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other than contaminated hands of medical staff. Nevertheless, environmental sources were continuously screened for CRE even after the outbreak had ended. Surprisingly, after removal of plastic coatings, systematic microbiological exploration of the inner foam padding of positioning pillows (designed for the prone position of patients with acute respiratory distress syndrome, figure), which had last come into contact with KPC-positive patients in the intensive care unit more than 6 months ago, showed a hidden retreat for long-term persistence of KPC-KP since cultures on chromogenic media (CHROMagar KPC) were positive and isolates were identifi ed as KPC-2-KP by molecular methods. By contrast, all regular pillows and mattresses used in the intensive care unit were tested negative, although in many publications contamination of mattresses with diff erent pathogens have been described.7 The negative results are possibly explainable by the regular steam sterilisation of mattresses done in our hospital.

Our fi ndings show that the search for environmental sources of outbreak strains has to be all-embracing.6 When tackling outbreaks of multidrug-resistant organisms such as KPC-KP clinicians have to take into account that a new generation of Gram-negative bacteria is perfectly adapted to hospital and intensive care unit settings because of their tremendous environmental resistance.8

NL and CL contributed equally. We declare that we have no competing interests. We thank Sylvia Köppen (Leipzig University Hospital, Germany) for her mindful clinical observance and Reinier Mutters (Marburg University Hospital, Germany) for his valuable support.

Norman Lippmann, *Christoph Lübbert, Thorsten Kaiser, Udo X Kaisers, Arne C Rodloff christoph.luebbert@medizin.uni-leipzig.de

Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Leipzig, Germany (NL, ACR); Hospital Hygiene Staff

with underlying colorectal neoplasia; patients with S gallolyticus subspecies gallolyticus (biotype I) had a higher risk of colorectal neoplasia than did patients infected by other S bovis subspecies.

We read with interest the Personal View by Annemarie Boleij and Harold Tjalsma (August, p 719),2 in which they affirm that a major drawback of most studies is the lack of discrimination between S bovis biotype II subspecies. S gallolyticus gallolyticus bacteraemia is an indication to search for colorectal neoplasia,3 but more detailed analysis of the other subspecies is needed to rule out or confi rm their association with colorectal neoplasia.

F a c k l a n 4 s u g g e s t e d t h a t S gallol yticus gallol yticus and S gallolyticus subspecies pasteurianus (formerly known as S bovis biotype II/2) are isolated from haemocultures of patients with colorectal neoplasia more often than is S infantarius (biotype II/1). We have noted significant differences between S gallolyticus gallolyticus and S infantarius in their association with colorectal neoplasia, both in the percentage (63·3% vs 10·3%, p<0·001) and with the stage of the illness.5 However, few studies have compared the frequency of colorectal neoplasia in patients with bacteraemia caused by S gallolyticus pasteurianus and S gallolyticus gallolyticus; in a recent report,6 no diff erences were noted.

We prospectively followed up all episodes of bacteraemia caused by S bovis group bacteria during 1988–2012. The isolates were identified as previously described.3 We recorded 119 cases of S gallolyticus gallolyticus and 29 cases of S gallolyticus pasteurianus. Colonoscopy was done in 108 patients with S gallolyticus gallolyticus bacteraemia (mean age 66 years, 89% male) and 22 patients with S gallolyticus pasteurianus bacteraemia (mean age 70 years, 55% male). Colorectal neoplasia was

Colorectal neoplasia associated with Streptococcus gallolyticus subspecies pasteurianus

The association of colorectal neoplasia with bacteraemia caused by Streptococcus bovis is well known. Findings from a systematic review1 showed that 69% of patients infected with S bovis had concomitant colorectal neoplasia, but there were diff erences among the S bovis subspecies and their association

Unit, Leipzig University Hospital, Leipzig, Germany (NL, ACR); Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr 20, D-04103 Leipzig, Germany (CL); Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, Leipzig University Hospital, Leipzig, Germany (TK); and Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany (UXK)

1 Munoz-Price LS, Poirel L, Bonomo RA, et al. Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases. Lancet Infect Dis 2013; 13: 785–96.

