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We describe a case of healthcare-associated bloodstream infection due to Mycobacterium fortuitum. Whole-genome sequencing showed that the same strain was isolated from the shared shower water of the unit. Nontuberculous mycobacteria frequently contaminate hospital water networks. Preventative actions are needed to reduce the exposure risk for immunocompromised patients.

Despite the quick implementation of infection prevention and control procedures and the use of personal protective equipment within healthcare facilities, many cases of nosocomial COVID-19 transmission have been reported. We aimed to estimate the frequency and impact of healthcare-associated COVID-19 (HA-COVID-19) and evaluate the contribution of whole-genome sequencing (WGS) in cluster investigation.We estimated the frequency and mortality of HA-COVID-19 infections from September 1 to November 30, 2020, with a focus on the evolution of hospitalized community-associated COVID-19 (CA-COVID-19) cases and cases detected among healthcare workers (HCWs) within the Sorbonne University Hospital Group (Paris, France). We thoroughly examined 12 clusters through epidemiological investigations and WGS.Overall, 209 cases of HA-COVID-19 were reported. Evolution of HA-COVID-19 incidence closely correlated with the incidence of CA-COVID-19 and COVID-19 among HCWs. During the study period, 13.9 % of hospitalized patients with COVID-19 were infected in the hospital and the 30-day mortality rate of HA-COVID-19 was 31.5 %. Nosocomial transmission of SARS-CoV-2 led to clusters involving both patients and HCWs. WGS allowed the exclusion of one-third of cases initially assigned to a cluster.WGS analysis combined with comprehensive epidemiological investigations is essential to understand transmission routes and adapt the IPC response to protect both patients and HCWs.

Summary Background Colonization pressure is a risk factor for intensive care unit (ICU)-acquired multi-drug-resistant organisms (MDROs). Aim To measure the long-term respective impact of colonization pressure on ICU-acquired extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) and meticillin-resistant Staphylococcus aureus (MRSA). Methods All patients admitted to two ICUs (medical and surgical) between January 1997 and December 2015 were included in this retrospective observational study. Rectal and nasal surveillance cultures were obtained at admission and weekly thereafter. Contact precautions were applied for colonized or infected patients. Colonization pressure was defined as the ratio of the number of MDRO-positive patient-days (PDs) of each MDRO to the total number of PDs. Single-level negative binomial regression models were used to evaluate the incidence of weekly MDRO acquisition. Findings Among the 23,423 patients included, 2327 (10.0%) and 1422 (6.1%) were colonized with ESBL-PE and MRSA, respectively, including 660 (2.8%) and 351 (1.5%) acquisitions. ESBL-PE acquisition increased from 0.51/1000 patient-exposed days (PEDs) in 1997 to 6.06/1000 PEDs in 2015 (P Conclusion Colonization pressure contributed to the increasing incidence of ESBL-PE but not MRSA. This study suggests that preventive control measures should be customized to MDROs.

The hospital water environment, including the wastewater drainage system, is increasingly reported as a potential reservoir for carbapenemase-producing Enterobacterales (CPE). We investigated a persistent outbreak of OXA-48 CPE (primarily Citrobacter freundii) in a haematological ward of a French teaching hospital by epidemiological, microbiological and environmental methods. Between January 2016 and June 2019, we detected 37 new OXA-48 CPE-colonised and/or ‑infected patients in the haematological ward. In October 2017, a unit dedicated to CPE-colonised and/or ‑infected patients was created. Eleven additional sporadic acquisitions were identified after this date without any obvious epidemiological link between patients, except in one case. Environmental investigations of the haematological ward (June–August 2018) identified seven of 74 toilets and one of 39 drains positive for OXA-48 CPE (seven C. freundii, one Enterobacter sakazakii, one Escherichia coli). Whole genome comparisons identified a clonal dissemination of OXA-48-producing C. freundii from the hospital environment to patients. In addition to strict routine infection control measures, an intensive cleaning programme was performed (descaling and bleaching) and all toilet bowls and tanks were changed. These additional measures helped to contain the outbreak. This study highlights that toilets can be a possible source of transmission of OXA-48 CPE.

