Efficacy of a coordinated strategy for containment of multidrug-resistant Gram-negative bacteria carriage in a Neonatal Intensive Care Unit in the context of an active surveillance program

Abstract

Background Antimicrobial resistance in neonatal intensive care unit (NICU) patients is a threat, due to the frequent use of antimicrobial treatment and invasive devices in fragile babies. Since 2014 an active surveillance program of multidrug-resistant Gram-negative bacteria (MDR-GNB) carriage has been in place in the five NICUs of Palermo, Italy. In 2017 an increase in the prevalence of MDR-GNB, and in particular of extended-spectrum β-lactamases-producing Klebsiella pneumoniae (ESBL-KP), was observed in “Civico” hospital NICU. Aim To assess the impact of a coordinated intervention strategy in achieving long-lasting reduction of MDR-GNB prevalence in the NICU. Methods Rectal swabs were obtained monthly and processed to detect MDR-GNB using standard methods. MDR-GNB were characterized by pulsed-field gel electrophoresis (PFGE). Since November 2017 the following intervention measures were applied: (a) two-months intensification of sample collection; (b) stakeholders meetings; (c) improvement of prevention measures and antimicrobial policies. Findings During the intensified microbiological surveillance MDR-GNB and ESBL-KP were detected in rectal swabs (34.8%; 23.2%), nasal swabs (24.6%; 14.5%), oral swabs (14.5%; 5.4%), milk samples (32.1%; 17.9%), pacifiers swabs (30.8%; 17.9%) and from sub-intensive room surfaces. Thirteen ESBL-KP strains isolated from clinical and environmental samples showed identical PFGE patterns. The prevalence of MDR-GNB and ESBL-KP carriage significantly decreased in the year after intervention compared to the previous year (20.6% vs 62.2%; p < 0.001 and 11.1% vs 57.8%; p < 0.001). MDR-GNB were not detected at all for three months and ESBL-KP for five months. Multivariate analysis of the principal exposure variables showed that admission in the post-intervention period significantly reduced the risk of MDR-GNB carriage (adj-OR = 0.21, 95% CI = 0.076–0.629; p < 0.001). Conclusions MDR-GNB broadly circulate in NICU setting, they can colonize different body sites and spread through various vehicles. A coordinated strategy of multiple interventions with active cooperation between epidemiologists and clinicians in the NICU can effectively reduce their circulation and in particular the carriage of the most dangerous ESBL-KP strains.

Carbapenemase-Producing Enterobacteriaceae (CPE) Newborn Colonization in a Portuguese Neonatal Intensive Care Unit (NICU): Epidemiology and Infection Prevention and Control Measures

“…The systematic approach used in our NICU enabled a prompt recognition of colonized patients and the introduction of effective infection control measures. We believe that in our sample, the continuous surveillance and cohorting of CPE-colonized neonates prevented further cross-transmission and progression to infection as described previously [1,7]. Moreover, the decreasing number of cross-colonized patients during this study probably reflects the healthcare workers' infection control measures compliance [4].…”

“…Efforts to identify risk factors and colonization sources are crucial. We emphasize the importance of routine screenings of mothers and babies, especially those with prolonged hospital stays, and NICU staff and surfaces, such as incubators, counters, sinks, medical devices, floor, and walls [4,7]. In our NICU, parents have an active role in newborns' care alongside the staff.…”

“…Carbapenemase-producing Enterobacterales are an emerging group of pathogens in neonatal units; however, only a few studies have addressed this public health issue thus far [7,8]. CPE colonization risk factors, epidemiology, management, and outcomes have not yet been accurately described for this vulnerable population [1].…”

“…Newborns in a neonatal intensive care unit (NICU) are especially vulnerable to colonization and infection by several pathogens, including multidrug-resistant (MDR) Gram-negative bacteria. These severe infections entail significant morbidity and mortality in an NICU [3][4][5][6][7].…”

“…NICU outbreaks may have serious neonatal implications, and thus maintaining a high level of suspicion is crucial for prompt identification and outbreak control [7,12]. An outbreak in an NICU should be suspected when there are at least two newborns colonized with the same species, a single case of a rare Gram-negative bacteria identification, or a single systemic infection with an extended-spectrum β-lactamase producing or carbapenem-resistant Gram-negative bacteria [11,13].…”