Pathogen Distribution and Antimicrobial Resistance Among Pediatric Healthcare-Associated Infections Reported to the National Healthcare Safety Network, 2011-2014

Pseudomonas aeruginosa bloodstream infections in children and adolescents: risk factors associated with carbapenem resistance and mortality

BACKGROUND

Pseudomonas aeruginosa bloodstream infections (PA-BSIs) are a serious disease and a therapeutic challenge due to increasing resistance to carbapenems. Our objectives were to describe the prevalence and risk factors associated with carbapenem resistance (CR) and mortality in children with PA-BSI.

METHODS

A retrospective, multi-centre study was carried out, including patients aged <20 years with PA-BSI in four tertiary hospitals in Madrid (Spain) during 2010-2020. Risk factors for CR PA-BSIs and 30-day mortality were evaluated in a multi-variable logistic regression model.

RESULTS

In total, 151 patients with PA-BSI were included, with a median age of 29 months (interquartile range: 3.5-87.1). Forty-five (29.8%) cases were CR, 9.9% multi-drug resistant and 6.6% extensively drug resistant. The prevalence of CR remained stable throughout the study period, with 26.7% (12/45) of CR mediated by VIM-type carbapenemase. Patients with BSIs produced by CR-PA were more likely to receive inappropriate empiric treatment (53.3% vs 5.7%, P<0.001) and to have been previously colonized by CR-PA (8.9% vs 0%, P=0.002) than BSIs caused by carbapenem-susceptible P. aeruginosa. CR was associated with carbapenem treatment in the previous month (adjusted odds ratio (aOR) 11.15) and solid organ transplantation (aOR 7.64). The 30-day mortality was 23.2%, which was associated with mechanical ventilation (aOR 4.24), sepsis (aOR 5.72), inappropriate empiric antibiotic therapy (aOR 5.86), and source control as a protective factor (aOR 0.16).

CONCLUSION

This study shows a concerning prevalence of CR in children with PA-BSIs, leading to high mortality. Inappropriate empiric treatment and sepsis were associated with mortality. The high prevalence of CR with an increased risk of inappropriate empiric treatment should be closely monitored.

Enterococcal quorum-controlled protease alters phage infection

Increased prevalence of multidrug resistant bacterial infections has sparked interest in alternative antimicrobials, including bacteriophages (phages). Limited understanding of the phage infection process hampers our ability to utilize phages to their full therapeutic potential. To understand phage infection dynamics we performed proteomics on Enterococcus faecalis infected with the phage VPE25. We discovered numerous uncharacterized phage proteins are produced during phage infection of Enterococcus faecalis. Additionally, we identified hundreds of changes in bacterial protein abundances during infection. One such protein, enterococcal gelatinase (GelE), an fsr quorum sensing regulated protease involved in biofilm formation and virulence, was reduced during VPE25 infection. Plaque assays showed that mutation of either the fsrA or gelE resulted in plaques with a "halo" morphology and significantly larger diameters, suggesting decreased protection from phage infection. GelE-associated protection during phage infection is dependent on the murein hydrolase regulator LrgA and antiholin-like protein LrgB, whose expression have been shown to be regulated by GelE. Our work may be leveraged in the development of phage therapies that can modulate the production of GelE thereby altering biofilm formation and decreasing E. faecalis virulence.

Nosocomial Infections in the Neonatal Intensive Care Unit

Nosocomial infections are relatively common in the NICU. These infections increase morbidity and mortality, particularly in the smallest and most fragile infants. The impact of these infections on long-term outcomes and health-care costs is devastating. Worldwide efforts to decrease the incidence of nosocomial infections have focused on implementing specific prevention protocols such as handwashing, central line teams, care bundles, and antimicrobial stewardship. This review summarizes common nosocomial infections in patients in the NICU.

Epidemiology of Enterococcus , Staphylococcus aureus , Klebsiella , Acinetobacter , Pseudomonas , and Enterobacter Species Transmission in the Pediatric Anesthesia Work Area Environment With and Without Practitioner Use of a Personalized Body-Worn Alcohol Dispenser

BACKGROUND

Personalized body-worn alcohol dispensers may serve as an important tool for perioperative infection control, but the impact of these devices on the epidemiology of transmission of high-risk Enterococcus , Staphylococcus aureus , Klebsiella, Acinetobacter , Pseudomonas , and Enterobacter (ESKAPE) pathogens is unknown. We aimed to characterize the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment with and without a personalized body-worn alcohol dispenser.

METHODS

This controlled before and after study included 40 pediatric patients enrolled over a 1-year study period. Two groups of operating room cases were compared: (1) operating room cases caring for patients with usual care (December 17, 2019, to August 25, 2020), and (2) operating room cases caring for patients with usual care plus the addition of a personalized, body-worn alcohol hand rub dispenser (September 30, 2020, to December 16, 2020). Operating rooms were randomly selected for observation of ESKAPE transmission in both groups. Device use was tracked via wireless technology and recorded in hourly hand decontamination events.

RESULTS

Anesthesia providers used the alcohol dispenser 3.3 ± 2.1 times per hour. A total of 57 ESKAPE transmission events (29 treatment and 28 control) were identified. The personalized body-worn alcohol dispenser impacted ESKAPE transmission by increasing the contribution of provider hand contamination at case start (21/29 device versus 10/28 usual care; relative risk, [RR] 2.03; 99.17% confidence interval [CI], 1.025-5.27; P = .0066) and decreasing the contribution of environmental contamination at case end (3/29 device versus 12/28 usual care; RR, 0.24; 99.17% CI, 0.022-0.947; P = .0059). ESKAPE pathogen contamination involved 20% (8/40) of patient intravascular devices. There were 85% (34/40) of preoperative patient skin surfaces contaminated with ≥1 (1.78 ± 0.19 [standard deviation {SD}]) ESKAPE pathogens.

CONCLUSIONS

A personalized body-worn alcohol dispenser can impact the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment. Improved preoperative patient decolonization and vascular care are indicated to address ESKAPE pathogens among pediatric anesthesia work area reservoirs.

Intestinal dysbiosis as an intraoperative predictor of septic complications: evidence from human surgical cohorts and preclinical models of peritoneal sepsis

Major surgery exposes the intestinal microbiota to inflammatory and antibiotic stressors, which alter the microbiota composition of the intestinal lumen and fecal contents. However, it is not sufficiently understood, if such dysbiosis develops already during surgery and if alterations in microbiota may be the cause of surgical complications. End-of-surgery composition of the microbiota in the rectum was assessed in 41 patients undergoing either rectal or duodenopancreatic resection and was compared to baseline before surgery using 16S-rRNA sequencing. A subset of patients developed severe dysbiosis at the end of surgery, which was characterized by an overgrowth of the Proteobacteria phylum that includes the facultative pathogen E. coli. To test if dysbiosis impacts on surgical outcomes, dysbiosis was modeled in mice by a single oral administration of vancomycin prior to cecal ligation and puncture. Dysbiosis was associated with impaired post-surgical survival, dysregulation of the host's immune response, elevated bacterial virulence and reduced bacterial metabolism of carbon sources. In conclusion, dysbiosis can be detected already at the end of surgery in a fraction of patients undergoing major surgery. Modelling surgery-associated dysbiosis in mice using single-shot administration of vancomycin induced dysbiosis and resulted in elevated mortality.

Enterococcus faecalis suppresses Staphylococcus aureus-induced NETosis and promotes bacterial survival in polymicrobial infections

Enterococcus faecalis is an opportunistic pathogen that is frequently co-isolated with other microbes in wound infections. While E. faecalis can subvert the host immune response and promote the survival of other microbes via interbacterial synergy, little is known about the impact of E. faecalis-mediated immune suppression on co-infecting microbes. We hypothesized that E. faecalis can attenuate neutrophil-mediated responses in mixed-species infection to promote survival of the co-infecting species. We found that neutrophils control E. faecalis infection via phagocytosis, ROS production, and degranulation of azurophilic granules, but it does not trigger neutrophil extracellular trap formation (NETosis). However, E. faecalis attenuates Staphylococcus aureus-induced NETosis in polymicrobial infection by interfering with citrullination of histone, suggesting E. faecalis can actively suppress NETosis in neutrophils. Residual S. aureus-induced NETs that remain during co-infection do not impact E. faecalis, further suggesting that E. faecalis possess mechanisms to evade or survive NET-associated killing mechanisms. E. faecalis-driven reduction of NETosis corresponds with higher S. aureus survival, indicating that this immunomodulating effect could be a risk factor in promoting the virulence polymicrobial infection. These findings highlight the complexity of the immune response to polymicrobial infections and suggest that attenuated pathogen-specific immune responses contribute to pathogenesis in the mammalian host.