Summary Background Vancomycin-resistant Enterococcus raffinosus has rarely been associated with nosocomial infection and outbreaks. Aim To report the successful control of a nosocomial outbreak of vanA -type vancomycin-resistant E. raffinosus in a surgical intensive care unit. Methods The investigation of the outbreak is reported with control measures taken. Molecular typing of vancomycin-resistant E. raffinosus isolates was performed by repetitive sequence-based polymerase chain reaction (PCR). Findings Between September and October 2014, vancomycin-resistant E. raffinosus isolates were isolated from four patients. The index patient had been hospitalized previously in Portugal, and was not found to be colonized by vancomycin-resistant enterococci on screening cultures obtained at admission. However, vancomycin-resistant E. raffinosus was isolated from a bile sample 19 days after hospital admission. All four isolates were resistant to both vancomycin and teicoplanin due to the presence of the vanA gene, while remaining susceptible to daptomycin and linezolid. Repetitive sequence-based PCR confirmed the spread of a single vanA -positive E. raffinosus clone. Infection control measures including direct PCR screening on rectal specimens, contact precautions, and cohorting of patients and personnel led to successful control of the outbreak. Conclusion This is the first reported outbreak of vanA -type vancomycin-resistant E. raffinosus in France in both clinical and screening specimens among hospitalized patients. The inability of routine selective screening media to detect the vancomycin-resistant E. raffinosus in the index case likely contributed to the outbreak.

Surgical site infection (SSI) is the third most frequent healthcare-associated infection in France. SSI rates in total hip or knee replacement are around 2%. The main bacteria implicated in SSI in clean surgery are those of the skin flora, whence the importance of skin preparation to eliminate transient flora and reduce resident flora. Guidelines for the prevention of SSI have progressed in recent years in France: firstly in 2013, and then in 2016. That preoperative hair removal and scrubbing of clean skin ahead of cutaneous asepsis is non-contributive was confirmed in 2013. A shower with normal soap taken as close to the beginning of surgery as possible is still recommended, as is use of alcoholic antiseptics for cutaneous asepsis. The debate remains open between chlorhexidine and povidone-iodine in several surgical specialties in the absence of any multicenter studies. Future choices of antiseptic may need to take account of resistance, especially to chlorhexidine, and possible side-effects. Finally, antimicrobial skin sealants and adhesive surgical drapes are not recommended for the prevention of infection.

