Background: Enterobacter cloacae species is responsible for nosocomial outbreaks in vulnerable patients in\nneonatal intensive care units (NICU). The environment can constitute the reservoir and source of infection in NICUs.\nHerein we report the impact of preventive measures implemented after an Enterobacter cloacae outbreak inside a\nNICU.\nMethods: This retrospective study was conducted in one level 3 NICU in Lyon, France, over a 6 year-period (2012â??\n2018). After an outbreak of Enterobacter cloacae infections in hospitalized neonates in 2013, several measures were\nimplemented including intensive biocleaning and education of medical staff. Clinical and microbiological\ncharacteristics of infected patients and evolution of colonization/infection with Enterobacter spp. in this NICU were\nretrieved. Moreover, whole genome sequencing was performed on 6 outbreak strains.\nResults: Enterobacter spp. was isolated in 469 patients and 30 patients developed an infection including 2\nmeningitis and 12 fatal cases. Preventive measures and education of medical staff were not associated with a\nsignificant decrease in patient colonisation but led to a persistent decreased use of cephalosporin in the NICU.\nInfection strains were genetically diverse, supporting the hypothesis of multiple hygiene defects rather than the\ndiffusion of a single clone.\nConclusions: Grouped cases of infections inside one setting are not necessarily related to a single-clone outbreak\nand could reveal other environmental and organisational problematics. The fight against implementation and\ntransmission of Enterobacter spp. in NICUs remains a major challenge.
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