Outbreak of<i>Enterobacter cloacae</i>Related to Understaffing, Overcrowding, and Poor Hygiene Practices

Abstract

Several factors caused and aggravated this outbreak: (1) introduction of E. cloacae into the NICU, likely by two previously colonized infants; (2) further transmission by HCWs' hands, facilitated by substantial overcrowding and understaffing in the unit; (3) possible contamination of multidose vials with E. cloacae. Overcrowding and understaffing in periods of increased work load may result in outbreaks of nosocomial infections and should be avoided.