Antibiotic resistance in bloodstream isolates from high-complexity paediatric units in Madrid, Spain: 2013-2021

BACKGROUND

Antimicrobial resistance (AMR) has become a significant challenge in high-complexity healthcare settings.

AIM

To evaluate the prevalence of AMR in bloodstream isolates from high-complexity paediatric units in Spain over a nine-year period.

METHODS

A retrospective observational multicentre study was conducted in three tertiary hospitals, analysing bloodstream isolates from patients aged <18 years admitted to the paediatric intensive care, neonatology, and oncology-haematology units between 2013 and 2021. Demographics, antimicrobial susceptibility, and resistance mechanisms were analysed in two periods (2013-2017 and 2017-2021).

FINDINGS

In all, 1255 isolates were included. AMR was more prevalent in older patients and those admitted to the oncology-haematology unit. Multidrug resistance was observed in 9.9% of Gram-negative bacteria (GNB); 20.0% of P. aeruginosa vs 8.6% of Entero-bacterales (P < 0.001), with an increase in Enterobacterales from 6.2% to 11.0% between the first and the second period (P = 0.021). Difficult-to-treat resistance was observed in 2.7% of GNB; 7.4% of P. aeruginosa vs 1.6% of Enterobacterales (P < 0.001), with an increasing trend in Enterobacterales from 0.8% to 2.5% (P = 0.076). Carbapenem resistance among Enterobacterales increased from 3.5% to 7.2% (P = 0.029), with 3.3% producing carbapenemases (67.9% VIM). Meticillin resistance was observed in 11.0% of S. aureus and vancomycin resistance in 1.4% of Enterococcus spp., with both rates remaining stable throughout the study period.

CONCLUSION

This study reveals a high prevalence of AMR in high-complexity paediatric units. Enterobacterales showed a concerning increasing trend in resistant strains, with higher rates among older patients and those admitted to oncology-haematology units.

A humanized monoclonal antibody targeting protein a promotes opsonophagocytosis of Staphylococcus aureus in human umbilical cord blood

Low and very-low-birth-weight (V/LBW) neonates are highly susceptible to bacterial sepsis and meningitis. Bacterial infections caused by Staphylococcus aureus can be particularly dangerous for neonates and can result in high mortality and long-term disabilities.Antibody-based strategies have been attempted to protect V/LBW neonates against staphylococcal disease. However, these efforts have so far been unsuccessful. Failures were attributed to the immaturity of the neonatal immune system but did not account for the anti-opsonic activity of Staphylococcal protein A (SpA). Here we show that monoclonal antibody 3F6, which blocks SpA activity, promotes complement-dependent cell-mediated phagocytosis of S. aureus in human umbilical cord blood. A substitution in the crystallizable fragment (Fc) region of 3F6 that enhances recruitment of complement component C1q further increases the phagocytic activity of cord blood. Our data demonstrate that the neonatal immune system possesses bactericidal activity that can be harnessed by antibodies that circumvent a key innate immune strategy of S. aureus.

High Burden of Intestinal Colonization With Antimicrobial-Resistant Bacteria in Chile: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

BACKGROUND

Antimicrobial resistance is a global threat, heavily impacting low- and middle-income countries. This study estimated antimicrobial-resistant gram-negative bacteria (GNB) fecal colonization prevalence in hospitalized and community-dwelling adults in Chile before the coronavirus disease 2019 pandemic.

METHODS

From December 2018 to May 2019, we enrolled hospitalized adults in 4 public hospitals and community dwellers from central Chile, who provided fecal specimens and epidemiological information. Samples were plated onto MacConkey agar with ciprofloxacin or ceftazidime added. All recovered morphotypes were identified and characterized according to the following phenotypes: fluoroquinolone-resistant (FQR), extended-spectrum cephalosporin-resistant (ESCR), carbapenem-resistant (CR), or multidrug-resistant (MDR; as per Centers for Disease Control and Prevention criteria) GNB. Categories were not mutually exclusive.

RESULTS

A total of 775 hospitalized adults and 357 community dwellers were enrolled. Among hospitalized subjects, the prevalence of colonization with FQR, ESCR, CR, or MDR-GNB was 46.4% (95% confidence interval [CI], 42.9-50.0), 41.2% (95% CI, 37.7-44.6), 14.5% (95% CI, 12.0-16.9), and 26.3% (95% CI, 23.2-29.4). In the community, the prevalence of FQR, ESCR, CR, and MDR-GNB colonization was 39.5% (95% CI, 34.4-44.6), 28.9% (95% CI, 24.2-33.6), 5.6% (95% CI, 3.2-8.0), and 4.8% (95% CI, 2.6-7.0), respectively.

CONCLUSIONS

A high burden of antimicrobial-resistant GNB colonization was observed in this sample of hospitalized and community-dwelling adults, suggesting that the community is a relevant source of antibiotic resistance. Efforts are needed to understand the relatedness between resistant strains circulating in the community and hospitals.

Identifying and Mitigating Disparities in Central Line-Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups

Importance

Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood.

Objective

To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities.

Design, Setting, and Participants

This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022.

Exposures

Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes.

Main Outcomes and Measures

Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes.

Results

Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27).

Conclusions and Relevance

The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

Factors linked to Staphylococcus aureus healthcare-associated infections among pediatric intensive care unit colonized patients

BACKGROUND

Staphylococcus aureus (SA) is one of the main pathogens responsible for healthcare-associated infection (HCAI) in pediatrics. The aim of this study was to describe the prevalence of SA-HCAI among colonized patients and the factors associated with it in the pediatric intensive care unit (PICU).

METHODS

We designed a 6-year retrospective cohort study of a PICU in a French university children's hospital including all children admitted to the PICU from January 1, 2011, to December 31, 2016, who had SA colonization on PICU admission. For each patient, the past medical history and the hospitalization data were collected. HCAIs related to SA were verified according to the criteria of the United States Centers for Disease Control and Prevention.

RESULTS

Among all patients colonized with SA (n = 1381, 26%), 105 (8%) had methicillin-resistant SA carriage and 41 (3%) developed an HCAI caused by SA. The main HCAIs were ventilator-associated pneumonia (51%) and central line-associated bloodstream infections (27%). Patients developing HCAI caused by SA had a significantly longer length of hospital stay and a higher mortality rate than the rest of the population. Using a multivariate logistic regression model, the presence of mechanical ventilation, the implementation of a surgical procedure during the PICU stay, and the onset of at least one episode of anemia during the PICU stay were significantly associated with the occurrence of HCAI due to SA.

CONCLUSION

HCAIs linked to SA carriage are rare but severe. Mechanical ventilation, surgery during the PICU stay, and anemia are factors associated with SA-HCAI.

Development of new spiro[1,3]dithiine-4,11'-indeno[1,2-b]quinoxaline derivatives as S. aureus Sortase A inhibitors and radiosterilization with molecular modeling simulation

Multi-drug resistant microbes have become a severe threat to human health and arise a worldwide concern. A total of fifteen spiro-1,3-dithiinoindenoquinoxaline derivatives 2-7 were synthesized and evaluated for their biological activities against five standard and MDRB pathogens. The MIC and MBC/MFC for the most active derivatives were determined in vitro via broth microdilution assay. These derivatives showed significant activity against the tested strains with microbicidal behavior, with compound 4b as the most active compound (MIC range between 0.06 and 0.25 µg/mL for bacteria strains and MIC = 0.25 µg/mL for C. albicans). The most active spiro-1,3-dithiinoindenoquinoxaline derivatives were able to inhibit the activity of SrtA with IC₅₀ values ranging from 22.15 ± 0.4 µM to 37.12 ± 1.4 µM. In addition, the active spiro-1,3-dithiinoindenoquinoxaline attenuated the in vitro virulence-related phenotype of SrtA by weakening the adherence of S. aureus to fibrinogen and reducing the biofilm formation. Surprisingly, compound 4b revealed potent SrtA inhibitory activity with IC₅₀ = 22.15 µM, inhibiting the adhesion of S. aureus with 39.22 ± 0.15 % compared with untreated 9.43 ± 1.52 %, and showed a reduction in the biofilm biomass of S. aureus with 32.27 ± 0.52 %. We further investigated the effect of gamma radiation as a sterilization method on the microbial load and found that a dose of 5 kGy was sufficient to eradicate the microbial load. The quantum chemical studies exhibited that the tested derivatives have a small energy band gap (ΔE = -2.95 to -3.61 eV) and therefore exert potent bioactivity by interacting with receptors more stabilizing.

