Abstract
BackgroundAntimicrobial 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.AimTo assess the impact of a coordinated intervention strategy in achieving long-lasting reduction of MDR-GNB prevalence in the NICU.MethodsRectal 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.FindingsDuring 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).ConclusionsMDR-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.
Highlights
The World Health Organization has declared antimicrobial resistance as one of the most dangerous public health threats of the last ten years with an increasing impact in the future [1].Control and prevention of antimicrobial resistance and healthcare-related infections have been included in the Italian National Prevention Plan of Antimicrobial Resistance 2017–2020.Neonatal Intensive Care Units (NICUs) are complex assistive settings, heavily burdened by antimicrobial resistance, due to the widespread use of antimicrobial treatments in critically ill patients exposed to invasive devices and procedures
Carriage was defined as a positive culture of multidrug-resistant Gram-negative bacteria (MDR-GNB) from at least one rectal swab collected during the NICU stay
The results indicate that MDR-GNB were significantly reduced during the post- intervention months and ESBLKP was not detected in the ward from January 23 to June 2018
Summary
Neonatal Intensive Care Units (NICUs) are complex assistive settings, heavily burdened by antimicrobial resistance, due to the widespread use of antimicrobial treatments in critically ill patients exposed to invasive devices and procedures In these settings, prevention and control of infections and multi-drug resistance can play a crucial role in the outcome of critically ill newborns with otherwise limited therapeutic options [2, 3]. The main focus of the program, which is still ongoing, is the epidemiological analysis of MDROs circulation, seasonal variability, associated risk factors, molecular typing of isolated bacteria and evaluation of antimicrobial resistance related to bacterial carriage This active surveillance program involves an epidemiological team with its laboratory, a neonatal team, and NICU healthcare providers. The ultimate purpose is prevention and control of infectious diseases through the early identification of new carriage clusters or changes in the time-line and pattern of colonization in a specific setting
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