Epidemic gram-negative bacteremia in a neonatal intensive care unit in Guatemala

Burkholderia cepacia-contaminated dentures possibly cause pneumonia

We report a case in which a patient was suspected of developing pneumonia due to wearing dentures that were immersed in a storage solution contaminated with 3.0 × 10⁸ colony-forming units (cfu)/mL of Burkholderia cepacia. It is highly possible that the contaminated denture solution entered the trachea and caused the pneumonia, possibly due to the prolonged supine positioning of the patient. We demonstrated that B. cepacia isolated from the sputum and B. cepacia isolated from the denture storage solution had the same DNA fingerprint, and that the patient recovered from pneumonia after stopping the use of dentures. These findings suggest the storage solution as the main source of infection.

Antimicrobial Resistance Trends at a Pediatric Hospital in Guatemala City, 2005-2019

Antimicrobial resistance (AMR) is increasing worldwide. We analyzed AMR rates for bacterial species identified from pediatric blood cultures between 2005 and 2019 at a single institution in Guatemala. We found significantly increased rates in Gram-negative resistance, with a high prevalence of carbapenem-resistant Acinetobacter and Klebsiella harboring the New Delhi metallo-beta-lactamase gene.

A Nosocomial Outbreak of Clinical Sepsis in a Neonatal Care Unit (NCU) in Port-Au-Prince Haiti, July 2014 - September 2015

Introduction

Between July 2014 and September 2015, a neonatal care unit (NCU) in Port Au Prince, Haiti, experienced an outbreak of sepsis, most probably due to nosocomial transmission of Extended Beta Lactamase (ESBL) producing gram negative bacteria, included Klebsiella pneumoniae.

Methods

We describe the epidemiological and microbiological activities performed as part of the outbreak investigation and the control measures implemented throughout this period.

Results

During the study period 257 cases of sepsis were reported, of which 191 died. The case fatality decreased from 100% in July 2014 to 24% in September 2015 and could be attributed to an improvement in clinical management and strengthened infection prevention and control measures. Risk factors identified to be associated with having late onset sepsis (sepsis onset >48 hours after birth)(n=205/257, 79. included: all categories of birthweight lower than <2500g (p=<0.0001) and all categories of gestational age younger than 36 weeks (p=0.0002). Microbiological investigations confirmed that out of 32 isolates (N=55; 58%) that were positive for gram negative bacteria, 27 (89%) were due to K. pneumoniae and most of these were from single MLST type (ST37).

Discussion 

This outbreak highlighted the importance of epidemiological and microbiological surveillance during an outbreak of sepsis in a NCU in a low resource setting, including regular point prevalence surveys.

Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications

Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.

Aetiology, source and prevention of waterborne healthcare-associated infections: a review

The purpose of this review is to discuss the scientific literature on waterborne healthcare-associated infections (HCAIs) published from 1990 to 2012. The review focuses on aquatic bacteria and describes both outbreaks and single cases in relation to patient characteristics, the settings and contaminated sources. An overview of diagnostic methods and environmental investigations is summarized in order to provide guidance for future case investigations. Lastly, on the basis of the prevention and control measures adopted, information and recommendations are given. A total of 125 reports were included, 41 describing hospitalized children. All cases were sustained by opportunistic pathogens, mainly Legionellaceae, Pseudomonadaceae and Burkholderiaceae. Hot-water distribution systems were the primary source of legionnaires’ disease, bottled water was mainly colonized by Pseudomonaceae, and Burkholderiaceae were the leading cause of distilled and sterile water contamination. The intensive care unit was the most frequently involved setting, but patient characteristics were the main risk factor, independent of the ward. As it is difficult to avoid water contamination by microbes and disinfection treatments may be insufficient to control the risk of infection, a proactive preventive plan should be put in place. Nursing staff should pay special attention to children and immunosuppressed patients in terms of tap-water exposure and also their personal hygiene, and should regularly use sterile water for rinsing/cleaning devices.

Antimicrobial activity of copper against organisms in aqueous solution: a case for copper-based water pipelines in hospitals?

BACKGROUND

An association exists between water of poor quality and health care-associated infections. Copper shows microbiocidal action on dry surfaces; it is necessary to evaluate its antimicrobial effect against organisms in aqueous solution.

OBJECTIVE

The objective was to determine the in vitro antimicrobial activity of copper against common nosocomial pathogens in aqueous solution.

METHODS

Copper and polyvinyl chloride containers were used. Glass was used as control material. Fourteen organisms isolated from hospital-acquired infections, and 3 control strains were tested. Inocula were prepared by direct suspension of colonies in saline solution and water in each container tested. Bacterial counts in colony-forming units (CFU)/mL were determined at the beginning of the experiment; at 30 minutes; and at 1, 2, 24, and 48 hours.

