Enterobacter cloacae outbreak in the NICU related to disinfected thermometers

The EC-COMPASS: Long-term, multi-centre surveillance of Enterobacter cloacae complex - a clinical perspective

BACKGROUND

Enterobacter cloacae complex (ECCO) comprises closely related Enterobacterales, causing a variety of infections ranging from mild urinary tract infections to severe bloodstream infections. ECCO has emerged as a significant cause of healthcare-associated infections, particularly in neonatal and adult intensive care.

AIM

The Enterobacter Cloacae COMplex PASsive Surveillance (EC-COMPASS) aims to provide a detailed multi-centre overview of ECCO epidemiology and resistance patterns detected in routine microbiological diagnostics in four German tertiary-care hospitals.

METHODS

In a sentinel cluster of four German tertiary-care hospitals, all culture-positive ECCO results between 1st January 2020 and 31st December 2022, were analysed based on Hybase® laboratory data.

FINDINGS

Analysis of 31,193 ECCO datasets from 14,311 patients revealed a higher incidence in male patients (P<0.05), although no significant differences were observed in ECCO infection phenotypes. The most common sources of ECCO were swabs (42.7%), urine (17.5%), respiratory secretions (16.1%), blood cultures (8.9%) and tissue samples (5.6%). The annual bacteraemia rate remained steady at approximately 33 cases per hospital. Invasive ECCO infections were predominantly found in oncology and intensive care units. Incidences of nosocomial outbreaks were infrequent and limited in scope. Notably, resistance to carbapenems was consistently low.

CONCLUSION

EC-COMPASS offers a profound clinical perspective on ECCO infections in German tertiary-healthcare settings, highlighting elderly men in oncology and intensive care units as especially vulnerable to ECCO infections. Early detection strategies targeting at-risk patients could improve ECCO infection management.

So, what's best? Accuracy and acceptance of thermometers in triage and inpatients in a low-resource tropical setting - The MaTe study

Objectives

We searched for the most-suitable thermometry method in the low-resource, tropical setting of Sierra Leone, both in terms of accuracy and also patient and user acceptance.

Methods

We conducted a prospective comparative study of different methods of body temperature measurement. Each participant had their temperature taken by four different methods: non-contact infrared temperature (NCIT), axillary, tympanic membrane and rectal measurements. Rectal temperature was considered clinical gold standard. Primary outcome was predicted sensitivity and specificity of thermometry methods in detecting fever (rectal temperature ≥38.0 °C). Questionnaires were used to explore patient and healthcare worker attitudes towards different methods of temperature-taking.

Results

824 rectal body temperature readings were taken from 562 participants. The mean rectal temperature was 37.4 °C (IQR 37 °C to 37.7 °C), with a minimum reading of 35.2 °C and maximum of 41.0 °C. Tympanic membrane thermometry showed the highest sensitivity of fever detection using the Genius3 TM thermometer (sensitivity 70.8 %, 95 % CI 60.2%-79.9 %; specificity 97.2 %, 95 % CI 95.5-98.4 %); and Braun TM (sensitivity 51.5 %, 95 % CI 42.6%-62.0 %; specificity 98.8 %, 95 % CI 97.7-99.5). NCIT thermometry sensitivity was low (36.8 %-41.4 % for the two devices used). Axillary thermometry sensitivity was 40.6 %. Participants ranked NCIT as the most and rectal as the least preferred method. Questionnaires from 32 participating nurses showed agreeability to using NCIT, TM and axillary methods routinely, but less so for rectal thermometry.

Conclusions

When combining the accuracy of different thermometry methods in detecting fever with user and patient acceptability, tympanic membrane thermometry appears most suitable but also has limitations.

Functional Annotation of Hypothetical Proteins From the Enterobacter cloacae B13 Strain and Its Association With Pathogenicity

Enterobacter cloacae B13 strain is a rod-shaped gram-negative bacterium that belongs to the Enterobacteriaceae family. It can cause respiratory and urinary tract infections, and is responsible for several outbreaks in hospitals. E. cloacae has become an important pathogen and an emerging global threat because of its opportunistic and multidrug resistant ability. However, little knowledge is present about a large portion of its proteins and functions. Therefore, functional annotation of the hypothetical proteins (HPs) can provide an improved understanding of this organism and its virulence activity. The workflow in the study included several bioinformatic tools which were utilized to characterize functions, family and domains, subcellular localization, physiochemical properties, and protein-protein interactions. The E. cloacae B13 strain has overall 604 HPs, among which 78 were functionally annotated with high confidence. Several proteins were identified as enzymes, regulatory, binding, and transmembrane proteins with essential functions. Furthermore, 23 HPs were predicted to be virulent factors. These virulent proteins are linked to pathogenesis with their contribution to biofilm formation, quorum sensing, 2-component signal transduction or secretion. Better knowledge about the HPs’ characteristics and functions will provide a greater overview of the proteome. Moreover, it will help against E. cloacae in neonatal intensive care unit (NICU) outbreaks and nosocomial infections.

