Flavobacterium meningosepticum infections in a neonatal intensive care unit

Elizabethkingia meningoseptica Outbreak in NICU: An Observational Study on a Debilitating Neuroinfection in Neonates

BACKGROUND

Elizabethkingia meningoseptica is an emerging nosocomial pathogen implicated in neonatal sepsis with high mortality and morbidities. However, there is very limited data regarding the characteristics as well as outcomes following this infection, particularly in developing countries.

METHODS

We conducted a retrospective observational study of all infants with culture-positive Elizabethkingia sepsis as part of an outbreak, to study their clinical and epidemiological characteristics, as well as their antimicrobial susceptibility patterns, using a structured proforma from the neonatal intensive care unit database. Analysis was done using descriptive statistics and predictors of mortality and hydrocephalus were also identified.

RESULTS

Of the 21 neonates enrolled, 9 (42.9%) were male, with a mean gestational age and birth weight of 31.7 ± 3.4 weeks and 1320 ± 364 g, respectively. The median (interquartile range) age of onset of illness was 7 (5-12) days. The overall mortality rate was 23.8%, and among survivors, 50% had neurologic complications requiring intervention. Vancomycin and ciprofloxacin were the most used antibiotics for treatment in our series, with a median duration of 26 (17-38) days. On univariate analysis, shock at presentation was significantly associated with increased mortality (P = 0.04) while, seizures (P = 0.04) and elevated cerebrospinal fluid protein levels (P = 0 .01) at onset of illness predicted progressive hydrocephalus in surviving neonates.

CONCLUSION

E. meningoseptica sepsis is associated with high morbidity and mortality. Early diagnosis and prompt initiation of appropriate antibiotics are critical for improving survival and neurodevelopmental outcomes. Though isolation of the organism by environmental surveillance is always not possible, with proper infection control measures, the infection can be controlled.

Investigation of an outbreak of Elizabethkingia meningoseptica on a pediatric intensive care unit

Objective: This paper reports an Elizabethkingia meningoseptica outbreak on a pediatric intensive care unit with emphasis on investigation of outbreak source, infection control interventions, patient characteristics and comparative antimicrobial susceptibility results. Methods: This was an ambidirectional cohort study conducted in a university hospital 20-bed pediatric intensive care unit. Patient ages ranged from 4 to 11 months, with a median age of 9 months. 83% of the patients had severe underlying conditions. Samples from staff and environmental surfaces were obtained to identify a common source of infection. Antimicrobial susceptibility tests of isolated bacteria were done using the disk diffusion method and the Vitek^®2 automated system. Results: Environmental surveillance revealed contamination of the water reservoirs of two different mechanical ventilators. In-vitro antimicrobial susceptibility testing results with two different methods (Vitek^®2 and disk diffusion) were coherent for most of the investigated antibiotics, but without coherence for ciprofloxacin and levofloxacin. Resistance was found to the relatively new antibiotics ceftaroline and ceftazidime-avibactam. Conclusions: E. meningoseptica is a significant cause of nosocomial infections, with high mortality especially in children. Investigation of the outbreak source and continuation of intensive infection control precautions are vital to handle E. meningoseptica outbreaks in PICUs. Using quinolones according to testing results of automated AST systems may lead to inadequate treatment and foster the selection of resistant strains.

Elizabethkingia meningoseptica: an important emerging pathogen causing healthcare-associated infections