Prolonged silent carriage, genomic virulence potential and transmission between staff and patients characterize a neonatal intensive care unit (NICU) outbreak of methicillin-resistant Staphylococcus aureus (MRSA)

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen in neonatal intensive care units (NICU) that confers significant morbidity and mortality.

OBJECTIVE

Improving our understanding of MRSA transmission dynamics, especially among high-risk patients, is an infection prevention priority.

METHODS

We investigated a cluster of clinical MRSA cases in the NICU using a combination of epidemiologic review and whole-genome sequencing (WGS) of isolates from clinical and surveillance cultures obtained from patients and healthcare personnel (HCP).

RESULTS

Phylogenetic analysis identified 2 genetically distinct phylogenetic clades and revealed multiple silent-transmission events between HCP and infants. The predominant outbreak strain harbored multiple virulence factors. Epidemiologic investigation and genomic analysis identified a HCP colonized with the dominant MRSA outbreak strain who cared for most NICU patients who were infected or colonized with the same strain, including 1 NICU patient with severe infection 7 months before the described outbreak. These results guided implementation of infection prevention interventions that prevented further transmission events.

CONCLUSIONS

Silent transmission of MRSA between HCP and NICU patients likely contributed to a NICU outbreak involving a virulent MRSA strain. WGS enabled data-driven decision making to inform implementation of infection control policies that mitigated the outbreak. Prospective WGS coupled with epidemiologic analysis can be used to detect transmission events and prompt early implementation of control strategies.

Ceftazidime resistance in Pseudomonas aeruginosa is multigenic and complex

Pseudomonas aeruginosa causes a wide range of severe infections. Ceftazidime, a cephalosporin, is a key antibiotic for treating infections but a significant proportion of isolates are ceftazidime-resistant. The aim of this research was to identify mutations that contribute to resistance, and to quantify the impacts of individual mutations and mutation combinations. Thirty-five mutants with reduced susceptibility to ceftazidime were evolved from two antibiotic-sensitive P. aeruginosa reference strains PAO1 and PA14. Mutations were identified by whole genome sequencing. The evolved mutants tolerated ceftazidime at concentrations between 4 and 1000 times that of the parental bacteria, with most mutants being ceftazidime resistant (minimum inhibitory concentration [MIC] ≥ 32 mg/L). Many mutants were also resistant to meropenem, a carbapenem antibiotic. Twenty-eight genes were mutated in multiple mutants, with dacB and mpl being the most frequently mutated. Mutations in six key genes were engineered into the genome of strain PAO1 individually and in combinations. A dacB mutation by itself increased the ceftazidime MIC by 16-fold although the mutant bacteria remained ceftazidime sensitive (MIC < 32 mg/L). Mutations in ampC, mexR, nalC or nalD increased the MIC by 2- to 4-fold. The MIC of a dacB mutant was increased when combined with a mutation in ampC, rendering the bacteria resistant, whereas other mutation combinations did not increase the MIC above those of single mutants. To determine the clinical relevance of mutations identified through experimental evolution, 173 ceftazidime-resistant and 166 sensitive clinical isolates were analysed for the presence of sequence variants that likely alter function of resistance-associated genes. dacB and ampC sequence variants occur most frequently in both resistant and sensitive clinical isolates. Our findings quantify the individual and combinatorial effects of mutations in different genes on ceftazidime susceptibility and demonstrate that the genetic basis of ceftazidime resistance is complex and multifactorial.

Formulation of Chrysomycin A Cream for the Treatment of Skin Infections

Chrysomycin A, a compound derived from marine microorganisms, proved to have a specific great in vitro inhibitory effect on methicillin-resistant Staphylococcus aureus (MRSA). It exhibits high safety for the skin, as well as a better therapeutic effect than the current clinical drug, vancomycin. Nevertheless, its poor water solubility highly limits the application and reduces the bioavailability. In view of this, we developed a cream of chrysomycin A (CA) to enhance the solubility for the treatment of skin infection, while avoiding the possible toxicity caused by systemic administration. A comprehensive orthogonal evaluation system composed of appearance, spreading ability, and stability was established to find the optimal formula under experimental conditions. The final product was odorless and easy to be spread, with a lustrous, smooth surface. The particle size of the product met Chinese Pharmacopoeia specifications and the entire cream showed long-term stability in destructive tests. The in vitro and in vivo studies indicated that CA cream had a similar anti-MRSA activity to commercially available mupirocin, showing its potential as an efficacious topical delivery system for skin infections treatment.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

The Changes in Epidemiology of Imipenem-Resistant Acinetobacter baumannii Bacteremia in a Pediatric Intensive Care Unit for 17 Years

BACKGROUND

Acinetobacter baumannii infections cause high morbidity and mortality in intensive care unit (ICU) patients. However, there are limited data on the changes of long-term epidemiology of imipenem resistance in A. baumannii bacteremia among pediatric ICU (PICU) patients.

METHODS

A retrospective review was performed on patients with A. baumannii bacteremia in PICU of a tertiary teaching hospital from 2000 to 2016. Antimicrobial susceptibility tests, multilocus sequence typing (MLST), and polymerase chain reaction for antimicrobial resistance genes were performed for available isolates.

RESULTS

A. baumannii bacteremia occurred in 27 patients; imipenem-sensitive A. baumannii (ISAB, n = 10, 37%) and imipenem-resistant A. baumannii (IRAB, n = 17, 63%). There was a clear shift in the antibiogram of A. baumannii during the study period. From 2000 to 2003, all isolates were ISAB (n = 6). From 2005 to 2008, both IRAB (n = 5) and ISAB (n = 4) were isolated. However, from 2009, all isolates were IRAB (n = 12). Ten isolates were available for additional test and confirmed as IRAB. MLST analysis showed that among 10 isolates, sequence type 138 was predominant (n = 7). All 10 isolates were positive for OXA-23-like and OXA-51-like carbapenemase. Of 27 bacteremia patients, 11 were male (41%), the median age at bacteremia onset was 5.2 years (range, 0-18.6 years). In 33% (9/27) of patients, A. baumannii was isolated from tracheal aspirate prior to development of bacteremia (median, 8 days; range, 5-124 days). The overall case-fatality rate was 63% (17/27) within 28 days. There was no statistical difference in the case fatality rate between ISAB and IRAB groups (50% vs. 71%; P = 0.422).

CONCLUSION

IRAB bacteremia causes serious threat in patients in PICU. Proactive infection control measures and antimicrobial stewardship are crucial for managing IRAB infection in PICU.

Distribution and Transfer of Plasmid Replicon Families among Multidrug-Resistant Enterococcus faecalis and Enterococcus faecium from Poultry

The presence and transfer of plasmids from commensal bacteria to more pathogenic bacteria may contribute to the dissemination of antimicrobial resistance. However, the prevalence of plasmids from commensal bacteria, such as the enterococci, in food animals remains largely unknown. In this study, the diversity and prevalence of plasmid families from multidrug-resistant (MDR; resistance to three or more antimicrobials) enterococci from poultry carcasses were determined. Plasmid-positive MDR enterococci were also tested for the ability to transfer plasmids to other enterococci using conjugation. MDR Enterococcus faecalis (n = 98) and Enterococcus faecium (n = 696) that were isolated from poultry carcass rinsates between 2004 and 2011 were tested for the presence of 21 plasmid replicon (rep) families using multiplex PCR. Approximately 48% of E. faecalis (47/98) and 16% of E. faecium (110/696) were positive for at least one rep-family. Fourteen rep-families were detected overall, and ten rep-families were shared between E. faecalis and E. faecium. The rep₇ and rep₁₇ families were unique to E. faecalis, while the rep₅ and rep₈ families were unique to E. faecium. The rep₉ family was predominant in both E. faecalis and E. faecium for all the years tested. The greatest number of rep-families detected was in 2005 (n = 10), and the least was in 2009 (n = 1). Eight rep-families were transferred from E. faecalis donors to the E. faecalis JH2-2 recipient using conjugation. Results from this study showed that E. faecalis and E. faecium from poultry carcasses contain numerous and diverse rep-families that are capable of conjugal transfer.