Case report: Thromboembolic heartworm induced lower limb necrosis in a dog

A 9-year-old spayed female boxer suffered from lameness in both hindlimbs with a perforated paw wound. Additionally, a linear, worm-like creature was penetrating out from the wound. On examination, the dog was emaciated and infected with heartworms, detected through a fresh blood smear, echocardiography, and transabdominal ultrasonography. Adult heartworms were detected at the right atrium (RA), right ventricle (RV), and pulmonary artery (PA), including the distal abdominal aorta, external iliac, and femoral arteries. During the surgery, adults heartworms were removed from both the heart (n = 8) and the femoral arteries (n = 5). Unfortunately, not all heartworms could be removed from these locations due to the extent of the heartworm infection. The opened, ischemic wounds in the distal limbs progressively expanded and the dog subsequently died, possibly due to caval syndrome complications and septicemia. The necropsy showed no evidence of an atrial septal defect, and a total of 25 adult heartworms were collected from the perforated paw, heart, pulmonary, and femoral arteries. All worms collected during the necropsy process were molecularly confirmed to be Dirofilaria immitis.

Disinfection of Stethoscope and Non-Infrared Thermometer: Practices of Physicians in Ethiopia in the Era of COVID-19

BACKGROUND

Stethoscopes and non-infrared thermometers are the customary medical equipment used by the physicians on a daily basis, among various patients. With the rise of potential infections in the healthcare facilities and the transmission nature of the current COVID-19 pandemic, consistent and correct disinfections of these devices after each use should not be pardoned. This study, therefore, aimed to assess the level of stethoscope and non-infrared thermometer disinfection practices among physicians involved in direct patient contact during the COVID-19 pandemic.

METHODS

A web-based cross-sectional survey was conducted among physicians working in Ethiopia to assess their practice of stethoscope and non-infrared thermometer disinfection. The online survey was circulated using an anonymous and self-reporting questionnaire via Google form with a consent form appended to it. The developed Google form link was shared with physicians through their email addresses and social media pages. A descriptive summary was computed and presented by tables and figures. Multivariable logistic regression model was used to identify factors associated stethoscope and non-infrared thermometer after every use.

RESULTS

The proportion of stethoscope and non-infrared thermometer disinfections after every use was 13.9% (95% CI: 10.9-17.6) and 20.4% (95% CI: 16.7-24.5), respectively. Taking COVID-19 training (AOR: 2.52; 95% CI: 1.29-4.92) and the availability of stethoscope disinfection materials at the workplace (AOR: 3.03; 95% CI: 1.29-7.10) were significantly increased the odds of stethoscope disinfection after every use. The odds of stethoscope disinfection after every use was significantly decreased for those who reported the use of shared stethoscope (AOR: 0.34; 95% CI: 0.12-0.92).

CONCLUSION

Only a wee share of the respondents reported that they have disinfected their stethoscopes and non-infrared thermometers after every use - possibly jeopardizing both patients and clinicians safety, particularly during the COVID-19 pandemic.

Temperature Monitoring Devices in Neonates

Introduction: Accurate temperature monitoring of neonates is vital due to the significant morbidities and mortality associated with neonatal hypothermia. Many studies have compared different thermometers in neonates, however, there is a lack of consensus regarding which of the currently available thermometers is most suitable for use in neonates. Objectives: The aim of this review was to identify and compare current methods available for temperature monitoring of neonates beyond the delivery room, including the accuracy, advantages and disadvantages of each. Methods: A recent search and narrative synthesis of relevant studies published between January 1, 1949 and May 5, 2021 on the OVID Medline, PubMed and Google Scholar databases. Results: A total of 160 papers were retrieved for narrative synthesis. The main methods available for temperature monitoring in neonates are human touch and mercury-in-glass, electronic, infrared tympanic and other infrared thermometers. Newer innovations that are also available include liquid crystal thermometers and the BEMPU TempWatch. This paper discusses the current evidence available regarding the utility of these devices, and identifies barriers to valid comparison of different thermometry methods. Conclusion: Many methods for temperature monitoring in neonates are currently available, each with their own advantages and disadvantages. However, the accuracies of different devices are hard to determine due to variable methodologies used in relevant studies and hence, further research that addresses these gaps is needed.

Fluorescent tagging for environmental surface cleaning surveillance in a veterinary hospital

OBJECTIVES

To evaluate the use of fluorescent tagging for environmental surface cleaning surveillance in a small animal veterinary hospital and identify factors associated with tag removal.

MATERIALS AND METHODS

Over 5.5 weeks, a commercial fluorescent dye (Glo Germ) was used to tag (mark) surfaces in a small animal veterinary teaching hospital. Twenty-four hours after tagging, cleaning was assessed with a black light (UV-A source). Surfaces were recorded as cleaned based on complete removal of fluorescent tagging at assessment. Proportions cleaned were calculated overall and by predictors (i.e. surface location/type, primary nature of surface contact - animal/human, week of study).

RESULTS

A total of 4984 surfaces were tagged and assessed. Overall cleaning was 50%. Cleaning varied by surface/object (range: 2 to 100%) and hospital location (4 to 78%). Surfaces designated as having primarily animal contact were cleaned more frequently than those with primarily human contact (75%, 42%; P<0.001). Cleaning varied over the study period (range by week: 45 to 54%;); a significant trend was not identified.

CLINICAL SIGNIFICANCE

Key surfaces in the small animal veterinary practice environment are unlikely to be adequately cleaned, posing a concern for animal and human health. Commercial products can be effectively used to asses environmental cleaning with findings used to target clinic-specific barriers to improve cleaning and reduce hospital-associated infections.

Beyond high-touch surfaces: Portable equipment and floors as potential sources of transmission of health care-associated pathogens

Efforts to improve environmental cleaning and disinfection typically focus primarily on high-touch surfaces in patient rooms. This review highlights evidence that portable equipment and other shared devices and floors may be underappreciated as sources of dissemination of health care-associated pathogens. Practical approaches to address these sites of contamination are emphasized.

