Managing and preventing outbreaks of Gram-negative infections in UK neonatal units (original) (raw)
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Management of outbreaks in neonatal intensive care units
Early Human Development, 2014
Outbreaks in neonatal intensive care units (NICUs) have disastrous consequences for neonates and raise enormous concerns in staff, altering usual practice patterns of the NICU. Our objective was to perform a systematic analysis for gaining insights into the control and prevention of NICUs outbreaks. Epidemiology, risk factors and outcomes are reviewed.
Outbreaks in neonatal intensive care units—They are not like others
American Journal of Infection Control, 2007
Background: Outbreaks of health care-associated infections in neonatal intensive care units (NICUs) are frequent and have received more attention in medical literature than outbreaks from other types of intensive care units (ICUs). The objective of this systematic review was to identify differences between outbreaks of health care-associated infections in NICUs and other ICUs as reported to date in the medical literature. Methods: Screening the outbreak database (http://www.outbreak-database.com), a systematic comparison of outbreaks was performed with the following categories: causing pathogen, type of infection, sources identified, and measures taken to stop the outbreak. Results: Two hundred and seventy-six outbreaks were reported from NICUs and 453 from other ICU types. Enterobacteriaceae were significantly more often responsible for NICU outbreaks, whereas nonfermenting bacteria are more frequently identified in other ICU types. On average, 23.9 patients and 1.8 health care workers were involved in NICU outbreaks. Average mortality in NICU outbreak was 6.4% (1.5 newborns on average). In 48.6% of NICU outbreaks the authors were unable to identify the sources compared with 38.0% in other ICU outbreaks. The most important infection control measures were significantly more often implemented in NICUs than in other ICUs. Conclusions: Systematic outbreak analysis is essential for gaining insights into the control of NICU outbreaks.
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).
Journal of Infection Prevention, 2012
Peer reviewed article nfection prevention is a cornerstone of good neonatal care. There are, however, few research data to support infection control approaches in this population. Through a structured telephone interview we surveyed all neonatal units in the United Kingdom to identify infection control issues, practices and policies. Eighty seven percent of the 198 neonatal units participated. Twenty one units (12.2%) had closed with infection control issues in the last year; 14.1% had current infection control concerns; 81.5% of units decolonised MRSA positive infants, but over 15 regimens were used. Wide variations in hygiene measures were identified; 22.1% of units used theatre scrubs for all staff, 7.6% used aprons and 5.8% required gloves to be worn when entering clinical areas. Only 54% required hand washing and alcohol gel before entry to a patient care area; 11.6% required only the use of alcohol gel.
Nosocomial Bacteremia in Neonates Related to Poor Standards of Care
Pediatric Infectious Disease Journal, 2005
Background: In developing countries, intravenous liquids are mixed and administered by nurses, sometimes under suboptimal infection control conditions. We hypothesized that outbreaks of infusate-associated neonatal bacteremias are common, and we evaluated whether they can be detected by vigilant microbiologic surveillance of infusates. Methods: We studied intravenous infusates administered to neonates in a Mexican hospital where mixtures of infusates were prepared in hospital wards. The study was performed in 3 stages: stage 1, initial culturing of in-use infusates under basal conditions; stage 2, prospective culturing during a cluster of clinical sepsis; and stage 3, final culturing once the outbreak was controlled. Results: In stage 1, 68 infusates were sterile, and 1 was contaminated with Staphylococcus aureus (1.45%), from 23 patients. In stage 2, of 182 infusates from 39 patients, 51 infusates (28%) were contaminated with Gram-negative rods. On the first day of stage 2, 11 of 15 infusates were contaminated with the same strain of Klebsiella pneumoniae, which continued to appear for 26 days. Another 4 strains of Gram-negative rods were also isolated during stage 2. The association between contaminated infusate and death was significant (odds ratio, 9.4; 95% confidence interval, 2-44.3; P Ͻ 0.001). Mixtures made by nurses were more likely contaminated than commercial preparations (odds ratio, 3.1; 95% confidence interval, 1.1-8.5; P ϭ 0.037). In stage 3, there were 42 sterile infusates from 22 patients. Conclusions: Our study suggests that poor standards of care common in hospitals from developing countries sometimes result in outbreaks of sepsis and death for newborn patients.
Hospital-acquired neonatal infections in developing countries
Lancet, 2005
Hospital-born babies in developing countries are at increased risk of neonatal infections because of poor intrapartum and postnatal infection-control practices. We reviewed data from developing countries on rates of neonatal infections among hospital-born babies, range of pathogens, antimicrobial resistance, and infection-control interventions. Reported rates of neonatal infections were 3-20 times higher than those reported for hospital-born babies in industrialised countries. Klebsiella pneumoniae, other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp), and Staphylococcus aureus were the major pathogens among 11 471 bloodstream isolates reported. These infections can often present soon after birth. About 70% would not be covered by an empiric regimen of ampicillin and gentamicin, and many might be untreatable in resource-constrained environments. The associated morbidity, mortality, costs, and adverse effect on future health-seeking behaviour by communities pose barriers to improvement of neonatal outcomes in developing countries. Low-cost, "bundled" interventions using systems quality improvement approaches for improved infection control are possible, but should be supported by evidence in developing country settings.