Epidemiology and genomics of a slow outbreak of methicillin-resistant Staphyloccus aureus (MRSA) in a neonatal intensive care unit: Successful chronic decolonization of MRSA-positive healthcare personnel

Objective:

To describe the genomic analysis and epidemiologic response related to a slow and prolonged methicillin-resistant Staphylococcus aureus (MRSA) outbreak.

Design:

Prospective observational study.

Setting:

Neonatal intensive care unit (NICU).

Methods:

We conducted an epidemiologic investigation of a NICU MRSA outbreak involving serial baby and staff screening to identify opportunities for decolonization. Whole-genome sequencing was performed on MRSA isolates.

Results:

A NICU with excellent hand hygiene compliance and longstanding minimal healthcare-associated infections experienced an MRSA outbreak involving 15 babies and 6 healthcare personnel (HCP). In total, 12 cases occurred slowly over a 1-year period (mean, 30.7 days apart) followed by 3 additional cases 7 months later. Multiple progressive infection prevention interventions were implemented, including contact precautions and cohorting of MRSA-positive babies, hand hygiene observers, enhanced environmental cleaning, screening of babies and staff, and decolonization of carriers. Only decolonization of HCP found to be persistent carriers of MRSA was successful in stopping transmission and ending the outbreak. Genomic analyses identified bidirectional transmission between babies and HCP during the outbreak.

Conclusions:

In comparison to fast outbreaks, outbreaks that are “slow and sustained” may be more common to units with strong existing infection prevention practices such that a series of breaches have to align to result in a case. We identified a slow outbreak that persisted among staff and babies and was only stopped by identifying and decolonizing persistent MRSA carriage among staff. A repeated decolonization regimen was successful in allowing previously persistent carriers to safely continue work duties.

Updates in the Pharmacologic Prophylaxis and Treatment of Invasive Candidiasis in the Pediatric and Neonatal Intensive Care Units

Purpose of review

The goal of this review was to provide an update on the prevention and treatment options for invasive candidiasis (IC) in the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU).

Recent findings

Studies have further validated the use of fluconazole for IC prophylaxis among high-risk patients in the NICU. It remains unclear if prophylaxis leads to resistance development and the ideal dosage regimen is still not clear. Recent studies have been published comparing caspofungin and micafungin to amphotericin B and illustrated similar efficacy outcomes in the NICU. Micafungin now has approval from the United States Food and Drug Administration (FDA) for use in infants < 4 months of age. Prophylactic strategies in the PICU could include zinc and vitamin D. Anidulafungin has recent non-comparative data supporting use in pediatric patients older than 1 month of age and also has a recent FDA approval for use in children 1 month of age and older.

Summary

Fluconazole prophylaxis remains a reasonable strategy in select NICU patients, although further analyses of resistance and the optimal dosage regimen are needed. Echinocandins are potential therapeutic options for non-meningitis or urinary tract infections in both the neonatal and pediatric population.

A Multicenter Analysis of Changes in Pediatric Antibiotic Susceptibilities Among Staphylococcus aureus and Pseudomonas aeruginosa Isolates: 2014–2018

OBJECTIVE

To describe antibiotic susceptibilities for Staphylococcus aureus and Pseudomonas aeruginosa among pediatric institutions in 2018. To assess correlations between antibiotic utilization and susceptibilities.

METHODS

Institutional antibiograms from 2018 were compiled among 13 institutions via a survey. Resistant pathogens and antibiotic days of therapy/1000 patient days (PD) were collected from 6 institutions over 5 years. Correlations were assessed as pooled data among all institutions and relative changes within individual institutions.

RESULTS

All 8552 S aureus isolates in 2018 were vancomycin susceptible and 40.1% were methicillin resistant (MRSA). Among MRSA, 96.3% and 78.8% were susceptible to trimethoprim/sulfamethoxazole and clindamycin, respectively. Pooled yearly MRSA/1000 PD decreased from 2014–2018 and correlated with pooled yearly decreases in vancomycin utilization (R = 0.983, p = 0.003). Institutional relative decreases in vancomycin utilization from 2014–2018 did not correlate with institutional relative decreases in MRSA susceptibility (R = −0.659, p = 0.16). Susceptibility to meropenem was 90.9% among 2315 P aeruginosa isolates in 2018. Antipseudomonal beta-lactam susceptibility ranged from 89.4% to 92.3%. Pooled yearly meropenem-resistant P aeruginosa/1000 PD and meropenem utilization did not significantly decrease over time or correlate (both p &gt; 0.6). Institutional relative change in meropenem utilization from 2013–2017 correlated with the institutional relative change in P aeruginosa susceptibility to meropenem from 2014–2018 (Rs = −0.89, p = 0.019).

CONCLUSIONS

Among included institutions, the burden of MRSA decreased over time. Institutional MRSA prevalence did not consistently correlate with institutional vancomycin utilization. Institutional changes in meropenem utilization correlated with P aeruginosa susceptibility the following year. Pooled analyses did not illustrate this correlation, likely owing to variability in utilization between institutions.

Antimicrobial Stewardship in Surgery: A Literature Bibliometric Analysis

Background

Antimicrobial resistance and the dwindling antibiotic development pipeline have resulted in a looming post-antibiotic era. Research related to antimicrobial stewardship (AMS) has grown rapidly in the past decade, especially in the field of surgery. We conducted a bibliometric analysis of these publications. In addition, we aimed to identify research hotspots and infer future research trends.

Methods

We screened global publications on AMS in the surgical field over ten years (between 2011 and 2020) from the Web of Science core collection database. The keywords “antimicrobial or antibiotic”, “stewardship”, “management”, “management strategies”, “programme”, “surgery” and “surgical” were used to search for related papers. VOS viewer, R software, and other machine learning and visualization tools were used to conduct the bibliometric analysis of the publications.

Results

We identified 674 publications on AMS in surgical fields; “antimicrobial stewardship” (with total link strength of 1,096) was the most frequent keyword, and had strong links to “antimicrobial resistance” and “guidelines”. The top 100 most cited papers had a mean citation count of 47.21 (range: 17–1155) citations, which were cited by survey research studies, clinical trials, and observational studies. The highest-ranking and most cited journal was Clinical Infectious Diseases with eight publications. Jason G. Newland from Washington University wrote seven papers and was cited 1,282 times. The University of Washington published 17 papers and was cited 1,258 times, with the largest number of publications by author and organization. The USA published 198 papers and cooperated with 21 countries, mainly partnering with Italy, the UK, and Canada. Published articles mainly focused on the current clinical situation regarding surgical AMS management, antibiotic prescription, and antibiotic resistance.

Conclusions

Publications on surgical AMS management have increased in recent decades, with the USA being the most prolific. Epidemiological investigations of surgical-related infections, antibiotic prescriptions, and antibiotic resistance are fast-developing research trends. However, further improvements are still needed according to the recommendations gained from the bibliometric analysis.

Staphylococcus aureus infections after elective pediatric surgeries

Objective:

To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries.

Design:

Retrospective cohort study utilizing the Premier Healthcare database (PHD).

Setting:

Inpatient and hospital-based outpatient elective surgical discharges.

Patients:

Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results.

Methods:

In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries.

Results:

Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10–17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10–17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116).

Conclusions:

These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.

Introduction of Probiotic-Based Sanitation in the Emergency Ward of a Children’s Hospital During the COVID-19 Pandemic

Background

Antimicrobial resistance (AMR) represents a major threat to public health, especially in the hospital environment, and the massive use of disinfectants to prevent COVID-19 transmission might intensify this risk, possibly leading to future AMR pandemics. However, the control of microbial contamination is crucial in hospitals, since hospital microbiomes can cause healthcare-associated infections (HAIs), which are particularly frequent and severe in pediatric wards due to children having high susceptibility.

