CID MS 67262_supporting information

Supporting information

Methods for Literature Search for nosocomial outbreaks of ESBL-producing Enterobacteriaceae

Medline ( was searched on February 17, 2012, using the terms “ESBL outbreak nosocomial). Excluded were reviews, reports on non- Enterobacteriaceae, reports not describing nosocomial outbreaks.

Results

The initial search found 47 citations within the years 1995 and 2011. Sixteen citations were excluded because they did not meet the criteria. Klebsiella pneumoniae was the responsible ESBL-producers in 20 of 31 (64.5%) reports, followed by Serratia marcescens (4 reports), Escherichia coli (3 reports), and one report each for Citrobacter spp, Enterobacter cloacae, Proteus mirabilis and Salmonella spp. Therefore, Klebsiella pneumoniae was by far the most frequent ESBL producing Enterobacteriaceae linked to nosocomial outbreaks [1-31].

Legend to the figure

Supplemental figure 1.Exposure network graph showing the transmission network of ESBL-producingK. pneumoniae(Kp) andE. coli(Ec) detected among in- and outpatients within the university hospital and households, respectively.

The graph was created using Pajek, Program for Large Network Analysis ( patients and contacts with ESBL-producing isolates are shown in red. Hospital contacts(squares) are connected by red (= transmission) and black (= no transmission) arrows to theirindex patient(red ellipses). Exposure days with and without isolation are shown in parenthesis (nwith/nwithout isolation).

Household contacts (triangles) are connected by red (= transmission) and black (= no transmission) non-directional lines to the index patient, since potential transmission could have gone either way or because ESBL producers could be acquired from a common source.

Isolate number, phylogenetic group and ST (Pasteur (Kp) and Achtman scheme (Ec)) of index patients are shown. Two additional suspected transmissions of ESBL-Kpwere detected retrospectively giving raise to index patients #192 and 194 (dotted red arrows). They occurred <48 hours of exposure between index and contact and were therefore not analyzed as contacts.

Isolates of the index patients of the group B2 being negative andpositive for thepabBgene (indicative for ST131 according to Achtman MLST scheme) are illustrated

Supplemental figure 1

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