RESULTS

Organisms in glass and polyvinyl chloride remained viable until the end of the experiment. Organisms in copper showed a reduction from more than 100,000 CFU/mL to 0 CFU/mL within the first 2 hours of contact (F > 4.29, P < .001).

CONCLUSION

Copper containers show microbiocidal action on organisms in aqueous solution. Copper may contribute to the quality of water for human use, particularly in hospitals.

An outbreak of Klebsiella pneumoniae late-onset sepsis in a neonatal intensive care unit in Guatemala

BACKGROUND

Gram-negative bloodstream infections are an important cause of neonatal mortality. In October 2009, we investigated a Klebsiella spp outbreak in a neonatal intensive care unit in Guatemala.

METHODS

Probable cases were defined as a Klebsiella spp isolated from blood in neonates aged <28 days in the neonatal intensive care unit between October 1 and November 10, 2009; confirmed cases were identified as Klebsiella pneumoniae. Clinical data were abstracted from medical charts. K pneumoniae isolates were genotyped by pulsed-field gel electrophoresis (PFGE) and tested for antimicrobial susceptibility. Infection control practices were inspected.

RESULTS

There were 14 confirmed cases. The median age at onset of infection was 3 days (range, 2-8 days). Nine patients died (64%). K pneumoniae isolates were resistant to multiple antimicrobials. PFGE revealed 2 distinct clusters. Breaches in infection control procedures included inappropriate intravenous solution use and inadequate hand hygiene and contact precautions.

CONCLUSIONS

We report a K pneumoniae outbreak with high neonatal mortality in Guatemala. PFGE clustering suggested a common source possibly related to reuse of a single-use intravenous medication or solution. The risk for K pneumoniae bloodstream infections in neonates in low-resource settings where sharing of solutions is common needs to be emphasized.

An outbreak of Serratia marcescens bloodstream infections associated with misuse of drug vials in a surgical ward

We report an outbreak of Serratia marcescens bloodstream infection due to contamination of total parenteral nutrition solution by insulin or poligeline solution when single-use vials were used for multiple doses in a surgical ward. Four patients had severe sepsis, and no patient died. Multidose vials, used either correctly or incorrectly, may be associated with bloodstream infection.

Infection Control: Old Problems and New Challenges

Infection control faces radical changes at the beginning of the third millennium. The first part of this review focuses on problems not yet solved, such as 1) surveillance systems, which should be active and extremely flexible; 2) infection outbreaks in hospitals and strategies to avoid them; 3) hand washing and alternatives such as rapid hand antisepsis; 4) water and food in the hospital as potential reservoirs of nosocomial pathogens; 5) upgrading of infection control programs to turn them into systems to improve the quality of care; 6) fatal Gram-negative bacteremias in hospitals from developing countries, which can be avoided with better standards of care; 7) the elemental role of the microbiology laboratory in the prevention and control of infections; 8) the unprecedented crisis due to the emergence of specific multi-resistant pathogens; 9) the risks for healthcare workers, such as tuberculosis, hepatitis, HIV, SARS, and hemorrhagic fevers; and 10) the need for the consistent application of guidelines. The second part of this review focuses on new challenges for infection control, such as 1) the ever-growing number of immunocompromised patients and basic control measures to avoid opportunistic infections; 2) the concerns about the capacity of the public health systems to deal with terrorist acts; 3) the practice of high-risk procedures in facilities lacking trained personnel, efficient laboratories, and protective items; and 4) gene therapy and its potential infectious complications. Consideration is given to the asymmetric development of infection control globally.

A simultaneous outbreak of Serratia marcescens and Klebsiella pneumoniae in a neonatal intensive care unit