Aim

We have previously reported that probiotic-based sanitation (PCHS) could stably decrease pathogens and their AMR in the hospital environment, reduce associated HAIs in adult hospitals, and inactivate enveloped viruses. Here, we aimed to test the effect of PCHS in the emergency room (ER) of a children’s hospital during the COVID-19 pandemic.

Methods

Conventional chemical disinfection was replaced by PCHS for 2 months during routine ER sanitation; the level of environmental bioburden was characterized before and at 2, 4, and 9 weeks after the introduction of PCHS. Microbial contamination was monitored simultaneously by conventional culture-based CFU count and molecular assays, including 16S rRNA NGS for bacteriome characterization and microarrays for the assessment of the resistome of the contaminating population. The presence of SARS-CoV-2 was also monitored by PCR.

Results and conclusions

PCHS usage was associated with a stable 80% decrease in surface pathogens compared to levels detected for chemical disinfection (P < 0.01), accompanied by an up to 2 log decrease in resistance genes (Pc < 0.01). The effects were reversed when reintroducing chemical disinfection, which counteracted the action of the PCHS. SARS-CoV-2 was not detectable in both the pre-PCHS and PCHS periods. As the control of microbial contamination is a major issue, especially during pandemic emergencies, collected data suggest that PCHS may be successfully used to control virus spread without simultaneous worsening of the AMR concern.

Diagnostic Stewardship in the Pediatric Intensive Care Unit

In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?

Extensive outbreak of colistin resistant, carbapenemase (blaOXA-48, blaNDM) producing Klebsiella pneumoniae in a large tertiary care hospital, India

BACKGROUND

Extensive drug resistance in Klebsiella pneumoniae (K. pneumoniae) causing major outbreaks in large hospitals is an emerging challenge. We describe a near fatal outbreak of colistin resistant, carbapenem resistant K. pneumoniae (CRKp) producing metallo beta-lactamases (blaNDM) and blaOXA-48 in the neonatal intensive care unit (NICU) at the background of a larger outbreak involving multiple parts of the hospital and the challenges in its containment.

METHODS

Following identification of an outbreak due to colistin resistant CRKp between April to June 2017 in the NICU, a thorough surveillance of similar cases and the hospital environment was performed to trace the source. All the isolated K. pneumoniae were tested for susceptibility to standard antibiotics by disc diffusion and microbroth dilution methods. Molecular detection of extended spectrum beta lactamases (ESBLs) and carbapenemases (classes A, B, D) genes was done. Enterobacterial repetitive intergenic consensus (ERIC) PCR and multi-locus sequence typing (MLST) was done to determine the genetic relatedness of the isolates. Characteristics of different sequence types were statistically compared (Student's t-test).

RESULTS

A total of 45 K. pneumoniae isolates were studied from NICU (14 cases of neonatal sepsis), ICU (18 cases), other wards (7 cases) along with 6 isolates from hospital environment and human colonizers. The primary case was identified in the ICU. All the K. pneumoniae from NICU and 94.4% from the ICU were colistin resistant CRKp. Majority (59.37% and 56.25%) harbored blaSHV/blaCTXM and blaOXA-48 genes, respectively. Two distinct sequence types ST5235 and ST5313 were noted with colistin resistance, distribution within the NICU and mortality as significant attributes of ST5235 (p < 0.05). The outbreak was contained with strengthening of the infection control practices and unintended short duration closure of the hospital.

CONCLUSION

Large hospital outbreaks with considerable mortality can be caused by non-dominant clones of colistin resistant CRKp harboring blaOXA-48 and blaNDM carbapenemases in endemic regions. The exact global impact of these sequence types should be further studied to prevent future fatal outbreaks.

Factors mediating Acinetobacter baumannii biofilm formation: Opportunities for developing therapeutics

•

A. baumannii rapidly acquires antimicrobial resistance and causes biofilm associated infections.

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Strategies to target intrinsic factors mediating A. baumannii biofilm formation offer therapeutic prospects.

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Antimicrobial polymers and coating medical devices with antibiofilm agents may prevent biofilm associated infections.

•

Biofilm matrix or regulatory mechanisms such as quorum sensing are potential targets for treating chronic infections.

•

Phage therapy, photodynamic therapy and nanoparticle therapy are novel promising approaches for treating biofilm associated infections.

Acinetobacter baumannii has notably become a superbug due to its mounting risk of infection and escalating rates of antimicrobial resistance, including colistin, the last-resort antibiotic. Its propensity to form biofilm on biotic and abiotic surfaces has contributed to the majority of nosocomial infections. Bacterial cells in biofilms are resistant to antibiotics and host immune response, and pose challenges in treatment. Therefore current scenario urgently requires the development of novel therapeutic strategies for successful treatment outcomes. This article provides a holistic understanding of sequential events and regulatory mechanisms directing A. baumannii biofilm formation. Understanding the key factors functioning and regulating the biofilm machinery of A. baumannii will provide us insight to develop novel approaches to combat A. baumannii infections. Further, the review article deliberates promising strategies for the prevention of biofilm formation on medically relevant substances and potential therapeutic strategies for the eradication of preformed biofilms which can help tackle biofilm-associated A. baumannii infections. Advances in emerging therapeutic opportunities such as phage therapy, nanoparticle therapy and photodynamic therapy are also discussed to comprehend the current scenario and future outlook for the development of successful treatment against biofilm-associated A. baumannii infections.

β-lactam Resistance in Pseudomonas aeruginosa: Current Status, Future Prospects

Pseudomonas aeruginosa is a major opportunistic pathogen, causing a wide range of acute and chronic infections. β-lactam antibiotics including penicillins, carbapenems, monobactams, and cephalosporins play a key role in the treatment of P. aeruginosa infections. However, a significant number of isolates of these bacteria are resistant to β-lactams, complicating treatment of infections and leading to worse outcomes for patients. In this review, we summarize studies demonstrating the health and economic impacts associated with β-lactam-resistant P. aeruginosa. We then describe how β-lactams bind to and inhibit P. aeruginosa penicillin-binding proteins that are required for synthesis and remodelling of peptidoglycan. Resistance to β-lactams is multifactorial and can involve changes to a key target protein, penicillin-binding protein 3, that is essential for cell division; reduced uptake or increased efflux of β-lactams; degradation of β-lactam antibiotics by increased expression or altered substrate specificity of an AmpC β-lactamase, or by the acquisition of β-lactamases through horizontal gene transfer; and changes to biofilm formation and metabolism. The current understanding of these mechanisms is discussed. Lastly, important knowledge gaps are identified, and possible strategies for enhancing the effectiveness of β-lactam antibiotics in treating P. aeruginosa infections are considered.

Creation of a Combination Antibiogram for Pseudomonas aeruginosa in a Pediatric Intensive Care Unit

OBJECTIVE

This study describes the creation of a combination antibiogram directed toward Pseudomonas aeruginosa to determine the most appropriate empiric antimicrobial regimen(s).

METHODS

P aeruginosa isolates were collected from all sites between January 2013 and December 2017 for patients admitted to the PICU. Patients with cystic fibrosis and isolates from the same site and susceptibility pattern obtained within 30 days were excluded. β-Lactam susceptibilities were determined and compared with the addition of an aminoglycoside or fluroquinolone and summarized in a combination antibiogram.

RESULTS

One hundred ninety-nine P aeruginosa isolates were included for analysis. The addition of a second agent to piperacillin-tazobactam was shown to have the most significant improvement among the β-lactams, with 70% susceptibility as monotherapy and increases to above 90% with the addition of an aminoglycoside or fluroquinolone. The addition of an aminoglycoside or fluroquinolone to cefepime and meropenem increased coverage to above 95%. The addition of a second agent was likely to increase susceptibility of a monotherapy backbone; however, as the susceptibility of the first-line agent decreased, the susceptibility of the second agent needed to be higher to achieve a 95% coverage threshold.

CONCLUSIONS

Our results support use of a second agent to significantly improve the likelihood of appropriate empiric coverage of P aeruginosa. Use of a combination antibiogram may be more beneficial than a simple antibiogram for units with increasing resistance rates, or for coverage of specific resistant organisms.