Elizabethkingia meningoseptica has been deemed a potentially important threat to patients in critical care areas because of its multidrug-resistant phenotype and its ability to adapt to various environments. This review considers the incidence, factors which predispose to, and clinical features of, E. meningoseptica sepsis, along with antimicrobial susceptibility patterns of clinical E. meningoseptica isolates and reportedly successful measures for the prevention and control of infections caused by this bacterium. The English-language literature from the PubMed database was reviewed. The incidence of E. meningoseptica bacteraemia has increased over the last decade. Patients at high risk of E. meningoseptica infection include preterm children, the immunocompromised and those exposed to antibiotics in critical care units. Vancomycin, rifampicin, newer fluoroquinolones, piperacillin-tazobactam, minocycline and possibly tigecycline are preferred empirical choices for E. meningoseptica infection according to in-vitro susceptibility data. Combination therapy has been used for infections not responding to single agents. Saline, lipid, and chlorhexidine gluconate solutions as well as contaminated sinks have been implicated as sources of infection following outbreak investigations. In addition to reinforcement of standard infection control measures, actions that have successfully terminated E. meningoseptica outbreaks include pre-emptive contact isolation, systematic investigations to identify the source of the bacterium and thorough cleaning of equipment and environmental surfaces. As the clinical complexity and incidence of E. meningoseptica infections increase, there is a need for heightened awareness of the potential for this bacterium to cause outbreaks. This will permit timely initiation of active surveillance for infected/colonized patients as well as investigations to identify the likely source of the bacterium, which will, in turn, allow implementation of appropriate infection control measures.

Elizabethkingia meningosepticum (Chryseobacterium meningosepticum) Infections in Children

Chryseobacterium meningosepticum is a ubiquitous Gram-negative bacillus historically associated primarily with meningitis in neonates and a wide variety of infections in immunocompromised patients. Neonatal infections often occur as outbreaks with environmental contamination being the source. C. meningosepticum infections are not common but are clinically important because the organism is naturally resistant to multiple antibiotics. In this paper, we have reviewed the nosocomial outbreaks of C. meningosepticum in newborns and infants reported so far in the literature and overviewed the infection control interventions, treatment modalities, and prevention measures.

A Chryseobacterium meningosepticum colonization outbreak in a neonatal intensive care unit

PURPOSE

To report the epidemiologic, bacteriologic, and clinical features of a Chryseobacterium meningosepticum outbreak in a neonatal intensive care unit (NICU) of a referral teaching hospital.

PATIENTS AND METHODS

From April to October 2002, a strain of C. meningosepticum was isolated from four neonates in the NICU. All neonates were colonized in the endotracheal tubes and respiratory secretions, but none of them progressed to clinical infection. Multiple samples were obtained for cultures.

RESULTS

Pulsed-field gel electrophoresis (PFGE) of isolates showed them to be representatives of a single strain. Environmental surveillance did not reveal the C. meningosepticum source. None of the neonates received specific treatment. The outbreak was only controlled by reinforcement of the usual measures and no additional colonization/infection was confirmed for more than a year after the last case.

CONCLUSION

This study suggests that C. meningosepticum colonization in neonates does not necessarily lead to infection and that such colonization outbreaks may be controlled with emphasis on the standard precautions.

Chryseobacterium meningosepticum sepsis complicated with retroperitoneal hematoma and pleural effusion in a diabetic patient

Intra-abdominal infection due to Chryseobacterium meningosepticum is rare, and bacteremia complicated with pleural effusion and retroperitoneal hematoma caused by C. meningosepticum has not been reported previously. A 57-year-old diabetic man presented with bacteremia with retroperitoneal abscess and pleural effusion caused by C. meningosepticum on the 12th day of hospitalization. His clinical condition improved after antimicrobial therapy with levofloxacin and rifampin, debridement of the retroperitoneal hematoma and left-side chest tube insertion. Antibiotics were administered for 1 month, and he was later transferred to a local respiratory care ward under afebrile condition. C. meningosepticum should be included in the list of suspected nosocomial infections, especially in patients with immunocompromised status. Administration of appropriate antibiotics, such as quinolone, minocycline, trimethoprim-sulfamethoxazole or rifampin, and treatment of local infection improve the clinical outcome of patients with C. meningosepticum infection.

[Microbiological monitoring of milk samples and surface samples in a hospital infant formula room]

OBJECTIVE

Analyze the microbiological quality of reconstituted milk formulas and the surface hygiene in a hospital infant formula room, in the context of a worldwide emergence of Enterobacter sakazakii infections.