We describe two concurrent outbreaks of Serratia marcescens and Klebsiella pneumoniae in a neonatal intensive care unit (NICU). Over a 16-month period, a total of 27 infants were either colonized (N=14) or infected (N=13). There were 15 cases of S. marcescens and 11 cases of K. pneumoniae. Both micro-organisms were involved in one fatal case. Seven preterm babies developed septicaemia, two had bacteraemia, three had respiratory infections and one had purulent conjunctivitis. The S. marcescens and K. pneumoniae isolates were investigated by three molecular methods: enterobacterial repetitive intergenic consensus polymerase chain reaction (PCR), arbitrary primed PCR with M13 primer, and random amplification of polymorphic DNA. Different patterns were found in the 16 S. marcescens epidemic isolates from 16 newborn infants. The major epidemic-involved genotype was linked to the first nine cases and this was subsequently replaced by different patterns. Eight different typing profiles were also determined for the 13 K. pneumoniae isolates from 12 newborn infants. Four K. pneumoniae bacteraemic strains proved to be identical. In conclusion, the typing results revealed that two different micro-organisms (S. marcescens and K. pneumoniae) were simultaneously involved in invasive nosocomial infections in preterm newborns. Two simultaneous clusters of cases were documented. Heterogeneous genotypes among both species were also demonstrated to be present in the NICU at the same time. A focal source for both micro-organisms was not identified but cross-transmission through handling was probably an important route in this outbreak. Strict adherence to handwashing policies, cohorting, isolation of colonized and infected patients, and rigorous environmental hygiene were crucial measures in the containment of the epidemic.

Epidemiology of nosocomial infections in selected neonatal intensive care units in Colombia, South America

OBJECTIVE

The epidemiology of nosocomial infections (NI) in neonatal intensive care units in developing countries has been poorly studied. We conducted a prospective study in selected neonatal units in Colombia, SA, to describe the incidence rate, causative organisms, and interinstitutional differences.

STUDY DESIGN

Data were collected prospectively from February 20 to August 30, 2001 from eight neonatal units. NI was defined as culture-proven infection diagnosed after 72 h of hospitalization, resulting in treatment with antibiotics for >3 days. Linear regression models were used to describe associations between institutional variables and NI rates.

RESULTS

A total of 1504 infants were hospitalized for more than 72 h, and therefore, at risk for NI. Of all, 127 infections were reported among 80 patients (5.3%). The incidence density rate was 6.2 per 1000 patient-days. Bloodstream infections accounted for 78% of NIs. Gram-negative organisms predominated over gram-positive organisms (55 vs 38%) and were prevalent in infants < or =2000 g (54%). The most common pathogens were Staphylococcus epidermidis (26%) and Klebsiella pneumonia (12%).

CONCLUSION

Gram-negative organisms predominate in Colombia among infants <2000 g. The emergence of gram-negative organisms and their associated risk factors requires further study.

Neonatal sepsis in Egypt associated with bacterial contamination of glucose-containing intravenous fluids

BACKGROUND

Rates of sepsis exceeding 50% in a neonatal intensive care unit (NICU) in Cairo, Egypt, were not controlled by routine antimicrobial therapy. We investigated these conditions in September 2001.

METHODS

Case series and retrospective cohort studies were conducted on 2 groups of NICU infants admitted to an academic medical center between February 12 and July 31, 2001. Observation of clinical practices led us to culture in-use intravenous (i.v.) fluids and medications. We monitored rates of i.v. fluid contamination, clinical sepsis and mortality after interventions to establish new procedures for handling and disposal of i.v. fluids, infection control training and improved clinical laboratory capacity.

RESULTS

Among infants in the retrospective cohort group, 88 (77%) of 115 had clinical sepsis, and 59 (51%) died. In the case series group, we documented the time of initial positive blood culture; 21 (64%) of 33 were septic <24 hours after birth. Klebsiella pneumoniae accounted for 24 (73%) of 33 isolates; 14 (58%) of 24 were extended spectrum beta-lactamase-producing and aminoglycoside-resistant. On admission, all neonates received glucose-containing i.v. fluids; i.v. bottles (500 mL) were divided among multiple infants. The i.v. fluids were prepared at the bedside; poor hand hygiene and poor adherence to aseptic techniques were observed. K. pneumoniae was isolated from 13 (65%) of 20 in-use glucose-containing i.v. fluids. Fluid contamination, sepsis and mortality rates declined significantly after intervention.

CONCLUSION

Extrinsically contaminated i.v. fluids resulted in sepsis and deaths. Standard infection control precautions significantly improve mortality and sepsis rates and are prerequisites for safe NICU care.

Neonatal pneumonia in developing countries

Pneumonia contributes to between 750,000 and 1.2 million neonatal deaths and an unknown number of stillbirths each year world wide. The aetiology depends on time of onset. Gram negative bacilli predominate in the first week of life, and Gram positive bacteria after that. Streptococcus pneumoniae probably causes about 25% of neonatal pneumonia. Interventions that would reduce mortality from this condition would have a large range of beneficial effects: improved maternal health, better management of other common neonatal conditions, and reduced long term childhood and adult morbidity.

Hospital-acquired neonatal infections in developing countries

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.

Nosocomial pediatric bacteremia: the role of intravenous set contamination in developing countries

OBJECTIVE

To assess the rate of bacterial contamination of intravenous administration sets at their rubber injection ports and matching infusates.