Enlisting Parents to Decrease Hospital-Acquired Central Line-Associated Infections in the Pediatric Intensive Care Unit

Hospital-acquired central line-associated bloodstream infections (CLABSIs) are the leading cause of infections in the pediatric intensive care unit. Bacteria responsible for CLABSIs are spread by health care workers, parents, and families and mitigated by scrupulous attention to hand hygiene and safety prevention strategies. Maintenance bundles are grouped elements, such as hand hygiene, standardized dressing and tubing changes, and aseptic technique for entering a central line, effective in preventing CLABSIs. Nurses can decrease the incidence of CLABSIs by using maintenance bundles and including parents and families in safety prevention strategies."

Central line placement at ECMO decannulation: A missed opportunity

INTRODUCTION

ECMO is a support modality for refractory critical illness. This study reviews the incidence and utility of central venous line (CVL) placement at pediatric ECMO decannulation.

METHODS

A single-institution retrospective study of patients undergoing open neck decannulation from 2015 to 2019. Patients were divided into two groups:  ≤ 28-days and > 28-days.

RESULTS

Of 65 patients, 31% had a CVL placed at decannulation. Sepsis and pneumonia were the most common indications for ECMO in the older-group compared to CDH in neonates. The most common indications for CVL were hemodialysis (45%), monitoring (25%), and access (25%). 89% of neonates had an access line placed, whereas 73% of the older group received hemodialysis catheters. Median CRRT requirement was 20 days. 85% of lines were functional at time of removal or death. None were removed for infection. 40% of the patients not receiving a CVL at decannulation required one within 30 days.

CONCLUSION

69% of patients did not have a CVL placed at decannulation, however 40% required a CVL within 30 days. Most lines placed at decannulation remained functional and none were removed for infection. Decannulation removes the circuit as a route for vascular access, but it also presents an opportunity to safely place an essential CVL.

Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward

Infection is the second leading cause of death in patients with cancer. Loss of efficacy in antibiotics due to antibiotic resistance in bacteria is an urgent threat against the continuing success of cancer therapy. In this review, the authors focus on recent updates on the impact of antibiotic resistance in the cancer setting, particularly on the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.). This review highlights the health and financial impact of antibiotic resistance in patients with cancer. Furthermore, the authors recommend measures to control the emergence of antibiotic resistance, highlighting the risk factors associated with cancer care. A lack of data in the etiology of infections, specifically in oncology patients in United States, is identified as a concern, and the authors advocate for a centralized and specialized surveillance system for patients with cancer to predict and prevent the emergence of antibiotic resistance. Finding better ways to predict, prevent, and treat antibiotic-resistant infections will have a major positive impact on the care of those with cancer.

Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations

Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.

Associations of Antimicrobial-Resistant Gram-Negative Bloodstream Infections with Outcomes among Hospitalized Pediatric Patients in the United States

Objective The aim of this study was to assess the impact of pediatric antimicrobial-resistant gram-negative bloodstream infections (GNBSIs).

Methods A retrospective cohort study (2009–2016) was conducted using the Premier Healthcare Database among pediatric admissions with GNBSIs at hospitals reporting microbiology data. Infections for neonates and nonneonates were classified as multidrug resistance (MDR), resistant to one or two antibiotic drug classes (1–2DR), or susceptible.

Results Among 1,276 GNBSIs, 266 (20.8%) infections were 1–2DR and 23 (1.8%) MDR. Compared with susceptible GNBSIs, MDR nonneonates had higher mortality and higher costs, whereas 1–2DR neonates had longer stays and higher costs.

Conclusions Antimicrobial-resistant GNBSIs were associated with worse outcomes among pediatric hospitalized patients.

Invasive Klebsiella pneumoniae Infections in Community-Settings and Healthcare Settings

Objective

To assess clinical characteristics, outcomes and antimicrobial resistance of invasive Klebsiella pneumoniae (KP) infections in Chinese pediatric patients in hospital and community settings.

Methods

This retrospective study was conducted in the nine tertiary hospitals during 2016–2018. The 324 pediatric inpatients who had KP isolated from blood and cerebrospinal fluid and had complete medical records reviewed were included. We analyzed the risk factors, outcomes and antimicrobial resistance pattern of KP-infected patients based on comparison between healthcare-associated KP infections (HAI) and community-acquired infections.

Results

Of the 324 enrolled patients, 275 (84.9%) were clinically defined as HAI, including 175 (63.6%) neonates and 100 (36.4%) aged >28 days. The overall prevalence of CRKP was 38.2% (43.4% in HAI verse 8.7% in CAI, P <0.05). Prematurity (odds ratio (OR): 37.07, 95% CI: 8.29–165.84), hematologic malignancies (OR: 15.52, 95% CI: 1.89–127.14) and invasive mechanical ventilation (OR: 13.09, 95% CI: 1.66–103.56) were independent risk factors for HAI. Patients from rural area (OR: 1.94, 95% CI: 1.12–3.35), invasive mechanical ventilation (OR: 2.33, 95% CI: 1.25–4.33), antibiotic therapy prior to admission (OR: 2.33, 95% CI: 1.25–4.33) and prior hospital stay in the past 30 days (OR: 3.46, 95% CI: 1.87–6.41) were associated with healthcare-associated CRKP infections. Organ dysfunction was independently correlated with poor outcomes (OR: 2.92, 95% CI: 1.23–6.95).

Conclusion

Pediatric invasive KP infections and high prevalence of CRKP infections largely occurred in healthcare settings in China. The adequate and intensified infection control measures should be focused on high-risk hematologic patients, neonatal patients and intubated patients.

Taxifolin, an Inhibitor of Sortase A, Interferes With the Adhesion of Methicillin-Resistant Staphylococcal aureus

The evolution and spread of methicillin-resistant Staphylococcus aureus (MRSA) poses a significant hidden risk to human public health. The majority of antibiotics used clinically have become mostly ineffective, and so the development of novel anti-infection strategies is urgently required. Since Staphylococcus aureus (S. aureus) cysteine transpeptidase sortase A (SrtA) mediates the surface-anchoring of proteins to its surface, compounds that inhibit SrtA are considered potential antivirulence treatments. Herein, we report on the efficacy of the potent SrtA inhibitor taxifolin (Tax), a flavonoid compound isolated from Chinese herbs. It was able to reversibly block the activity of SrtA with an IC₅₀ of 24.53 ± 0.42 μM. Tax did not display toxicity toward mammalian cells or S. aureus at a concentration of 200 μM. In addition, Tax attenuated the virulence-related phenotype of SrtA in vitro by decreasing the adherence of S. aureus, reducing the formation of a biofilm, and anchoring of S. aureus protein A on its cell wall. The mechanism of the SrtA-Tax interaction was determined using a localized surface plasmon resonance assay. Subsequent mechanistic studies confirmed that Asp-170 and Gln-172 were the principal sites on SrtA with which it binds to Tax. Importantly, in vivo experiments demonstrated that Tax protects mice against pneumonia induced by lethal doses of MRSA, significantly improving their survival rate and reducing the number of viable S. aureus in the lung tissue. The present study indicates that Tax is a useful pioneer compound for the development of novel agents against S. aureus infections.

Faucet aerator design influences aerosol size distribution and microbial contamination level

Faucet aerators have been linked to multiple opportunistic pathogen outbreaks in hospital, especially Pseudomonas aeruginosa, their complex structure promoting biofilm development. The importance of bacteria aerosolization by faucet aerators and their incidence on the risk of infection remain to be established. In this study, ten different types of aerators varying in complexity, flow rates and type of flow were evaluated in a controlled experimental setup to determine the production of aerosols and the level of contamination. The aerosol particle number density and size distribution were assessed using a particle spectrometer. The bacterial load was quantified with a 14-stage cascade impactor, where aerosol particles were captured and separated by size, then analysed by culture and flow cytometry. The water was seeded with Pseudomonas fluorescens as a bacterial indicator. Aerosol particle size and mean mass distribution varied depending on the aerator model. Devices without aeration or with laminar flow produced the lowest number and mass of aerosol particles when measured with spectrometry. Models with aeration displayed wide differences in their potential production of aerosol particles. A new aerator with a low flow, no air inlet in its structure, and a spray stream produced 12 to 395 times fewer aerosol particles containing bacteria. However, the impact of low flow on biofilm development and incorporation of pathogens should be further investigated. Repeated use of aerators resulted in fouling which increased the quantity of bacteria released through aerosol particles. An in-depth mechanical cleaning including complete dismantling of the aerator was required to recover initial performances. Aerators should be selected to minimize aerosol production, considering the ease of maintenance and the main water usage at each sink. Low flow aerators produced a lower number of contaminated aerosol particles when new but may be more susceptible to fouling and quickly lose their initial advantage.

