30 Chapter 2 Outbreaks with Plasmid AmpC Within the Netherlands outbreaks with plasmid encoded AmpC producing Enterobacterales have not yet been described. However, transmission can occur within hospitals which has been described in other countries as summarized below. One of the first reports of an outbreak was made by Papanicolaou et al. in 1990 of a blaMIR producing K. pneumoniae in Rhode Island, USA (n=11 patients) (Papanicolaou, Medeiros, and Jacoby 1990). A larger outbreak with a blaACC producing K. pneumoniae was later described in France, where a cluster of 57 patients was detected between 1999 and 2003 (Ohana et al. 2005). Clusters of both blaDHA and blaCMY-2 producing K. pneumoniae were identified at a liver transplant facility in Japan (Matsumura et al. 2015). Interestingly, eight of the blaDHA positive and one of the blaCMY-2 positive isolates showed carbapenem resistance, probably due to a combination of AmpC production and changes in membrane permeability. In 2013, Wendorf et al. reported a small outbreak (n=7) of E. coli carrying a blaCMY-2 variant gene in the United States. It concerned patients who had undergone endoscopic retrograde cholangiopancreatography, which suggested an association with contaminated endoscopes (Wendorf et al. 2015). AmpC and Infection Prevention Guidelines on infection prevention and plasmid AmpC-producing Enterobacterales are scarce. Currently, plasmid encoded AmpC is not yet specified in the WIP guidelines ‘High resistant micro-organisms in hospitals” and “‘High resistant micro-organisms in nursing homes, residential care centres and facilities for small-scale living for the elderly’’ (Werkgroep Infectiepreventie et al. 2018; 2014). However, given the similarity to ESBL-producing Enterobacterales, it is expected that comparable measures will be effective against the spread of AmpC producing Enterobacterales. A revision of this guideline is currently under review by the Partnership for Infection Prevention Guidelines. In the revised version, plasmid AmpC-producing Enterobacterales are not classified as highly resistant microorganisms in routine care settings. However, it is recommended to monitor nosocomial transmission, and in the event of an outbreak of plasmid AmpC-producing Enterobacterales, additional interventions are advised to prevent further spread (Severin, J.A. et al. 2023). Treatment recommendations for AmpC- producing Enterobacterales Treating infections of AmpC producing Enterobacterales can be complicated due to their resistance to many of the first-choice beta-lactam antibiotics. Both penicillins
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