Letter to the Editor
Serratia marcescens bacteraemia outbreak in haemodialysis. Comment on “Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience in 4 hospitals”
Brote de bacteriemia por Serratia marcescens en hemodiálisis. Comentario a «Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros»
Silvia González Sanchidrián
, Jesús Pedro Marín Álvarez, Javier Deira Lorenzo, Pedro Jesús Labrador Gómez, Juan Ramón Gómez-Martino Arroyo
Corresponding author
Servicio de Nefrología, Complejo Hospitalario Universitario de Cáceres, Hospital San Pedro de Alcántara, Cáceres, Spain
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elsevierViewall">Changes over time in potassium laboratory values.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paola Rodríguez, Evangelina Mérida, Eduardo Hernández, Mónica Milla, Manuel Praga" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Paola" "apellidos" => "Rodríguez" ] 1 => array:2 [ "nombre" => "Evangelina" "apellidos" => "Mérida" ] 2 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Hernández" ] 3 => array:2 [ "nombre" => "Mónica" "apellidos" => "Milla" ] 4 => array:2 [ "nombre" => "Manuel" "apellidos" => "Praga" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699517300206" "doi" => "10.1016/j.nefro.2017.01.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => 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"cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Renal lymphomatous infiltration in patient with nefrotic syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "92" "paginaFinal" => "94" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infiltración renal linfomatosa en paciente con síndrome nefrótico" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1084 "Ancho" => 1417 "Tamanyo" => 485371 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histological characteristics of the lymphoid infiltrates that affected both the renal parenchyma (A: H&E, ×10) and the perirenal tissue (B: H&E, ×10). The lymphoid infiltrate had destroyed the parenchyma, leaving isolated residual tubules with images that may suggest lymphoepithelial lesion (C: H&E, ×20). Cells were monomorphic, small in size, with an irregular nuclear outline, barely visible nucleolus and no significant mitotic activity (D: H&E, ×40).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Enoc Merino García, María Pilar Pérez del Barrio, Josefa Borrego Hinojosa, Francisco J. Borrego Utiel, María Carmen Sánchez Perales" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Enoc" "apellidos" => "Merino García" ] 1 => array:2 [ "nombre" => "María Pilar" "apellidos" => "Pérez del Barrio" ] 2 => array:2 [ "nombre" => "Josefa" "apellidos" => "Borrego Hinojosa" ] 3 => array:2 [ "nombre" => "Francisco J." "apellidos" => "Borrego Utiel" ] 4 => array:2 [ "nombre" => "María Carmen" "apellidos" => "Sánchez Perales" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699517300127" "doi" => "10.1016/j.nefro.2016.12.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699517300127?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251417301712?idApp=UINPBA000064" "url" => "/20132514/0000003800000001/v1_201802180616/S2013251417301712/v1_201802180616/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Serratia marcescens bacteraemia outbreak in haemodialysis. Comment on “Serratia marcescens bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience in 4 hospitals”" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "94" "paginaFinal" => "96" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Silvia González Sanchidrián, Jesús Pedro Marín Álvarez, Javier Deira Lorenzo, Pedro Jesús Labrador Gómez, Juan Ramón Gómez-Martino Arroyo" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Silvia" "apellidos" => "González Sanchidrián" "email" => array:1 [ 0 => "silvia_goz@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jesús Pedro" "apellidos" => "Marín Álvarez" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "Deira Lorenzo" ] 3 => array:2 [ "nombre" => "Pedro Jesús" "apellidos" => "Labrador Gómez" ] 4 => array:2 [ "nombre" => "Juan Ramón" "apellidos" => "Gómez-Martino Arroyo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Complejo Hospitalario Universitario de Cáceres, Hospital San Pedro de Alcántara, Cáceres, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote de bacteriemia por Serratia marcescens en hemodiálisis. Comentario a «Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with particular interest the article published recently by Merino et al., entitled “<span class="elsevierStyleItalic">Serratia marcescens</span> bacteraemia outbreak in haemodialysis patients with tunnelled catheters due to colonisation of antiseptic solution. Experience in 4 hospitals”,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> to which we would like to contribute our experience.