A 10-year prospective surveillance of nosocomial infections in neonatal intensive care units
American Journal of Infection Control, 2007
Background: We report on nosocomial infections (NIs), causative organisms, and antimicrobial susceptibility patterns in neonates who were admitted to neonatal intensive care units (NICUs), and assess the performance of birth weight (BW) as a variable for riskstratified NI rate reporting. Methods: A prospective, 10-year follow-up, open cohort study that involved six Brazilian NICUs was conducted. The NI incidence rates were calculated using different denominators. Results: Six thousand two hundred forty-three newborns and 450 NICU-months of data were available for analysis. This included 3603 NIs that occurred in 2286 newborns over 121,008 patient-days. The most frequent NIs were primary bloodstream infection (pBSI; 45.9%), conjunctivitis (12.1%), skin infections (9.6%), and pneumonia (6.8%). Only the pBSI (but not pneumonia or central venous catheter-related pBSI) rate distribution differed significantly with varying BW. Gram-negative rods (mainly Klebsiella sp. and Escherichia coli) were responsible for 51.6% episodes of pBSI. Gram-positive organisms (mainly coagulase-positive staphylococci) accounted for 37.4%. Candida sp. was the fourth isolated organism. A high resistance to third-generation cephalosporins was recorded in K pneumoniae and E coli isolates. Conclusions: This report highlights the burden of NI, and identifies the major focus for future NI control and prevention programs. Except for pBSI, BW had a poor performance as a variable for risk-stratified NI rate reporting. (Am J Infect Control 2007;35:183-9.) From the Health Sciences Postgraduate Course,
Late Onset Gram Negative Infection in Inborn Neonates - Experience of A Tertiary Care Centre
IOSR Journals , 2019
Aim & Objective: To study the incidence, mortality and risk factors of late onset neonatal sepsis caused by gram negative bacteria (late onset gram negative sepsis or LOGNS) in inborn babies. Design and setting: Retrospective case control study at NICU of NMCH Patna from November 2017 to April 2019 (1.5 years). Participants: Inborn infants with evidence of invasive infection caused by Gram negative bacteria presenting at 72 hours or more of life .Controls were infants with no evidence of invasive infection by gram negative organism at 72 hours of age and beyond, matched for gestational age and time of presentation at our NICU. Main outcomes measured: incidence, risk factors and mortality data. Results: 67 neonates with LOGNS were identified of which 44 were inborn and included in our study. The majority of infants with LOGNS were VLBW. The incidence of LOGNS was 4.8 per 100 NICU admissions at our hospital. Klebsiella spp was the commonest organism followed closely by E. coli and Pseudomonas spp. There was no significant difference between cases and controls regarding maternal risk factors, gestational age or birth weight.There was a significant association in univariate analysis between the occurrence of LOGNS and mechanical ventilation as well as its duration, parenteral nutrition for >7 days, delayed commencement of enteral feeds (mean delay of > 7 days), presence of a central venous catheter and occurrence of NEC. However, in multivariate analysis, only the duration of Mechanical ventilation remained significantly associated with LOGNS.
Pediatric Infectious Disease Journal, 2019
Background: Late-onset sepsis (LOS) is still an important cause of morbidity and mortality in premature infants. Indwelling devices and lower birth weight (BW) are the most important risk factors. Quality improvement programmes are implemented to reduce incidence of LOS. An increasing number of extremely low BW infants (ELBWs) (≤1000 g) are treated in the Netherlands, including infants with gestational age (GA) 24 weeks since Dutch law changed in 2010. We evaluated the incidence and causative microorganisms of LOS in ELBWs over an 8-year period in 2 Dutch neonatal intensive care units (NICUs). Methods: The first LOS episodes of all ELBWs admitted to the NICU of the Wilhelmina Children's Hospital Utrecht and the Isala Hospital Zwolle were included retrospectively from January 2008 to December 2015. LOS was defined as clinical signs of sepsis >72 hours postpartum, combined with a positive blood culture and C-reactive protein of ≥10 mg/L. Results: Two hundred fifty-five out of 923 ELBWs (27.6%) had an episode of LOS, and no decrease in incidence was seen over the years. ELBWs with LOS had lower GA and BW. The percentage of Gram-negative organisms increased from 0% in 2008 to 27% in 2015, mainly in infants with GA <26 weeks. The number of invasive fungal infections decreased to zero. Conclusions: No significant decrease in incidence of LOS in ELBWs was seen, despite the introduction of quality improvement programmes and attention to antibiotic stewardship. Furthermore, an increase in Gram-negative LOS was observed, with an overrepresentation among the growing proportion of the NICU population at the lowest GA and weight. Prevention, including high compliance to hand hygiene policies, may be an impactful intervention.