2 Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneumoniae carbapenemase-producing bacteria. Lancet Infect Dis 2009; 9: 228–36.

3 Lübbert C, Faucheux S, Becker-Rux D, et al. Rapid emergence of secondary resistance to gentamicin and colistin following selective digestive decontamination in patients with KPC-2-producing Klebsiella pneumoniae: a single-centre experience. Int J Antimicrob Agents 2013; 42: 565–70.

4 Lübbert C, Lippmann N, Busch T, et al. Long-term carriage of Klebsiella pneumoniae carbapenemase-2-producing K. pneumoniae after a large single-center outbreak in Germany. Am J Infect Control 2014; 42: 376–80.

5 US Centers for Disease Control and Prevention. 2012 CRE toolkit—guidance for control of carbapenem-resistant enterobacteriaceae. http://www.cdc.gov/hai/organisms/cre/cre-toolkit/ (accessed March 7, 2014).

6 Lerner A, Adler A, Abu-Hanna J, Meitus I, Navon-Venezia S, Carmeli Y. Environmental Contamination by Carbapenem-Resistant Enterobacteriaceae. J Clin Microbiol 2013; 51: 177–81.

7 Creamer E, Humphreys H. The contribution of beds to healthcare-associated infection: the importance of adequate decontamination. J Hosp Infect 2008; 69: 8–23.

8 Sandora TJ, Goldmann DA. Preventing lethal hospital outbreaks of antibiotic-resistant bacteria. N Engl J Med 2012; 367: 2168–70.

Correspondence

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detected in 77 patients (71%) with S gallolyticus gallolyticus bacteraemia and five patients (23%) with S gallolyticus pasteurianus bacteraemia (p=0·001). Rates of non-advanced adenoma, advanced adenoma, and carcinoma were increased in the S gallolyticus gallolyticus group (19% vs 9%; 40% vs 14% [p<0·02]; and 12% vs 0%, respectively). The rates of colorectal neoplasia in patients with S gallolyticus pasteurianus bacteraemia were similar to those reported in studies of screening for colorectal neoplasia in the general population. Our data suggest that colonoscopy should not be done in all patients with S gallolyticus pasteurianus bacteraemia. However, further studies with more patients are needed to support our fi ndings.

We declare that we have no competing interests.

*Juan Corredoira Sánchez, Fernando García-Garrote, Amparo Coira, Hugo López-Agreda, María Pilar Alonso-Garcíajuan.corredoira.sanchez@sergas.es

Infectious Disease Unit, Hospital Lucus Augusti, Lugo, Spain (JCS); Department of Clinical Microbiology, Hospital Lucus Augusti, Lugo, Spain (FG-G, AC, MPA-G); and Department of Internal Medicine, Hospital Lucus Augusti, Lugo, Spain (HL-A)

1 Boleij A, van Gelder MM, Swinkels DW, Tjalsma H. Clinical impotance of Streptococcus gallolyticus infection among colorectal cancer patients: systematic review and meta-analysis. Clin Infect Dis 2011; 53: 70–78.

2 Boleij A, Tjalsma H. The itinerary of Streptococcus bovis infection in patients with colonic malignant disease. Lancet Infect Dis 2013; 13: 719–23.

3 Corredoira J, García-Garrote F, Rabuñal R, et al. Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (S. bovis I) and colorectal neoplasia: a case-control study. Clin Infect Dis 2012; 55: 491–96.

4 Facklan R. What happened to the streptococci: overview of taxonomic changes in the streptococci. Clin Microbial Rev 2002; 15: 613–30.

5 Corredoira J, Coira A, Iñiguez I, Pita J, Varela J, Alonso MP. Advanced bowel cancer associated with Streptococcus infantarius (former S. bovis II / 1) sepsis. Int J Clin Pract 2013; 67: 1358–59.

6 Romero B, Morosini M, Loza E, et al. Reidentifi cation of Streptococcus bovis isolates causing bacteremia according to the new taxonomy criteria: still an issue? J Clin Microbiol 2011; 49: 3228–33.