Translating research to policy at the NCSE 2017 symposium "Microbiology of the Built Environment: Implications for Health and Design"

Here, we summarize a symposium entitled "Microbiology of the Built Environment: Implications for Health and Design" that was presented at the National Council for Science and the Environment (NCSE) 17th National Conference and Global Forum in January 2017. We covered topics including indoor microbial exposures and childhood asthma, the influence of hospital design on neonatal development, the role of the microbiome in our premise (i.e., building) plumbing systems, antibiotic resistance, and quantitative microbial risk assessment. This symposium engaged the broader scientific and policy communities in a discussion to increase awareness of this critical research area and translate findings to practice.

The Role of Patient Care Items as a Fomite in Healthcare-Associated Outbreaks and Infection Prevention

Patient-care items can serve as a source or reservoir for healthcare-associated pathogens in hospitals. We reviewed healthcare- associated outbreaks from medical equipment and provide infection prevention recommendations. Multiple healthcare-associated outbreaks via a contaminated patient-care item were identified, including infections with multidrug-resistant organisms. The type of patient care items implicated as a fomite causing healthcare-associated infections (HAIs) has changed over time. Patient populations at risk were most commonly critically ill patients in adult and neonatal intensive care units. Most fomite related healthcare-associated outbreaks were due to inappropriate disinfection practices. Repeated healthcare-associated outbreaks via medical equipment highlight the need for infectious disease professionals to understand that fomites/medical devices may be a source of HAIs. The introduction of new and more complex medical devices will likely increase the risk that such devices serve as a source of HAIs. Assuring appropriate cleaning and disinfection or sterilization of medical equipment is necessary to prevent future fomite-associated outbreaks.

Tympanic temperature versus temporal temperature in patients with pyrexia and chills

Accurate body temperature (BT) measurement is critical for immediate and correct estimation of core BT; measurement of changes in BT can provide physicians the initial information for selecting appropriate diagnostic approach and may prevent unnecessary diagnostic investigation. This study aimed to assess differences in tympanic and temporal temperatures among patients with fever in different conditions, especially in those with and without chills. This prospective study included patients from the emergency department between 2011 and 2012. All temperature measurements were obtained using tympanic thermometers and infrared skin thermometers. Differences in tympanic and temporal temperatures were analyzed according to 6 age groups, 5 ambient temperature groups, and 6 tympanic and temporal temperature subgroups. General linear model analysis and receiver operating characteristic curve analysis were used to estimate the differences in mean tympanic and temporal temperatures. Of the 710 patients enrolled, 246 had tympanic temperature more than 38.0°C, including 46 with chills (18.7%). Fourteen patients (3.0%) had chills and tympanic temperature less than 38°C. In the tympanic temperature subgroup of 39.0 to less than 39.5°C, approximately one-third of the patients had chills (32.3%). In the tympanic temperature subgroup of 38.0 to less than 39.0°C, the tympanic temperature was 0.4°C higher than the temporal temperature in patients without chills and 0.9°C higher in patients with chills. In the tympanic temperature subgroup of 39.0°C or more, tympanic temperature was 0.7°C higher than temporal temperature in patients without chills and 0.8°C higher in patients with chills. Temporal thermometer is more reliable in the age group of less than 1 year and 18 to less than 65 years. When the patients show tympanic temperature range of 38.0 to less than 39.0°C, 0.4°C should be added for patients without chills and 0.9°C for patients with chills to obtain core temperature. However, in patients with tympanic temperature of 39.0°C or more, 0.7°C to 0.8°C should be added, regardless of the presence of chills.

Microorganisms in Confined Habitats: Microbial Monitoring and Control of Intensive Care Units, Operating Rooms, Cleanrooms and the International Space Station

Indoor environments, where people spend most of their time, are characterized by a specific microbial community, the indoor microbiome. Most indoor environments are connected to the natural environment by high ventilation, but some habitats are more confined: intensive care units, operating rooms, cleanrooms and the international space station (ISS) are extraordinary living and working areas for humans, with a limited exchange with the environment. The purposes for confinement are different: a patient has to be protected from infections (intensive care unit, operating room), product quality has to be assured (cleanrooms), or confinement is necessary due to extreme, health-threatening outer conditions, as on the ISS. The ISS represents the most secluded man-made habitat, constantly inhabited by humans since November 2000 – and, inevitably, also by microorganisms. All of these man-made confined habitats need to be microbiologically monitored and controlled, by e.g., microbial cleaning and disinfection. However, these measures apply constant selective pressures, which support microbes with resistance capacities against antibiotics or chemical and physical stresses and thus facilitate the rise of survival specialists and multi-resistant strains. In this article, we summarize the available data on the microbiome of aforementioned confined habitats. By comparing the different operating, maintenance and monitoring procedures as well as microbial communities therein, we emphasize the importance to properly understand the effects of confinement on the microbial diversity, the possible risks represented by some of these microorganisms and by the evolution of (antibiotic) resistances in such environments – and the need to reassess the current hygiene standards.