International audience; We report a patient with an unusual initial metabolic presentation of imported human rabies who became symptomatic within 2 weeks of returning from Mali to France. This is the single case of imported human rabies identified in France within the past 11 years and the first report of viral RNA in bronchial secretions. CASE REPORT A 57-year-old male without past medical history presented to an emergency room in March 2014 because of fever and generalized pain. He had been a resident of France for the previous 15 years and had returned 2 weeks earlier following a 6-month stay in Mali. Approximately 1 month before his return to France, he underwent a right foot injury from a tree branch which eventually healed with local care. On admission, he was conscious and cooperative but appeared anxious; he had fever (38.2°C) and abundant sweating and complained of generalized pain, mostly in the lower limbs. A clean, noninflammatory wound scar was noted on the right foot. He had marked tachypnea (rate, 40 inspirations/minute) and periodic deeper inspirations. Chest examination results were unremark-able. Arterial blood gas measurements while the patient was breathing room air were as follows: pH 7.79; partial pressure of carbon dioxide (PaCO 2), 11 mm Hg; PaO 2 , 136 mm Hg; bicar-bonates, 16 mmol/liter; and lactate, 3.7 mmol/liter. The capillary blood glucose was measured at 12 mmol/liter, and a urine dipstick revealed glycosuria (3) and ketonuria (3). Serum creatinine was at 94 mol/liter and sodium at 136 mmol/liter. Thick and thin blood smears were negative for malaria. Chest X-ray results were normal. The patient was transferred to our intensive care unit (ICU) with a presumptive diagnosis of uncontrolled diabetes and unexplained severe respiratory alkalosis. He received intravenous fluids, continuous insulin infusion, and tetanus prevention with vaccination and serotherapy. Hyperventilation, ketonuria, and metabolic abnormalities resolved within 2 days, with normaliza-tion of pH and PaCO 2. Glycated hemoglobin was 6.5%, and the patient required no further insulin administration during his ICU stay. Two days after ICU admission, he developed bouts of hyper-activity, disorientation, and delirium with thoughts of impending death associated with persecution ideas, alternating with periods of drowsiness and returns to normal behavior when he seemed aware of his disorder and criticized it. Hypersalivation was remarkable , and the patient occasionally spat on ICU personnel. Motor weakness, deep tendon reflexes, and limb sensory perceptions were normal. The results of a computed tomography scan and magnetic resonance imaging (MRI) of the brain were unre-markable. Electroencephalogram results showed no epileptic activity. The cerebrospinal fluid (CSF) test result was normal, with a negative PCR test for herpes simplex virus 1 (HSV-1) and HSV-2. Serological tests for human immunodeficiency virus type 1 (HIV-1) and HIV-2 and HIV-1 p24 antigen were negative. Thyroid stimulating hormone and ammonia levels were in the normal range. Syphilis serologic tests, including Venereal Disease Research Laboratory (VDRL) and Treponema Pallidum Hem Agglutination (TPHA) tests, were negative. On day 8 of ICU admission, the patient developed a rapidly extensive flaccid and areflectic tetraparesis without involvement of cranial nerves. His condition deteriorated, with altered consciousness and hypercapnic acidosis, and the patient required mechanical ventilation on day 9. Results of a repeated CSF analysis were normal. Results of a second cerebral and cervical MRI test were normal. Electroneuromyography showed an acute motor ax-onal neuropathy of both upper and lower limbs without sensory impairment. The results of a search for antineuron antibodies were negative, and the urinary porphobilinogen level was normal. The patient received methylprednisolone (1 g/day from day 8 to day 10) and intravenous immunoglobulin (2 g/kg of body weight from day 8 to day 12) for suspected paraneoplastic limbic enceph-alitis or Guillain-Barré syndrome. A search for rabies was performed on a skin biopsy specimen and salivary swabs obtained on day 13. A profound coma with periodic inspiratory spasms persisted , and the patient died on day 19 after ICU admission.

Background. Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization is a well-established riskfactor for subsequent infection and a key event in interindividual transmission. Some studies have showed an asso-ciation between fluoroquinolones and MRSA colonization or infection. The present study was performed to identifyspecific risk factors for MRSA acquisition in long-term care facilities (LTCFs).Methods. A prospective cohort of patients naive for S. aureus colonization was established and followed(January 2008 through October 2010) in 4 French LTCFs. Nasal colonization status and potential risk factorswere assessed weekly for 13 weeks after inclusion. Variables associated with S. aureus acquisition were identifiedin a nested-matched case-case-control study using conditional logistic regression models. Cases were patientswho acquired MRSA (or methicillin-sensitive S. aureus [MSSA]). Patients whose nasal swab samples were alwaysnegative served as controls. Matching criteria were center, date of first nasal swab sample, and exposure time.Results. Among451includedpatients,76MRSAcaseswerematchedto207controlsand112MSSAcasesto208controls. Multivariable analysis retained fluoroquinolones (odds ratio, 2.17; 95% confidence interval, 1.01–4.67),male sex (2.09; 1.10–3.98), and more intensive care at admission (3.24; 1.74–6.04) as significantly associated withMRSA acquisition, and body-washing assistance (2.85; 1.27–6.42) and use of a urination device (1.79; 1.01–3.18)as significantly associated with MSSA acquisition.Conclusions. OurresultssuggestthatfluoroquinolonesareariskfactorforMRSAacquisition.Controlmeasuresto limit MRSA spread in LTCFs should also be based on optimization of fluoroquinolone use.Keywords. methicillin-resistantStaphylococcusaureus;fluoroquinolone;case-case-controlstudy;long-termcarefacility; acquisition.Staphylococcus aureus is a commensal organism colo-nizing several sites in the human body, especially theanteriornares.ThisGram-positivebacteriumisrespon-sible for numerous infections including skin infections,bacteremia or respiratory diseases. Notably, 30%–50%of healthy adults are colonized by S. aureus, and nasalcolonization is known tobe an important risk factor forsubsequentinfection[1,2],withinfectionrateshigherincarriers than noncarriers [3–5]and individuals usually