Correspondence

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 KPCpositive patients in the intensive care unit more than 6 months ago, showed a hidden retreat for longterm persistence of KPC-KP since cultures on chromogenic media (CHROMagar KPC) were positive and isolates were identified 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 different pathogens have been described.7 The negative results are possibly explainable by the regular steam sterilisation of mattresses done in our hospital. Our findings show that the search for environmental sources of outbreak strains has to be all-embracing.6 When tackling outbreaks of multidrugresistant organisms such as KPC-KP clinicians have to take into account that a new generation of Gramnegative 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 [email protected] Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Leipzig, Germany (NL, ACR); Hospital Hygiene Staff

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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

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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. Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneumoniae carbapenemase-producing bacteria. Lancet Infect Dis 2009; 9: 228–36. 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 singlecentre experience. Int J Antimicrob Agents 2013; 42: 565–70. Lübbert C, Lippmann N, Busch T, et al. Longterm 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. US Centers for Disease Control and Prevention. 2012 CRE toolkit—guidance for control of carbapenem-resistant enterobacteriaceae. http://www.cdc.gov/hai/organisms/cre/cretoolkit/ (accessed March 7, 2014). 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. Creamer E, Humphreys H. The contribution of beds to healthcare-associated infection: the importance of adequate decontamination. J Hosp Infect 2008; 69: 8–23. Sandora TJ, Goldmann DA. Preventing lethal hospital outbreaks of antibiotic-resistant bacteria. N Engl J Med 2012; 367: 2168–70.

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 differences among the S bovis subspecies and their association

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 confirm their association with colorectal neoplasia. Facklan4 suggested that S gallolyticus gallolyticus 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