Survival of Cephalosporin-Resistant Enterobacteriaceae on Fingers

Five strains ofEnterobacterspecies (n= 4) andPantoeaspecies (n= 1) resistant to third-generation cephalosporins and isolated from clusters of 3-25 premature infants and small children and 5 strains (4Enterobacterstrains and 1Pantoeastrain) with the same resistance pattern that were isolated from 1 premature infant or small child each were inoculated on the fingertips of 10 volunteer study participants to test whether survival on fingertips is correlated with horizontal transmission. Although there was no significant difference in survival between the groups of transmitted and sporadic strains, there were significant differences in bacterial survival between the participants.

Concentrations and Sources of Airborne Particles in a Neonatal Intensive Care Unit

Premature infants in neonatal intensive care units (NICUs) have underdeveloped immune systems, making them susceptible to adverse health consequences from air pollutant exposure. Little is known about the sources of indoor airborne particles that contribute to the exposure of premature infants in the NICU environment. In this study, we monitored the spatial and temporal variations of airborne particulate matter concentrations along with other indoor environmental parameters and human occupancy. The experiments were conducted over one year in a private-style NICU. The NICU was served by a central heating, ventilation and air-conditioning (HVAC) system equipped with an economizer and a high-efficiency particle filtration system. The following parameters were measured continuously during weekdays with 1-min resolution: particles larger than 0.3 μm resolved into 6 size groups, CO2 level, dry-bulb temperature and relative humidity, and presence or absence of occupants. Altogether, over sixteen periods of a few weeks each, measurements were conducted in rooms occupied with premature infants. In parallel, a second monitoring station was operated in a nearby hallway or at the local nurses' station. The monitoring data suggest a strong link between indoor particle concentrations and human occupancy. Detected particle peaks from occupancy were clearly discernible among larger particles and imperceptible for submicron (0.3-1 μm) particles. The mean indoor particle mass concentrations averaged across the size range 0.3-10 μm during occupied periods was 1.9 μg/m(3), approximately 2.5 times the concentration during unoccupied periods (0.8 μg/m(3)). Contributions of within-room emissions to total PM10 mass in the baby rooms averaged 37-81%. Near-room indoor emissions and outdoor sources contributed 18-59% and 1-5%, respectively. Airborne particle levels in the size range 1-10 μm showed strong dependence on human activities, indicating the importance of indoor-generated particles for infant's exposure to airborne particulate matter in the NICU.

Use of ward closure to control outbreaks among hospitalized patients in acute care settings: a systematic review

BACKGROUND

Though often used to control outbreaks, the efficacy of ward closure is unclear. This systematic review sought to identify studies defining and describing ward closure in outbreak control and to determine impact of ward closure as an intervention on outbreak containment.

METHODS

We searched these databases with no language restrictions: MEDLINE, 1946 to 7 July 2014; EMBASE, 1974 to 7 July 2014; CINAHL, 1937 to 8 July 2014; and Cochrane Database of Systematic Reviews, 2005 to May 2014. We also searched the following: IndMED; LILACS; reference lists from retrieved articles; conference proceedings; and websites of the CDCP, the ICID, and the WHO. We included studies of patients hospitalized in acute care facilities; used ward closure as a control measure; used other control measures; and discussed control of the outbreak(s) under investigation. A component approach was used to assess study quality.

RESULTS

We included 97 English and non-English observational studies. None included a controlled comparison between ward closure and other interventions. We found that ward closure was often used as part of a bundle of interventions but could not determine its direct impact separate from all the other interventions whether used in parallel or in sequence with other interventions. We also found no universal definition of ward closure which was widely accepted.

CONCLUSIONS

With no published controlled studies identified, ward closure for control of outbreaks remains an intervention that is not evidence based and healthcare personnel will need to continue to balance the competing risks associated with its use, taking into consideration the nature of the outbreak, the type of pathogen and its virulence, mode of transmission, and the setting in which it occurs. Our review has identified a major research gap in this area.

Using axillary temperature to approximate rectal temperature in newborns

AIM

Various factors have been shown to potentially affect the difference between axillary and rectal temperature measurements in newborns. We aimed to explore their roles and, if possible, to construct a formula that explained the difference.

METHODS

The study was based on a consecutive sample of 175 infants, with a gestational age of 24-42 weeks, whose rectal and axillary temperatures were measured simultaneously at the neonatal unit at Skaraborg Hospital in Sweden. Data were analysed using multiple regressions.

RESULTS

Premature infants had a significantly smaller mean difference (0.33°C) between rectal and axillary temperatures than full-term infants (0.43°C). Significant associated factors for premature infants were chronological age (p = 0.025), time of day (p = 0.004) and axillary temperature (p < 0.001). For full-term infants, the only significant associated factor was axillary temperature (p = 0.015).

CONCLUSION

Although it is possible to construct a formula that estimates neonate rectal temperature based on axillary temperature with a slightly higher reliability than simply adding a fixed value like 0.4°C, such a formula would be too complex to apply in practice. Adding 0.3°C or 0.4°C to the measured axillary temperature for premature infants or full-term infants, respectively, yields acceptable approximations in most cases.

Outbreak of AmpC β-lactamase-hyper-producing Enterobacter cloacae in a neonatal intensive care unit in a French teaching hospital

We report the investigation of an outbreak of colonization by a wild-type Enterobacter cloacae and its AmpC-hyper-producing derivative E cloacae in a neonatal intensive care unit. E cloacae hyper-producing AmpC β-lactamase isolates were found from neonate specimens and from environmental samples. All the isolates belonged to the same clone.