Spa Typing of Staphylococcus aureus in a Neonatal Intensive Care Unit During Routine Surveillance

BACKGROUND

Staphylococcus aureus protein A (spa) typing can be used to expand characterization of the epidemiology of methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) in neonatal intensive care units (NICU).

METHODS

From January 2017 to June 2018, twice-monthly surveillance for S. aureus was performed in an academically affiliated NICU. Decolonization of infants colonized with S. aureus included chlorhexidine gluconate bathing and/or mupirocin for those with mupirocin-susceptible strains. Spa typing and mupirocin-resistance testing were performed. Demographic and clinical characteristics were compared between infants colonized with MSSA vs MRSA and infants with and without the most common MSSA spa type, MSSA-t279.

RESULTS

Overall, 14% and 2% of 1556 hospitalized infants had positive surveillance cultures for MSSA and MRSA, respectively. Thirty-six infants harbored unique MSSA spa types, 5 infants harbored unique MRSA spa types, and 30 MSSA and 6 MRSA spa types were identified in ≥2 infants. No outbreaks were identified during the study period. MSSA-t279 was isolated from 3% of infants and largely detected from infants hospitalized in one section of the NICU; 96% of t279 isolates were mupirocin resistant. Infection rates, length of hospitalization, and mortality were similar among infants initially colonized with t279 vs other MSSA spa types.

CONCLUSIONS

The MSSA colonization burden was 5-fold larger than that of MRSA. Numerous unique spa types were identified. The most common spa type, MSSA-t279, was not associated with increased morbidity or mortality but was mupirocin resistant and associated with clustered NICU beds. This suggests potential transmission from the environment, shared staff, and/or workflow issues requiring further study. Other decolonization strategies for S. aureus in the NICU are needed.

Infection Prevention in the Neonatal Intensive Care Unit

Although many aspects of infection prevention and control (IPC) mirror institutional efforts, optimization of IPC practices in the neonatal intensive care unit requires careful consideration of its unique population and environment, addressed here for key IPC domains. In addition, innovative mitigation efforts to address challenges specific to limited resource settings are discussed.

Oral and tracheal microbiota of pediatric and adolescent patients in an intensive care unit

OBJECTIVE

To characterize the oral and tracheal microbiota of patients admitted to a pediatric intensive care unit (PICU).

METHODS AND RESULTS

This is an exploratory study conducted on patients aged 5 months to 13 years admitted to the PICU of a referral hospital. Two microbiological samples were collected with a swab in the posterior region of the tongue from patients receiving spontaneous and mechanical ventilation within the first 24 and 48 h after admission to the PICU. Among patients receiving mechanical ventilation, tracheal secretion was also collected in a second sampling. The caries experience was evaluated using the DMFT/dmf index, and the quality of oral hygiene was assessed based on the visual plaque index (VPI). A questionnaire was applied to obtain data on hospital routine and sample characteristics. The DMFT/dmf index was 1.66 (SD = 2.18) and the mean VPI was 43.03 (SD = 36.93). The most prevalent microorganisms were Klebsiella pneumoniae (15%). Oral colonization by opportunistic pathogens was significantly higher in patients receiving mechanical ventilation compared to those on spontaneous ventilation (p < .05). There was no relationship of VPI or DMFT/dmf with oral microbiological changes.

CONCLUSION

The results indicate that PICU patients are susceptible to colonization by respiratory and opportunistic pathogens since the first hours of hospitalization.

Importance of Reviewing Antibiotic Courses by 48 Hours: Risk Factors for Third-Generation Cephalosporin Resistance Among AmpC Harboring Organisms in Urine and Respiratory Cultures

BACKGROUND

Citrobacter, Enterobacter, Morganella, and Serratia (AmpC organisms) species can exhibit third-generation cephalosporin (TGC) resistance after TGC exposure. We aimed to assess if institutional TGC utilization correlated with institutional AmpC organism susceptibility and if prior TGC exposure ≤48 hours were associated with TGC resistance in the first culture of a future infection episode caused by an AmpC organism.

METHODS

A 5-year retrospective cohort study was performed, including AmpC organisms isolated from pediatric urinary and respiratory tract cultures at an institution with TGC courses reviewed by the antimicrobial stewardship program at 48 hours. Correlations were assessed by Pearson's correlation. Multivariable logistic regression identified factors independently associated with TGC resistance in a subcohort of infection episodes.

RESULTS

Among 654 cultures, AmpC organism TGC susceptibility increased from 74% in 2013 to 89.3% in 2017, and this correlated with a 26.1% decrease in TGC utilization (R = -0.906; P = 0.034). Among 275 AmpC organism infections, 21.1% were resistant. Resistance occurred in 13.6%, 17.4%, and 56.5% of infections with no exposure, ≤48 hours, and >48 hours of TGC exposure in the past 30 days, respectively. TGC exposure ≤48 hours was not associated with resistance (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.32-4.94; P = 0.74), whereas, TGC exposure >48 hours was (OR, 8.7; 95% CI, 3.67-20.6; P  < 0.001). Infections in 2017 were less likely to be resistant (OR, 0.25; 95% CI, 0.08-0.8; P = 0.019).

CONCLUSIONS

Decreased TGC utilization, likely related to antimicrobial stewardship, correlated with increased AmpC organism susceptibility. Limiting TGC exposure to ≤48 hours when possible may reduce AmpC organism resistance in future infections.

Prevalence, Antimicrobial Susceptibility Patterns, and Risk Factors Associated with Enterococci among Pediatric Patients at Dessie Referral Hospital, Northeastern Ethiopia

BACKGROUND

Enterococcus species, which is previously considered as medically not important, now becomes one of the leading causes of nosocomial infections. Even though it becomes the most public health concern and emerging multidrug-resistant pathogen, there is no enough data in the study area.

OBJECTIVE

To determine the prevalence, antimicrobial resistance pattern, and associated risk factors of enterococci infection in pediatric patients.

METHODS

A hospital-based cross-sectional study was conducted from February to May 2019 at Dessie Referral Hospital, Northeastern Ethiopia. A total of 403 pediatric patients were included in the study, and a pretested structured questionnaire was used to collect sociodemographic and risk factor-related data. Clinical samples such as urine, blood, wound swabs, discharges, and other body fluids were collected aseptically and inoculated on to Bile Esculin Azide Agar, and colony characteristics, Gram stain, catalase, salt, and temperature tolerance tests were employed for bacterial identification. Antimicrobial sensitivity tests were performed using the modified Kirby-Bauer disk diffusion method. Data was entered into SPSS software version 25 and descriptive statistics; bivariate and multivariate logistic regression analyses were performed. In all cases, a P value ≤ 0.05 with corresponding 95% confidence interval were considered as statistically significant.

RESULT

The overall prevalence of enterococci was 2.7% (11/403). Of which, the highest number of enterococci infection was recovered from urine sample (54.5%) followed by blood (27.3%), wound swab (9.1%), and other body fluids (9%). The overall multidrug resistance rate was 54.5%. Higher drug resistance pattern was observed against tetracycline, chloramphenicol, and amoxicillin/clavulanate. Having history of invasive procedure (P < 0.001), chronic illness (P < 0.001) and previous admission history of the children (P < 0.001) were statistically significant associated risk factors for pediatrics enterococci infection.

CONCLUSION

The prevalence of enterococci from pediatric patients in this study was relatively low compared to other studies. Significant rates of MDR and VRE were identified, and the risk of infection became high when children had a history of different chronic illnesses and history of admission and underwent invasive treatment procedures. Therefore, efforts should be made to prevent enterococci infections and spread of multidrug-resistant enterococci.

Comparative analysis of perioperative prophylactic antibiotics in prevention of surgical site infections in stented, distal hypospadias repair

PURPOSE

There is limited evidence that prophylactic antibiotics prevent surgical site infection in stented, distal hypospadias repair. Our hypothesis is that the use of prophylactic antibiotics does not affect the rate of surgical site infection in this setting.