</p><p id="par0010" class="elsevierStylePara elsevierViewall">As reported in the aforementioned article,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> between December 2014 and January 2015, we recorded several cases of catheter-related bacteraemia (CRB) due to <span class="elsevierStyleItalic">Serratia marcescens</span> (<span class="elsevierStyleItalic">S. marcescens</span>) in our haemodialysis (HD) unit. On 19 December 2014, the Spanish Agency of Medicines and Medical Devices (AEMPS) ordered the withdrawal from the market of BohmClorh<span class="elsevierStyleSup">®</span> chlorhexidine 2% aqueous antiseptic solution for healthy skin as a result of the contamination of several lots with <span class="elsevierStyleItalic">S. marcescens</span>.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Several subsequent warnings were issued extending the restriction of its use to the remaining lots and presentations and, finally, on 9 January 2015, the master formulae developed by the company were withdrawn.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Between 1 December 2014 and 16 January 2015, we recorded 14 cases of blood culture-confirmed CRB due to <span class="elsevierStyleItalic">S. marcescens</span>, 26.9% of the patients in our unit; all had been or were catheter users.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Suspicion of an epidemic outbreak arose after the appearance in the same week of 4 cases of bacteraemia caused by a microorganism that was unusual in the HD unit, in patients on different shifts, with differing dialysis stations and healthcare staff.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The Medical Prevention Service was informed and the corresponding protocol was carried out, reviewing the asepsis measures for catheter handling, and investigating the unit consumables and non-consumables and healthcare staff as possible foci and vectors of transmission.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 9 men and 5 women with mean age 64<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20 years were affected. Twelve patients (85.7%) were catheter users: 11 had a tunnelled catheter while only one had a temporary catheter; the remaining two recently had temporary catheters. A total of 26 episodes were recorded (mean of 1.85 episodes per patient), considering these as the onset of general malaise, hypotension and fever during the dialysis session, with blood cultures positive for <span class="elsevierStyleItalic">S. marcescens</span>. Two patients had up to 4 episodes of bacteraemia, one patient had 3 episodes, 4 patients had 2 episodes, and 7 patients had a single episode before the causal agent was identified. The catheter had to be removed in 5 patients, all of who were found to have infection with the same epidemic agent. Half the patients required hospitalisation for sepsis, with an average stay of 3.3 days. There were no deaths. One patient died due to CRB associated with a different microorganism.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the early cases, patients were empirically administered intravenous vancomycin (1<span class="elsevierStyleHsp" style=""></span>g post-dialysis) and gentamicin (at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/weight post-dialysis) until the blood culture results became available. Ciprofloxacin treatment was then instigated in all patients according to antibiotic susceptibility testing (AST), and the catheter was locked with the same antibiotic solution; one case required carbapenems due to poor clinical progress, and no antibiotic resistance was noted in the AST.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pharyngeal and perianal exudates were systematically collected from all patients in the unit. Only one of the patients was a pharyngeal carrier. In two of the controls, the pharyngeal exudate was positive for <span class="elsevierStyleItalic">S. marcescens</span>, but for a strain other than the original one in the outbreak.</p><p id="par0045" class="elsevierStylePara elsevierViewall">There were cases in other hospital units and other Spanish hospitals.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,5</span></a> Once the outbreak had been notified by AEMPS, the antiseptic product was cultured and confirmed as the reservoir of the epidemic. No further cases were recorded after the contaminated lots had been withdrawn.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Most CRB in HD patients is caused by Gram-positive bacteria.