Microbes in the neonatal intensive care unit resemble those found in the gut of premature infants

BACKGROUND

The source inoculum of gastrointestinal tract (GIT) microbes is largely influenced by delivery mode in full-term infants, but these influences may be decoupled in very low birth weight (VLBW, <1,500 g) neonates via conventional broad-spectrum antibiotic treatment. We hypothesize the built environment (BE), specifically room surfaces frequently touched by humans, is a predominant source of colonizing microbes in the gut of premature VLBW infants. Here, we present the first matched fecal-BE time series analysis of two preterm VLBW neonates housed in a neonatal intensive care unit (NICU) over the first month of life.

RESULTS

Fresh fecal samples were collected every 3 days and metagenomes sequenced on an Illumina HiSeq2000 device. For each fecal sample, approximately 33 swabs were collected from each NICU room from 6 specified areas: sink, feeding and intubation tubing, hands of healthcare providers and parents, general surfaces, and nurse station electronics (keyboard, mouse, and cell phone). Swabs were processed using a recently developed 'expectation maximization iterative reconstruction of genes from the environment' (EMIRGE) amplicon pipeline in which full-length 16S rRNA amplicons were sheared and sequenced using an Illumina platform, and short reads reassembled into full-length genes. Over 24,000 full-length 16S rRNA sequences were produced, generating an average of approximately 12,000 operational taxonomic units (OTUs) (clustered at 97% nucleotide identity) per room-infant pair. Dominant gut taxa, including Staphylococcus epidermidis, Klebsiella pneumoniae, Bacteroides fragilis, and Escherichia coli, were widely distributed throughout the room environment with many gut colonizers detected in more than half of samples. Reconstructed genomes from infant gut colonizers revealed a suite of genes that confer resistance to antibiotics (for example, tetracycline, fluoroquinolone, and aminoglycoside) and sterilizing agents, which likely offer a competitive advantage in the NICU environment.

CONCLUSIONS

We have developed a high-throughput culture-independent approach that integrates room surveys based on full-length 16S rRNA gene sequences with metagenomic analysis of fecal samples collected from infants in the room. The approach enabled identification of discrete ICU reservoirs of microbes that also colonized the infant gut and provided evidence for the presence of certain organisms in the room prior to their detection in the gut.

Temperature measurement in the preterm and term neonate: a review of the literature

The maintenance of a constant body temperature is important to all humans but even more so for newborn babies (neonates), especially those born pre-term. Because accurate measurement of body temperature is an important component of thermoregulation management in the neonate, a review of the literature was undertaken to determine the most appropriate method and site of temperature measurement in both the preterm and term neonate. The available evidence indicates that the axilla remains the most common place for temperature measurement.

Surveillance of bacterial contamination in small animal veterinary hospitals with special focus on antimicrobial resistance and virulence traits of enterococci

OBJECTIVE

To determine the prevalence of bacterial contamination on 4 surfaces of 4 types of standard equipment in small animal veterinary hospitals.

DESIGN

Surveillance study.

SAMPLE

10 small animal veterinary hospitals.

PROCEDURES

Each hospital was visited 3 times at 4-month intervals; at each visit, a cage door, stethoscope, rectal thermometer, and mouth gag were swabbed. Swab samples were each plated onto media for culture of enterococci and organisms in the family Enterobacteriaceae. Enterococci were identified via a species-specific PCR assay and sodA gene sequencing; species of Enterobacteriaceae were identified with a biochemical test kit. Antimicrobial susceptibility was assessed via the disk diffusion method. Enterococci were screened for virulence traits and genotyped to assess clonality.

RESULTS

Among the 10 hospitals, enterococci were isolated from cage doors in 7, from stethoscopes in 7, from thermometers in 6, and from mouth gags in 1; contamination with species of Enterobacteriaceae was rare. Enterococci were mainly represented by Enterococcus faecium (35.4%), Enterococcus faecalis (33.2%), and Enterococcus hirae (28.3%). Antimicrobial resistance was common in E. faecium, whereas virulence traits were present in 99% of E. faecalis isolates but not in E. faecium isolates. Clonal multidrug-resistant E. faecium was isolated from several surfaces at 1 hospital over multiple visits, whereas sporadic nonclonal contamination was detected in other hospitals.

CONCLUSIONS AND CLINICAL RELEVANCE

Contamination of surfaces in small animal veterinary hospitals with multidrug-resistant enterococci is a potential concern for pets and humans contacting these surfaces. Implementing precautions to minimize enterococcal contamination on these surfaces is recommended.

Use of quantitative microbiological analyses to trace origin of contamination of parenteral nutrition solutions

In the summer of 2010, parenteral nutrition (PN) admixtures were administered to neonates in the Pediatric Department of the University Medical Center Mainz that provoked severe clinical sequelae. Contamination of a dummy infusion with Enterobacter cloacae and Escherichia hermannii was detected on the day of the incident, and the same isolates were subsequently grown from all PN admixtures as well as from the parent amino acid solution from which the admixtures had been prepared. Quantitative microbiological analyses paired with the determination of endotoxin concentrations enabled the conclusion to be reached that the amino acid solution had represented the primary source of contamination, which must have occurred in the distant past and may have derived from passage of the bacteria through a crack in the glass container. The findings have large implications, and the approaches employed should become of value when similar incidents occur again in the future.

Triage assessment in pediatric emergency departments: a national survey

OBJECTIVES

Because of the varying physiological and developmental stages in children, the taking of vital signs and other assessments at triage in an emergency department (ED) can be challenging. The purpose of this study was to examine current triage practices in pediatric EDs in the United States.