DESIGN

Cultures of injection ports and infusate during 26 visits to 4 hospitals.

SETTING

Four public general pediatric hospitals in Mexico City with substandard care practices.

PATIENTS

Hospitalized pediatric patients receiving intravenous solutions.

RESULTS

Overall, 176 of 251 injection ports were contaminated (70.1%; 95% confidence interval [CI95], 64.5% to 75.8%), 35 (13.9%; CI95, 9.7% to 18.2%) with gram-negative rods, primarily of the tribe Klebsielleae. Cultures of infusates were positive in 17 cases (6.8%, CI95, 3.7% to 9.9%), 5 of which grew gram-negative rods (2%; CI95, 0.6% to 4.6%). In 3 cases (1.2%), the same species with gram-negative rods was found in the infusates and on the injection ports. During one visit, 8 clustered cases of injection port contamination with a clonal Enterobacter cloacae were found; this agent was also found in the blood culture, intravenous fluid, and parenteral nutrition of one patient. Inadequate chlorination of tap water, a potential risk factor, was recorded during 22 visits (84.6%).

CONCLUSION

These data suggest that external contamination of the intravenous administration set could play a role in infusate contamination.

Nosocomial bloodstream infections in pediatric patients in United States hospitals: epidemiology, clinical features and susceptibilities

BACKGROUND

We identified the predominant pathogens and antimicrobial susceptibilities of nosocomial bloodstream isolates in pediatric patients in the US Prospective surveillance for nosocomial bloodstream infections at 49 hospitals during a 6-year period [Surveillance and Control of Pathogens of Epidemiologic Importance (SCOPE)] detected 22 609 bloodstream infections, of which 3432 occurred in patients < or =16 years of age.

RESULTS

Gram-positive organisms accounted for 65% of cases, Gram-negative organisms accounted for 24% of cases and 11% were caused by fungi. The overall crude mortality was 14% (475 of 3432) but notably higher for infections caused by Candida spp. and Pseudomonas aeruginosa, 20 and 29%, respectively. The most common organisms were coagulase-negative staphylococci (43%), enterococci, Staphylococcus aureus and Candida spp. (each, 9%). The mean interval between admission and infection averaged 21 days for coagulase-negative staphylococci, 25 days for S. aureus and Candida spp., 32 days for Klebsiella spp. and 34 days for Enterococcus spp. The proportion of methicillin-resistant S. aureus increased from 10% in 1995 to 29% in 2001. Vancomycin-resistance was seen in 1% of Enterococcus faecalis and in 11% of Enterococcus faecium isolates.

CONCLUSION

Nosocomial BSI occurred predominantly in very young and/or critically ill children. Gram-positive pathogens predominated across all ages, and increasing antimicrobial resistance was observed in pediatric patients.

Molecular epidemiology of an outbreak of Serratia marcescens in a neonatal intensive care unit

OBJECTIVE

To investigate and control a biphasic outbreak of Serratia marcescens in a neonatal intensive care unit (NICU).

DESIGN

Epidemiological and laboratory investigation of the outbreak.

SETTING

The NICU of the 1,470-bed teaching hospital of the University "Federico II," Naples, Italy.

PATIENTS

The outbreak involved 56 cases of colonization by S marcescens over a 15-month period, with two epidemic peaks of 6 and 3 months, respectively. Fourteen (25%) of the 56 colonized infants developed clinical infections, 50% of which were major (sepsis, meningitis, or pneumonia).

METHODS

Epidemiological and microbiological investigations, analysis of macrorestriction pattern of genomic DNA through pulsed-field gel electrophoresis (PFGE) of clinical and environmental isolates, and institution of infection control measures.

RESULTS

Analysis of macrorestriction patterns of genomic DNA by PFGE demonstrated that the vast majority of S marcescens isolates, including three environmental strains isolated from two handwashing disinfectants and the hands of a nurse, were of the same clonal type. The successful control of the outbreak was achieved through cohorting of noncolonized infants, isolation of S marcescens-infected and -colonized infants, and an intense educational program that emphasized the need for adherence to glove use and handwashing policies. The NICU remained open to new admissions.

CONCLUSIONS

Outbreaks caused by S marcescens are very difficult to eradicate. An infection control program that includes molecular typing of microorganisms and the proper dissemination among staff members of the typing results is likely to be very effective in reducing NICU-acquired infections and in controlling outbreaks caused by S marcescens, as well as other multiresistant bacteria.

