of the episode were associated with mortality according to univariate analysis. By multivariate analysis, hypotensive shock and carbapenem use within 30 days of the episode were factors significantly correlated with mortality. The 102 isolates were mostly susceptible in vitro to trimethoprim-sulfamethoxazole (97.1%), levofloxacin (92.9%), ceftazidime (53.0%) and ticarcillin-clavulanic acid (49.2%)., Conclusion: Our data describe the characteristics of patients with Stenotrophomonas maltophilia bacteraemia and emphasize the importance of careful evaluation of vascular access devices in those patients., (Copyright © 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Extended-spectrum beta-lactamase (ESBL) genes are distributed worldwide and their epidemiology is complex. Using the Check-ESBL assay, the distribution of class A ESBL genes in clinical isolates of aerobic Gram-negative bacilli from three laboratories in the East of The Netherlands was determined. Four patient categories were distinguished: (i) patients admitted to an intensive care unit (ICU); (ii) non-ICU inpatients; (iii) outpatients admitted less than a year before collection of the isolate, (<1); (iv) outpatients admitted more than one-year prior to isolate collection or who had never been hospitalized (>1). From February 2009 until March 2010, out of 491 putative ESBL-positive isolates detected by the Vitek2 or Phoenix automated sensitivity testing systems, ESBL genes were detected in 247 (50.3%) by the Check-ESBL assay. Of these, 116 were from hospitalized patients (35 ICU, 81 non-ICU) and 131 were from outpatients (43 <1, 88 >1). In all, 274 ESBL genes were identified in these 247 isolates: 153 CTX-M-1 group (predominantly in E. coli and K. pneumoniae, 70.4% and 51.6% respectively), 67 CTX-M-9 group (predominantly in E. cloacae, 57.9%), 32 SHV, 14 TEM and 8 CTX-M-2 group. ESBL-producing E. cloacae were significantly more common in hospitalized patients than in outpatients, 20.7% and 3.8% respectively (P=0.001). CTX-M-9 group ESBLs were significantly more prevalent in ICU patients (P=0.003), whereas SHV ESBLs were more common in hospitalized patients than in outpatients (P<0.001). There was no significant difference in distribution of ESBL genes between the two outpatient groups., (Copyright © 2011 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Prosthetic joint infection is a devastating complication of arthroplasty. Previous epidemiological studies have assessed factors associated with arthroplasty infections but have not assessed the impact of comorbidity on infection at different arthroplasty locations. We used a case-control design to investigate risk factors for prosthetic joint infection with reference to the anatomical site. During an eight-year period at a single hospital, 63 patients developed a prosthetic joint infection (36 hips, 27 knees). Cases of prosthetic hip or knee joint infection were matched 1:2 to controls. The results suggest that factors associated with arthroplasty infections differ with anatomical location. Following knee arthroplasty, wound discharge was associated with an increased risk of prosthetic joint infection whereas the presence of a drain tube reduced the risk. By contrast, increased body mass index, increased drain tube loss and superficial incisional surgical site infections (SSIs) were associated with prosthetic hip infection. When analysed as a combined cohort, systemic steroid use, increased SSI drain tube losses, wound discharge, and superficial incisional SSIs were predictors of infection., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Non-fermenting Gram-negative bacilli create a significant problem in clinical settings, being the most widespread cause of nosocomial infections. They are opportunistic pathogens that take advantage of underlying conditions and diseases. Sphingomonas paucimobilis, a non-fermenting Gram-negative bacillus, is regarded as of minor clinical significance; however, many instances of infections with this organism can be found in the literature. Infections include bacteraemia/septicaemia caused by contaminated solutions, e.g. distilled water, haemodialysis fluid and sterile drug solutions. Cases of pseudobacteraemia have been recorded in association with S. paucimobilis, as have many cases of unusual infections both invasive and severe, e.g. septic arthritis and osteomyelitis. No cases of death have been recorded in the literature related to S. paucimobilis. This review illustrates that S. paucimobilis is a more important pathogen than previously thought., (Copyright 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.)