METHODS

A mailed survey was sent in August 2006 to the medical directors of the 99 pediatric EDs listed on the National Association of Children's Hospitals and Related Institutions Web site, with follow-up mailing in October 2006 and subsequent phone contact.

RESULTS

Eighty-eight surveys were returned (90% response rate). When asked what assessments are done on all patients at triage, all EDs (100%) obtain pulse rate and respiratory rate, 92% measure temperature, 60% measure blood pressure, 41% measure pulse oximetry, and 13% assess Glasgow Coma Scale. The methods used to measure temperature were widely variable. Multiple methods are used to assess pain: for those aged 0 to 2 years, 44% use a Wong FACES Scale and 48% use a behavioral scale; at 2 to 4 years, most (80%) use the Wong FACES Scale, but in older 10- to 18-year-old patients, most (81%) use a numerical scale. The use of standing orders at triage is variable.

CONCLUSIONS

Despite the important decisions made based on triage assessment in a pediatric ED, there is wide variability in the parameters assessed and the methodology used. Additional research should focus on the validity and reliability of each assessment to determine the best practices.

Clinical characteristics of nosocomial infections in neonatal intensive care unit in eastern China

A retrospective cohort study on nosocomial infections (NI) in the neonatal intensive care unit (NICU) was performed in the Children's Hospital of Zhejiang University, Hangzhou district, China. The most common infection site was pneumonia and bloodstream infection. Low admission age, long NICU stay, and mechanical ventilation were significant risk factors for NI. Klebsiella pneumoniae was the most common pathogen, followed by Acinetobacter baumannii, Staphylococcus epidermidi, Pseudomonas aeruginosa, Enterobacter cloacae, and Stenotrophomonas maltophilia. Antibiotic resistance of the isolated bacterium was high. In conclusion, this study described the clinical characteristics of NI in a Chinese NICU, which might contribute to implementation of more effective therapeutic and preventive strategies.

Late-onset Enterobacter cloacae sepsis in very-low-birth-weight neonates: experience in a medical center

OBJECTIVE

The objective of this study was to review the early clinical profiles and outcomes of very-low-birth-weight (VLBW) neonates with late-onset sepsis caused by Enterobacter cloacae.

METHODS

We reviewed the medical records of VLBW neonates whose blood and/or cerebral spinal fluid yielded E. cloacae after 3 days of hospitalization in our neonatal intensive care unit.

RESULTS

From January 1997 to December 2006, a total of 29 episodes of E. cloacae infection occurred in 28 VLBW neonates. The onset of E. cloacae infection ranged from 4 to 70 days (27.4 +/- 9.6) days after birth. The most common symptoms and signs of sepsis were desaturation (58.6%), tachycardia (58.6%), apnea (55.2%), unstable body temperature (48.3%), and decreased activity (44.8%). The infected neonates had an average of four kinds of symptoms in each sepsis episode. The most common laboratory findings in VLBW neonates with E. cloacae sepsis were thrombocytopenia (65.5%), C-reactive protein > or = 1 mg/dL (55.2%), band-form neutrophils > or = 5% (41.4%), and leucopoenia (20.7%). Empirical intravenous antibiotic therapy comprising piperacillin (or piperacillin and tazobactam) and gentamicin (or amikacin) was successful in the early treatment of 24 episodes of E. cloacae sepsis in 25 patients. Three neonates (10.7%) died due to E. cloacae sepsis. Four neonates (14.3%) developed E. cloacae meningitis, and two of them developed brain abscesses.

CONCLUSIONS

E. cloacae infection in VLBW neonates usually presents with nonspecific symptoms and signs. Early recognition of sepsis and empirical combination of piperacillin (or piperacillin and tazobactam) and gentamicin (or amikacin) may be useful for treatment of sepsis caused by this highly virulent pathogen.

Axillary and rectal temperature measurements poorly agree in newborn infants

AIM

Evaluation of the agreement between axillary temperature measurements and rectal temperature measurements in neonates.

METHODS

Rectal and axillary body temperatures were simultaneously measured for 3 min in 33 neonates (gestational age 25-42 weeks, weight 840-4,005 g). Two investigators performed paired measurements, one in each neonate. A single type of thermometer was used in this study: one thermometer for each rectal and another thermometer for each axillary measurement. The Bland-Altman method was used (95% 'limits of agreement': mean +/- 2 SD) to determine the level of agreement between axillary and rectal measurements.

RESULTS

The axillary temperature was significantly lower than the rectal temperature (mean +/- SD 0.27 +/- 0.20 degrees C, p < 0.05). The '95% limits of agreement' ranged from -0.13 to +0.67 degrees C. Increasing postnatal age (days) showed a significant increase in temperature difference (rectal minus axillary; r = 0.54; p < 0.05).

CONCLUSIONS

The mean difference between axillary and rectal temperature shows a wide variation. Axillary temperature measurements cannot be used interchangeably with rectal measurements in neonates.