METHODS

We conducted a retrospective study of consecutive patients over a 6-year period with distal penile hypospadias treated with urethral stenting. Variables analyzed include age, type of repair, usage of preoperative and/or postoperative antibiotics, and length of follow-up. Patients with a history of proximal or re-operative hypospadias repair were excluded. Surgical site infection was defined by the presence of postoperative penile erythema and/or purulent drainage treated with therapeutic antibiotics. Secondary outcome analysis included the presence of other hypospadias complications.

RESULTS

441 consecutive subjects met our inclusion criteria with a mean age of 13.3 months. Patients were categorized into groups: Group 1 - Preoperative antibiotics (n = 64), Group 2 - Both Preoperative & Postoperative antibiotics (n = 159), Group 3 - Postoperative antibiotics (n = 122), Group 4 - No Preoperative or Postoperative antibiotics (n = 96). Two surgical site infections were reported out of the 441 patients: 1 in Group 3 and 1 in Group 4 (p = 0.513). There was no significant difference in the total patients with a hypospadias complication between groups. In the table below, Groups 1-3 were combined (345 patients) for comparison to Group 4 (No antibiotics, 96 patients) for further analysis with no difference in SSIs (p = 0.388) or respective hypospadias complications.

CONCLUSIONS

The use of perioperative prophylactic antibiotics, both before and after surgery for distal, stented hypospadias repair, have not been shown to reduce the rate of surgical site infections nor hypospadias complications. Consequently, the benefit of prophylactic antibiotics in this setting is unclear.

Burden of healthcare-associated infections among hospitalized children within community hospitals participating in an infection control network

We describe the frequency of pediatric healthcare-associated infections (HAIs) identified through prospective surveillance in community hospitals participating in an infection control network. Over a 6-year period, 84 HAIs were identified. Of these 51 (61%) were pediatric central-line-associated bloodstream infections, and they often occurred in children <1 year of age.

Active Surveillance of Healthcare-associated Infections in Pediatric Intensive Care Units: Multicenter ECDC HAI-net ICU Protocol (v2.2) Implementation, Antimicrobial Resistance and Challenges

BACKGROUND

Surveillance is essential to all aspects of management of healthcare-associated infections (HAIs) in critically ill children, where data are limited. We conducted an active surveillance study to elucidate epidemiology, resistance, antimicrobial treatment practices and outcomes of pediatric intensive care unit-acquired HAIs in a southern European country.

METHODS

Four Greek pediatric intensive care unit encounters (153 patients, 2183 patient-days) during a 6-month period participated using the European Centre for Disease Prevention and Control HAI-net ICU (v2.2) protocol. Bloodstream infections and device-associated HAIs were recorded. Clinical severity, isolated pathogens, antimicrobial resistance and antibiotic prescriptions were collected on a daily basis. Mortality and excess length of stay due to HAI were also assessed.

RESULTS

Overall rate of HAIs was 18.3 per 1000 patient-days. Aggregate rates for device-associated HAI were: catheter-related bloodstream infection 2.32, intubation-associated pneumonia 10.5, and catheter-associated urinary tract infection 4.6 per 1000 device-days. Children with HAI (n = 28, 18.3%) had higher severity of illness (Pediatric Risk Mortality Score 7.5 vs. 4, P < 0.001), longer hospitalization (23 vs. 6 days, P < 0.001), but not higher mortality, compared with those without. Most frequent recovered pathogens were Klebsiella pneumoniae (40%), Pseudomonas aeruginosa (22.5%), Acinetobacter baumannii (12.5%), with respective carbapenem resistance 50%, 44% and 80%, and Staphylococcus aureus (12.5%). Total antibiotic use was 2142 days of treatment per 1000 patient-days.

CONCLUSIONS

Our study, based on the updated ECDC HAI-net ICU (v2.2) protocol, effectively addresses the significant burden of HAIs in critically ill children in Greece. Using a well-standardized system facilitates inter- and intra-countries reliable recordings and comparative assessments of infection control programs.

The Impact of a Dedicated Nurse on the Prevention of Central Line-Associated Bloodstream Infections in the NICU

BACKGROUND

The neonatal population is at increased risk for central line-associated bloodstream infections (CLABSIs) related to prematurity, critical illness, and compromised immune function.^1,4,5 METHODS: To address a 30 percent CLABSI rate increase, a quality improvement (QI) project in a Level IV NICU was developed and implemented by the NICU CLABSI team in 2018. The project trialed a dedicated CLABSI prevention-registered nurse (DCP-RN) role with select responsibilities aimed at rate reduction. The DCP-RN spearheaded an RN education plan, addressed prevention bundle compliance, and aided in establishing a reliable apparent cause analysis (ACA) process.

RESULTS

The outcome resulted in an over 50% reduction in the CLABSI rate and permanent adoption of the DCP-RN role in the NICU.

Safety and clinical application of nonbronchoscopic bronchoalveolar lavage in preterm neonates with clinical ventilator-associated pneumonia

BACKGROUND

The safety and clinical application of nonbronchoscopic bronchoalveolar lavage (NB-BAL) in preterm neonates with ventilator-associated pneumonia (VAP) have not been fully investigated, and limited data on the feasibility of this method are available.

METHODS

Premature infants with clinically suspected VAP between October 2017 and June 2019 were enrolled, and NB-BAL was performed. The tolerance and safety of NB-BAL were prospectively recorded during the procedure, and the clinical applications of NB-BAL were observed.

RESULTS

A total of 46 NB-BAL procedures were performed in 31 neonates with clinically suspected VAP. The median (interquartile range) gestational age and birth body weight were 28.7 (26.7-31.3) weeks and 1055.0 (817.0-1475.0) grams, respectively. Overall, all episodes of the procedure were well tolerated, with only 9 (19.5%) episodes showing transient desaturation and one patient (2.2%) showing bradycardia during the NB-BAL procedure. There were no impairments in arterial blood gas, cardiopulmonary parameters or respiratory severity scores after NB-BAL. No significant complications occurred in any of the patients who received NB-BAL. No chronic comorbidities affected the safety and clinical application of NB-BAL in these mechanically ventilated preterm neonates. NB-BAL yielded a diagnosis in 32 (69.6%) of these VAP episodes. Staphylococcus aureus was the most common isolated bacterium and accounted for 7 (15.2%) confirmed cases of VAP in our study, followed by polymicrobial microorganisms (n = 6, 13.0%). The appropriate antibiotics were prescribed and modified according to the NB-BAL results in 25 (54.3%) cases of VAP.

CONCLUSIONS

NB-BAL is a safe and clinically applicable method for determining the etiology and diagnosis of VAP in the NICU, even in extremely preterm neonates with major chronic comorbidities. Further studies to investigate the diagnostic accuracy and impact of NB-BAL on VAP treatment in neonates are warranted in the future.

Sustainable neonatal CLABSI surveillance: consensus towards new criteria in the Netherlands

BACKGROUND

Central line-associated bloodstream infections (CLABSI) are a main focus of infection prevention and control initiatives in neonatal care. Standardised surveillance of neonatal CLABSI enables intra- and interfacility comparisons which can contribute to quality improvement. To date, there is no national registration system for CLABSI in neonatal care in the Netherlands and several criteria are used for local monitoring of CLABSI incidence rates. To achieve standardised CLABSI surveillance we conducted a consensus procedure with regard to nationwide neonatal CLABSI surveillance criteria (SC).

METHODS

A modified Delphi consensus procedure for the development of nationwide neonatal CLABSI SC was performed between January 2016 and January 2017 in the Netherlands. An expert panel was formed by members of the Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society. The consensus procedure consisted of three expert panel rounds.

RESULTS

The expert panel achieved consensus on Dutch neonatal CLABSI SC. Neonatal CLABSI is defined as a bloodstream infection occurring more than 72 h after birth, associated with an indwelling central venous or arterial line and laboratory confirmed by one or more blood cultures. In addition, the blood culture finding should not be related to an infection at another site and one of the following criteria can be applied: 1. a bacterial or fungal pathogen is identified from one or more blood cultures; 2. the patient has clinical symptoms of sepsis and 2A) a common commensal is identified in two separate blood cultures or 2B) a common commensal is identified by one blood culture and C-reactive protein level is above 10 mg/L in the first 36 h following blood culture collection.

CONCLUSIONS

The newly developed Dutch neonatal CLABSI SC are concise, specified to the neonatal population and comply with a single blood culture policy in actual neonatal clinical practice. International agreement upon neonatal CLABSI SC is needed to identify best practices for infection prevention and control.

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

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.