MATERIAL AND METHODS

Over 3.5 years, monthly samples of reconstituted milk formulas as well as quarterly infant formula room surface samples were taken for bacteriological analysis.

RESULTS

Of the 156 formulas analyzed, 54 carried microorganisms but no pathogenic bacteria. The presence of Bacillus species was found in 54% of the formulas for premature infants and in 19% of the other formulas (significant difference). Bacteria, probably brought by operators during reconstitution of the powdered formulas, were found in four of 156 samples (two negative-coagulase staphylococcus, one alpha-hemolytic streptococcus, and one Clostridium bifermentans). Surfaces were studied using 117 samples divided into 11 series: 4.3% of the points carried pathogenic bacteria (Enterobacter cloacae, Pseudomonas fluorescens, Bulhkholderia cepacia, Staphylococcus aureus).

DISCUSSION

The presence of Bacillus species should be analyzed thoroughly so as to differentiate Bacillus cereus from other nonpathogenic species. The microbiological analysis techniques used for reconstituted infant formulas can be simplified.

CONCLUSION

The quality of the infant formulas seems satisfactory. Hygiene practices provide good microbiological quality in reconstituted infant milk formulas. Microbiological monitoring of these preparations and the infant formula room surfaces is an important aspect of the quality assurance policy, which makes it possible to take corrective measures when an unsatisfactory result is found.

Bacterial Infections

In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.

A Chryseobacterium meningosepticum outbreak in a neonatal ward

OBJECTIVE

To report epidemiologic, bacteriologic, and clinical features of a Chryseobacterium meningosepticum outbreak.

DESIGN

Outbreak investigation.

SETTING

A neonatal intensive care unit (NICU) of a referral teaching hospital.

METHODS

During 2 weeks in September 2001, four neonates in the NICU developed sepsis and underwent laboratory investigation. Multiple samples were obtained for cultures from endotracheal tubes, mechanical ventilators and humidifier boxes, infant incubators, parenteral and antiseptic solutions, feeding bottles, sinks, faucets, doors, and healthcare workers.

RESULTS

C. meningosepticum was isolated from the blood cultures of four patients. The first isolate was identified 5 days after the death of the index case. Although all isolates were ciprofloxacin susceptible in vitro, the remaining three patients did not respond to ciprofloxacin therapy given for 6 or 7 days. Therapy was switched to vancomycin and rifainpin and all three patients survived, with one having a complication (hydrocephalus). Environmental surveillance revealed C. meningosepticum in the stock lipid solution as the source of the epidemic. The outbreak was controlled after discontinuation of intravenous lipid solution, restriction of further neonatal admissions, and thorough disinfection of the unit and its equipment.

CONCLUSION

Early identification of an epidemic and its source is important in avoiding morbidity and mortality. A contaminated lipid stock bottle was the source of this outbreak associated with multiple cases and one death.

Three consecutive outbreaks of Serratia marcescens in a neonatal intensive care unit

We investigated an outbreak of Serratia marcescens in the neonatal intensive care unit (NICU) of the University Hospital of Zurich. S. marcescens infection was detected in 4 children transferred from the NICU to the University Children's Hospital (Zurich). All isolates showed identical banding patterns by pulsed-field gel electrophoresis (PFGE). In a prevalence survey, 11 of 20 neonates were found to be colonized. S. marcescens was isolated from bottles of liquid theophylline. Despite replacement of these bottles, S. marcescens colonization was detected in additional patients. Prospective collection of stool and gastric aspirate specimens revealed that colonization occurred in some babies within 24 hours after delivery. These isolates showed a different genotype. Cultures of milk from used milk bottles yielded S. marcescens. These isolates showed a third genotype. The method of reprocessing bottles was changed to thermal disinfection. In follow-up prevalence studies, 0 of 29 neonates were found to be colonized by S. marcescens. In summary, 3 consecutive outbreaks caused by 3 genetically unrelated clones of S. marcescens could be documented. Contaminated milk could be identified as the source of at least the third outbreak.