Enterobacter colonisation in newborn infants: predictors, follow-up and implications for infection control

Outbreaks with Enterobacter spp. have been described frequently in neonatal intensive care units (NICUs). This study investigated the factors that determine whether a neonate becomes colonised with Enterobacter spp., how long colonisation continues and whether the termination of isolation measures leads to spread of the organism. Neonates transferred from the NICUs of tertiary care hospitals were screened for the presence of Enterobacter spp. and any potential predictors for colonisation recorded. Those infected were monitored during their hospital stay and colonised neonates were screened every month for six months. Isolation infection control precautions were lifted and all neonates were screened for the presence of Enterobacter spp. six and 12 months later. Fifteen colonised neonates and 33 non-colonised controls were identified for study. Multivariate analysis showed that antibiotic therapy for more than three days and an Apgar score of <8 after 1 min were independently associated with Enterobacter spp. colonisation. Molecular typing using single-enzyme amplified-fragment length polymorphism (seAFLP) analysis revealed 22 different seAFLP genotypes. Three infants remained colonised with the same Enterobacter genotype after discharge; however, most neonates lost their strain or became colonised with another genotype. Lifting infection control measures for neonates colonised with Enterobacter spp. in a neonatal ward did not lead to increased incidence of colonisation and none of the infants became infected. Isolating neonates with susceptible Enterobacter spp. was not found to be necessary.

Prevention of catheter-related bloodstream infections in the neonatal intensive care setting

Nosocomial infection causes substantial morbidity and mortality among neonates treated in the neonatal intensive care setting. Colonization and subsequent infection of central venous catheters leading to catheter-related bloodstream infection is among the most common causes of nosocomial sepsis in this patient population. Prevention of catheter-related bloodstream infection is a major challenge and numerous strategies have been attempted in this context with varying success. Given the dynamic epidemiology of nosocomial infection among neonates and the emergence of antimicrobial resistance, novel prevention strategies are urgently required.

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.

Evidence-based practice: examining the risk of toys in the microenvironment of infants in the neonatal intensive care unit

Toys placed in the bed or microenvironment of infants in the neonatal intensive care unit (NICU) demonstrate high rates of colonization (92%). As with other fomites, toys may be one potential source of nosocomial infection (NI). This project critically evaluated the practice of placing toys in the microenvironment of critically ill infants by using the Iowa Model of Evidence-Based Practice to Promote Quality Care. With the model as a guide for decision making, the existing evidence was explored using a systematic review of the literature, case studies, scientific principles, theory, and expert opinion. A comprehensive review of the literature did not clearly identify a causal relationship between toys in the NICU microenvironment and NI. Levels of evidence suggesting an association between toys and NI were determined to be moderately strong and consistent. A plausible relationship between the practice of placing toys in the beds of NICU patients and risk for infection was found. These findings prompted a pilot practice change, eliminating toys in the NICU, to test the potential impact of this intervention. Pre- and postintervention infection rates were compared. NI rates decreased from 4.6 to 1.99 per 1,000 patient days over a 6-month evaluation period. Although this decrease was not statistically significant, it was the lowest rate recorded in 5 years. Ongoing evaluation of NI rates is in progress. Individual NICUs must determine if the evidence warrants a practice change in their setting.

Antibiotic-resistant gram-negative bacteria in hospitalized children

Antibiotic-resistant Gram-negative bacilli are a prominent and growing problem among hospitalized children. Epidemics caused by these organisms have been implicated in many outbreaks in children's hospitals, primarily in neonatal intensive care units. These epidemics are characterized by efficient patient-to-patient transmission of the outbreak clone via the hands of caregivers and through exposure of contaminated inanimate sources. The epidemiology of these resistant organisms in pediatric hospitals during endemic periods is more complex. The isolates cultured from hospitalized individuals in the absence of an outbreak usually are unique to each individual and are derived from the patient's endogenous flora or other disparate sources. As in adults, chronic care facilities for children represent significant reservoirs of antibiotic-resistant bacilli that are circulated back into the acute care hospital environment when the child becomes ill.

Emergence of Enterobacter cloacae as a common pathogen in neonatal units: pulsed-field gel electrophoresis analysis

In the first week of December 2002, three infants hospitalized in the neonatal department of our hospital had blood cultures positive with Enterobacter cloacae. Screening cultures and genotyping showed that 10 of 25 screened patients also carried E. cloacae and that nine isolates belonged to the same clone as that responsible for all three bacteraemias. This epidemic cluster was limited to one of the two units of the department. Surveillance of both units continued until the end of March 2003; 51 of 159 neonates screened were colonized with E. cloacae, 38 out of 80 (47.5%) in the premature unit (PU) and 13 out of 79 (16.4%) in the paediatric intensive care unit (PICU). Pulsed-field gel electrophoresis (PFGE) analysis of 130 available isolates revealed 30 different pulsotypes, including 24 unique pulsotypes from individual patients and six from multiple patients. Antibiotic (particularly beta-lactam) use did not significantly vary from 1999 to 2003. The consumption of alcohol-based hand rub (four-fold higher in the PICU than in the PU) and nurse-to-patient ratio (1:2 in the PICU and 1:4 in the PU) might explain the higher cross-transmission rate in the PU. Finally, despite an epidemiological survey, we failed to identify the causes of the emergence of E. cloacae in our neonatology units. However, improved hygiene practices combined with restriction of admission led to the progressive disappearance of the epidemic strain. The increasing importance of this type of unit and the dramatic consequences of infections emphasize the need for additional research on the constitution of the flora of newborns and the mode of acquisition Gram-negative multi-resistant bacteria.

Descriptive and molecular epidemiology of Gram-negative bacilli infections in the neonatal intensive care unit

PURPOSE OF REVIEW

The critically ill neonate is particularly prone to life threatening bacterial infections compared with other patient populations. Current patterns of neonatal sepsis caused by Gram-negative bacilli are reviewed to enable the clinician to better anticipate and effectively respond to neonatal infection by these serious pathogens.