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleItalic">S. marcescens</span> is a gram-negative bacillus found predominantly in humid conditions; it is pathogenic for man and causes outbreaks of resistant infections, especially in immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The general rule in CRB is to remove the catheter, but conservative treatment is accepted in HD patients despite evidence of serious infection, as a measure to preserve the vascular access.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In our experience, AST-directed treatment and catheter locking provided a good outcome, although the delay in identifying the source and probable formation of <span class="elsevierStyleItalic">biofilms</span> meant that a significant number of catheters had to be removed due to the high percentage of recurrences.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although the finding of <span class="elsevierStyleItalic">S. marcescens</span> in HD units is rare, and identification of the reservoir in an antiseptic product is paradoxical, outbreaks have previously been described.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> A methodological search for the causal agent and appropriate preventive strategies should therefore be instigated at an early stage when an epidemic outbreak is suspected. An initiative to record the experience in the HD units of all the affected hospitals would be interesting.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sanchidrián SG, Álvarez JP, Lorenzo JD, Gómez PJ, Arroyo JR. Brote de bacteriemia por Serratia marcescens en hemodiálisis. Comentario a «Brote de bacteriemia por Serratia marcescens en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros». Nefrologia. 2018;38:94–96.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brote de bacteriemia por <span class="elsevierStyleItalic">Serratia marcescens</span> en pacientes portadores de catéteres tunelizados en hemodiálisis secundario a colonización de la solución antiséptica. Experiencia en 4 centros" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.L. Merino" 1 => "H. Bouarich" 2 => "M.J. Pita" 3 => "P. Martínez" 4 => "B. Bueno" 5 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 9 | 15 |
| 2024 October | 50 | 35 | 85 |
| 2024 September | 41 | 23 | 64 |
| 2024 August | 91 | 61 | 152 |
| 2024 July | 59 | 24 | 83 |
| 2024 June | 73 | 28 | 101 |
| 2024 May | 84 | 29 | 113 |
| 2024 April | 87 | 37 | 124 |
| 2024 March | 86 | 21 | 107 |
| 2024 February | 43 | 30 | 73 |
| 2024 January | 27 | 24 | 51 |
| 2023 December | 30 | 29 | 59 |
| 2023 November | 65 | 27 | 92 |
| 2023 October | 90 | 28 | 118 |
| 2023 September | 63 | 31 | 94 |
| 2023 August | 40 | 26 | 66 |
| 2023 July | 39 | 35 | 74 |
| 2023 June | 45 | 22 | 67 |
| 2023 May | 50 | 37 | 87 |
| 2023 April | 39 | 19 | 58 |
| 2023 March | 48 | 20 | 68 |
| 2023 February | 36 | 19 | 55 |
| 2023 January | 50 | 32 | 82 |
| 2022 December | 52 | 41 | 93 |
| 2022 November | 53 | 43 | 96 |
| 2022 October | 55 | 35 | 90 |
| 2022 September | 45 | 36 | 81 |
| 2022 August | 43 | 43 | 86 |
| 2022 July | 47 | 40 | 87 |
| 2022 June | 56 | 50 | 106 |
| 2022 May | 45 | 33 | 78 |
| 2022 April | 31 | 50 | 81 |
| 2022 March | 42 | 56 | 98 |
| 2022 February | 42 | 46 | 88 |
| 2022 January | 33 | 38 | 71 |
| 2021 December | 46 | 47 | 93 |
| 2021 November | 72 | 46 | 118 |
| 2021 October | 62 | 44 | 106 |
| 2021 September | 36 | 34 | 70 |
| 2021 August | 30 | 40 | 70 |
| 2021 July | 30 | 32 | 62 |
| 2021 June | 26 | 30 | 56 |
| 2021 May | 46 | 36 | 82 |
| 2021 April | 121 | 64 | 185 |
| 2021 March | 73 | 39 | 112 |
| 2021 February | 36 | 50 | 86 |
| 2021 January | 42 | 27 | 69 |
| 2020 December | 37 | 29 | 66 |
| 2020 November | 40 | 22 | 62 |
| 2020 October | 29 | 25 | 54 |
| 2020 September | 39 | 30 | 69 |
| 2020 August | 40 | 36 | 76 |
| 2020 July | 39 | 17 | 56 |
| 2020 June | 51 | 25 | 76 |
| 2020 May | 58 | 16 | 74 |
| 2020 April | 58 | 18 | 76 |
| 2020 March | 30 | 9 | 39 |
| 2020 February | 44 | 28 | 72 |
| 2020 January | 60 | 29 | 89 |
| 2019 December | 45 | 30 | 75 |
| 2019 November | 53 | 33 | 86 |
| 2019 October | 50 | 16 | 66 |
| 2019 September | 66 | 15 | 81 |
| 2019 August | 60 | 30 | 90 |
| 2019 July | 64 | 23 | 87 |
| 2019 June | 59 | 31 | 90 |
| 2019 May | 76 | 29 | 105 |
| 2019 April | 94 | 40 | 134 |
| 2019 March | 58 | 22 | 80 |
| 2019 February | 50 | 21 | 71 |
| 2019 January | 26 | 22 | 48 |
| 2018 December | 97 | 44 | 141 |
| 2018 November | 158 | 25 | 183 |
| 2018 October | 101 | 4 | 105 |
| 2018 September | 74 | 23 | 97 |
| 2018 August | 102 | 17 | 119 |
| 2018 July | 67 | 15 | 82 |
| 2018 June | 65 | 16 | 81 |
| 2018 May | 66 | 13 | 79 |
| 2018 April | 48 | 8 | 56 |
| 2018 March | 68 | 14 | 82 |
| 2018 February | 52 | 2 | 54 |
| 2018 January | 39 | 8 | 47 |
| 2017 December | 47 | 6 | 53 |
| 2017 November | 26 | 4 | 30 |
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