Chryseobacterium meningosepticum: an emerging pathogen among immunocompromised adults. Report of 6 cases and literature review

Chryseobacterium meningosepticum is a ubiquitous Gram-negative bacillus historically associated with meningitis in premature neonates. We report 15 positive cultures and 6 cases of infection among immunocompromised adults at our institution over a 10-year period and review the English-language literature on C. meningosepticum. Excluding the present series, there are 308 reports of positive cultures in the literature, of which 59% were determined to represent true infections. Sixty-five percent of those infected were younger than 3 months of age. Meningitis was the most common infectious syndrome among neonates, seen in 84% of cases and associated with a 57% mortality rate. Less commonly reported infections among infants included sepsis (13%) and pneumonia (3%). Pneumonia was the most frequent infection among the postneonatal group, accounting for 40% of cases, followed by sepsis (24%), meningitis (18%), endocarditis (3%), cellulitis (3%), abdominal infections (3%), eye infections (3%), and single case reports of sinusitis, bronchitis, and epididymitis. The 6 cases in our series were all adults, with a mean age of 58.7 years. Sites of C. meningosepticum infection were limited to the lungs, bloodstream, and biliary tree. Infection in our series was associated with prolonged hospitalization, prior exposure to multiple antibiotics, and host immunocompromise, particularly neutropenia. C. meningosepticum is resistant to multiple antibiotics, and disk dilution is notoriously unreliable for antibiotic sensitivity testing. Sensitivity testing on the 15 isolates from our institution revealed the most efficacious antibiotics to be minocycline (100% sensitive), rifampin (93%), trimethoprim-sulfamethoxazole (67%), and ciprofloxacin (53%). In contrast to reports in the literature, the isolates in our series displayed widespread resistance to vancomycin (100% resistant or intermediately sensitive), erythromycin (100%), and clindamycin (86%). These findings have important implications for the clinician when choosing empiric antibiotic regimens for patients with risk factors for C. meningosepticum infection.

Food and microbiological problems in the newborn: data and practice

We have reviewed the relationships of food, nutrition and feeding practices to various infections in the newborn. Tentative conclusions are made: (a) the initial use of human milk (raw or pasteurized) continues to offer advantages in the care of babies in intensive care; (b) attempts to mimic the microbiological effects of breast milk by manipulation of the composition of infant formulas have so far achieved little success, but this is a rapidly developing field; (c) we are wary of the widespread use of breast milk "fortifiers" until there is evidence that they do not adversely affect the protective properties of breast milk; (d) the doubtful advantages of nasojejunal feeding need to be weighed against the increased bacterial contamination of the upper small bowel; (e) systems monitoring in milk kitchens and the handling of feeds in the neonatal unit are an integral part of comprehensive neonatal care; (f) to limit nosocomial infection, particular attention to the faecal-food-oral route is necessary since there is potential for multiplication of initial contamination of food.

Flavobacterium meningosepticum infection in a neonatal ward

An outbreak of infections due to Flavobacterium meningosepticum type C in a neonatal intensive care unit is described. During a period of two weeks, two infants developed meningitis and a third was colonized in the respiratory tract and had transient bacteremia. The two meningitis patients were treated with clindamycin, rifampicin and cefotaxime systemically, plus rifampicin intraventricularly. Bacteriological eradication was achieved within 48 h, and both infants recovered from the meningitis without apparent neurological sequelae; however, one infant died two months later of unrelated causes. Environmental surveillance cultures failed to demonstrate a reservoir for the epidemic strain, but other Flavobacterium strains were recovered. Two clinically healthy infants were found to be colonized in the nasopharynx with strains that were extremely difficult to differentiate phenotypically from the epidemic strain. Extensive characterization of strains is necessary in order to differentiate between strains and subsequently to determine a certain source of infection.