RECENT FINDINGS

With increasing use of intrapartum antibiotics for prophylaxis against early-onset group B streptococcal infection, there is growing concern that the incidence of neonatal sepsis by Gram-negative pathogens may rise. Although several surveys indicate no such increase to date, studies in selected neonatal intensive care unit populations have suggested a recent elevation in newborn infection caused by Escherichia coli and other bacillary pathogens. Most recent investigations reveal growing antibiotic resistance in those Gram-negative bacilli causing neonatal infection. Modern molecular genotyping methods have been applied to Gram-negative bacilli in the neonatal intensive care unit in order to understand their epidemiology in greater detail. In most instances these techniques have been used to identify the sources and prevalence of an outbreak strain, and to devise rational interventions to control the epidemic. Studies utilizing molecular genotyping during non-outbreak periods indicate that Gram-negative bacilli, even those expressing antibiotic resistance, may be acquired very early in the intensive care unit course, and that different clones are introduced and lost in the infants' indigenous flora throughout their stay. These studies further indicate that cross-transmission of bacillary pathogens occurs regularly even in the absence of a recognized epidemic.

SUMMARY

Gram-negative bacilli are prominent causes of infection in the neonatal intensive care unit. Their incidence, antibiotic susceptibility pattern, and modes of acquisition continue to evolve in the modern intensive care unit setting.

Nosocomial infections

Nosocomial infections and antimicrobial resistance are topics that have been intensely studied in human medicine because of their significant impact on human health. In recent years, concerns have been raised that the use of antibiotics in veterinary medicine, animal husbandry, and agriculture may be contributing to the development of resistance in common bacterial species affecting human beings. Although there is inadequate proof at this time that the resistance is transmitted from animals to people, if antibiotics continue to be used indiscriminately in veterinary medicine, veterinarians may find themselves facing regulations restricting the use of some antibiotics. Nosocomial infections have been reported in veterinary medicine and are likely to increase in prevalence with the increase in intensive care practices in many hospitals. Prolonged hospitalization and the use of invasive devices and procedures increase the risk of nosocomial disease. As in human medicine, organisms isolated in the nosocomial infections reported in veterinary patients have an increasingly broad spectrum of antimicrobial resistance. Despite these findings, the use of empiric and prophylactic antibiotic therapy is still widespread in veterinary medicine. Nosocomial infections and antimicrobial resistance may have a serious impact on the future of [table: see text] veterinary medicine, because the cost and ability to treat our patients may be affected by the loss of access to or effectiveness of antimicrobial drugs. Despite the millions of dollars spent on research to reduce the incidence of nosocomial infections in human patients, the strategies that have consistently proven successful are simple and inexpensive to implement. The most important factor in preventing nosocomial infections is improving the hygiene practices of health care providers. Hand-washing or the use of disposable gloves can dramatically reduce the transmission of bacteria between patients. Aseptic technique should be used in the placement and management of all invasive devices. All staff members should be educated on the risks and symptoms associated with nosocomial infections so that cases can be detected early and treated appropriately. We in the veterinary profession have the opportunity to learn from the experiences of the human medical profession and can take steps to prevent the escalation of nosocomial infections and their impact on our profession.

Urinary tract infections caused by endemic multi-resistant Enterobacter cloacae in a dialysis and transplantation unit

In the period 1994-1998, 42 multi-resistant Enterobacter cloacae isolates responsible for urinary tract infections (UTIs) were obtained from children hospitalized in our dialysis and transplantation unit. E. cloacae isolates obtained between 1994 and 1996 were susceptible to aminoglycosides, carbapenems and fluoroquinolones, whereas E. cloacae isolates obtained between 1997 and 1998 were susceptible to carbapenems and fluoroquinolones, only. All isolates were characterized by use of the polymerase chain reaction-based random amplification of polymorphic DNA and pulsed-field gel electrophoresis. It was found that the majority of multiresistant E. cloacae isolates obtained during 1997-1998, and all isolates obtained during 1994-1996, belonged to predominant clones A or B. These strains were responsible for gastrointestinal tract colonization and UTI of renal transplant recipients for several years, and persisted as endemic E. cloacae strains in the dialysis and transplantation unit from 1994 to 1998.

Management of an outbreak of Enterobacter cloacae in a neonatal unit using simple preventive measures

Enterobacter cloacae is becoming an increasingly important nosocomial pathogen. Outbreaks of E. cloacae in intensive care units and burns units have been described frequently. In December 1999, a neonate with line sepsis was transferred from a university hospital to the neonatal unit of the Diakonessen Hospital. Blood culture yielded E. cloacae. An outbreak of E. cloacae was occurring in the university hospital at that time. In February 2000, a second neonate in our hospital developed line sepsis caused by E. cloacae. Direct measures taken included cohorting of infected children, disinfection of incubators, thermometers and wards, and screening patients. Of nine neonates, seven were colonized with E. cloacae. Despite these measures, the outbreak continued. Forty-one patients were screened; 15 were colonized. Environmental searches yielded E. cloacae in a sink and on two thermometers. Sixteen isolates were typed by arbitrarily primed PCR using four primers. All the patient isolates and the two isolates from thermometers were identical. The strain isolated from the sink was unrelated. Amplified fragment length polymorphism typing showed that the outbreak clone was identical to that in the university hospital. After the introduction of disposable thermometer covers, E. cloacae colonization slowly decreased.