Wastewater drainage system as an occult reservoir in a protracted clonal outbreak due to metallo-β-lactamase-producing Klebsiella oxytoca S. Vergara-López,

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Wastewater drainage system as an occult reservoir in a protracted clonal outbreak due to metallo-β-lactamase-producing Klebsiella oxytoca S. Vergara-López, M.C. Domínguez, M.C. Conejo, Á. Pascual, J. Rodríguez-Baño Clinical Microbiology and Infection Volume 19, Issue 11, Pages E490-E498 (November 2013) DOI: 10.1111/1469-0691.12288 Copyright © 2013 European Society of Clinical Infectious Diseases Terms and Conditions

FIG. 1 Plan of the ICU. Grey square: sink. Grey circle: wastepipe. Discontinous line: drainpipe. S: sink. W: wastepipe. Clinical Microbiology and Infection 2013 19, E490-E498DOI: (10.1111/1469-0691.12288) Copyright © 2013 European Society of Clinical Infectious Diseases Terms and Conditions

FIG. 2 Synoptic curve of patients colonized and/or infected due to multidrug-resistant Klebsiella oxytoca and control measures. ES (in red): environmental study. SS (in green): staff study. PCLIP (in blue): Prevention and Control of Legionella Infection Protocol. Discontinuous purple arrow: basic cross-transmission control measures. Continuous orange arrow: additional cross-transmission control measures. Circle with cross: admission date of patient. Open circle: discharge date of case. Black circle: date of death of case patient. Grey square: date of first isolation of MDRKO. Discontinous line: ICU stay. Black square: positive environmental culture. White square: negative environmental culture. Clinical Microbiology and Infection 2013 19, E490-E498DOI: (10.1111/1469-0691.12288) Copyright © 2013 European Society of Clinical Infectious Diseases Terms and Conditions

FIG. 3 Consumption of antimicrobial before, during and after the outbreak in the intensive care unit, Hospital La Merced, Osuna, Seville, Spain. DDD: defined daily dose. *p <0.05. Aminoglycosides: amikacin, tobramycin and gentamycin. Carbapenems: imipenem. Fluoroquinolones: ciprofloxacin andlevofloxacin. Third-generation cephalosporins: ceftriaxone, cefotaxime and ceftazidime. Fourth-generation cephalosporins: cefepime. Glycopeptides: vancomycin. Clinical Microbiology and Infection 2013 19, E490-E498DOI: (10.1111/1469-0691.12288) Copyright © 2013 European Society of Clinical Infectious Diseases Terms and Conditions