Elsevier

The Journal of Pediatrics

Volume 163, Issue 3, September 2013, Pages 672-679.e3
The Journal of Pediatrics

Original Article
Prompt Control of an Outbreak Caused by Extended-Spectrum β-Lactamase–Producing Klebsiella pneumoniae in a Neonatal Intensive Care Unit

Presented in part at the Pediatric Academic Societies' Annual Meeting, Boston, MA, April 27 to May 1, 2012.
https://doi.org/10.1016/j.jpeds.2013.03.001Get rights and content

Objectives

To assess the effectiveness of a set of multidisciplinary interventions aimed at limiting patient-to-patient transmission of extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) during a neonatal intensive care unit (NICU) outbreak, and to identify risk factors associated with ESBL-KP colonization and disease in this setting.

Study design

A 61-infant cohort present in the NICU during an outbreak of ESBL-KP from April 26, 2011, to May 16, 2011, was studied. Clinical characteristics were compared in infected/colonized infants and unaffected infants. A multidisciplinary team formulated an outbreak control plan that included (1) staff reeducation on recommended infection prevention measures; (2) auditing of hand hygiene and environmental services practices; (3) contact precautions; (4) cohorting of infants and staff; (5) alleviation of overcrowding; and (6) frequent NICU-wide screening cultures. Neither closure of the NICU nor culturing of health care personnel was instituted.

Results

Eleven infants in this level III NICU were infected/colonized with ESBL-KP. The index case was an 18-day-old infant born at 25 weeks' gestation who developed septicemia from ESBL-KP. Two other infants in the same room developed sepsis from ESBL-KP within 48 hours; both expired. Implementation of various infection prevention strategies resulted in prompt control of the outbreak within 3 weeks. The ESBL-KP isolates presented a single clone that was distinct from ESBL-KP identified previously in other units. Being housed in the same room as the index infant was the only risk factor identified by logistic regression analysis (P = .002).

Conclusion

This outbreak of ESBL-KP affected 11 infants and was associated with 2 deaths. Prompt control with eradication of the infecting strain from the NICU was achieved with multidisciplinary interventions based on standard infection prevention practices.

Section snippets

Methods

PMH is a 672-bed public tertiary care center that provides a wide range of services, including high-risk obstetrics. The PMH NICU is a 90-bed level 3C, predominantly inborn unit with approximately 1200 admissions annually (Figure 1; available at www.jpeds.com). The NICU consists of 7 bays (“rooms” hereinafter) each with a maximum capacity of 12 infants depending on acuity (Figure 1, rooms A to G; Table I). There is 1 separate single bed, in a negatively ventilated isolation room (room H). A

Results

The index patient (infant 1; Table II; available at www.jpeds.com) was an 18-day-old infant born at 25 weeks' gestation (birth weight, 790 g) who developed respiratory distress, hypotension, and metabolic acidosis on April 26. Aerobic cultures were obtained from a peripherally inserted central venous catheter and peripheral blood, urine, and endotracheal tube aspirate, and antibiotic therapy with oxacillin and gentamicin was initiated. On April 28, Gram-negative rods were identified from both

Discussion

It has been suggested that there is a small but consistent background rate of gram-negative MDROs that colonize infants in NICUs, but with the maintenance of optimal infection prevention and control practices, horizontal transmission is low and colonization is short-lived.21, 22 In our NICU, ESBL-KP had not been identified previously from any clinical culture, although surveillance cultures had not been performed routinely before the outbreak. Although the source of the outbreak remains

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    The authors declare no conflicts of interest.

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