Parenteral infusions bacterial contamination in a multi-institutional survey in Mexico: considerations for nosocomial mortality

BACKGROUND

Parenteral infusions can be contaminated during administration (extrinsic contamination). A previous survey found that extrinsic contamination was not uncommon in a hospital in Mexico with lapses in aseptic techniques. To determine whether this problem exists in other similar institutions, we undertook a multi-institutional study.

METHODS

We surveyed 6 hospitals (A to F) lacking an infection control committee to determine the level of extrinsic contamination. We visited each hospital and obtained samples of all the parenteral infusions in use, drawing 0.5-1 mL from the tubing injection port. Quantitative and qualitative bacterial cultures were performed. Chlorine levels of the tap water were measured. Visits were repeated until the survey was completed.

RESULTS

A total of 751 infusions were cultured, of which 16 (2.13%) were contaminated. Hospital contamination rates varied from zero to 5.56%. Klebsiella pneumoniae was the most common isolate (10 cases). During the first sampling day in hospital C, the 7 infusions from the pediatric ward were found to be contaminated with a similar K pneumoniae strain. In-service education was started in this hospital. Infusion contamination was eliminated followed by a reduction in mortality rate. Overall, a higher risk for infusion contamination was noted for pediatric patients (P =.01, odds ratio = 3.28, 95% CI, 1.10-9.91) and in wards with inadequate water chlorine levels (P =. 02, odds ratio = 3.64, 95% CI, 1.08-13.51).

CONCLUSIONS

If the hospitals surveyed are representative of others in developing countries, an endemic level of parenteral infusion contamination could exist in many hospitals throughout the world.

Neonatal airway colonization with gram-negative bacilli: association with severity of bronchopulmonary dysplasia

BACKGROUND

Airway colonization with Gram-negative bacilli (GNB) and Gram-positive cocci (GPC) is common in mechanically ventilated neonates. Whether GNB are related to nosocomial bloodstream infection (BSI) and/or to the severity of bronchopulmonary dysplasia (BPD) is unknown.

METHODS

We prospectively examine this relationship using a cohort design. Data from 260 < or = 1250-g birth weight inborn infants (1991 to 1995) intubated > or = 2 weeks included 917 serial tracheal cultures and 583 blood cultures. The severity of BPD was assessed by duration of mechanical ventilation, oxygen dependency at 36 weeks of postconceptional age and the use of home oxygen supplementation.

RESULTS

After 2 weeks of ventilation, 80% of the infants were colonized with GPC (Staphylococus epidermidis and Staphylococcus haemolyticus in 90% of the cases). Superimposed on 36% of these infants was GNB airway colonization with Klebsiella pneumoniae (25%), Enterobacter cloacae (25%), Escherichia coli (25%), Pseudomonas aeruginosa (10%), Serratia marcescen (10%), Acinetobacter baumannii and Haemophilus influenzae (5%). Comparison between 174 GPC- and 86 GNB-colonized infants showed that demographics, birth weight, gestational age, perinatal risk factors and mortality were similar. Fifteen percent of GNB-colonized infants developed BSI caused by GNB and 14% developed BSI caused by GPC. No significant temporal relationship between airway colonization and BSI was noted. GNB infants were ventilated longer and required oxygen at 36 weeks of postconceptional age and home oxygen supplementation twice as often as infants colonized only with GPC. GNB colonization was a predictor of severe BPD after controlling for ventilation. Ureaplasma colonization occurred in 28% of GNB-colonized and 33% of noncolonized infants and was not a predictor of BPD severity.

CONCLUSION

GNB airway colonization creates a moderate risk for BSI. Antibiotic treatment does not regularly eradicate GNB. GNB airway colonization is associated with severe BPD, but further studies will be necessary before therapeutic efforts to eradicate GNB from the airways should be undertaken.

Bacterial contamination of commercially available ethacridine lactate (acrinol) products

Bacterial contamination of commercially available ethacridine lactate (acrinol) solutions and cotton gauze soaked in ethacridine lactate solution was investigated. Of 56 samples from ethacridine lactate solutions (eight products, seven manufacturers), seven samples (12.5%) of two products (two manufacturers) were contaminated with 10(1)-10(4) colony forming units (cfu)/mL of Burkholderia pickettii. Of 67 samples obtained from gauze soaked in ethacridine lactate solution (seven products, seven manufacturers), 41 (61.2%) of six products (six manufacturers) were contaminated with 10(2)-10(6) cfu/mL of bacteria. The major bacteria detected were Burkholderia cepacia and Burkholderia pickettii. This relatively high incidence of bacterial contamination in commercially available cotton gauze soaked in ethacridine lactate solution may be due to the presence of gauze in ethacridine lactate solution.