Epidemic gram-negative bacteremia in a neonatal intensive care unit in Guatemala

doi:10.1016/0196-6553(94)90005-1

American Journal of Infection Control

Volume 22, Issue 3, June 1994, Pages 163-171

https://doi.org/10.1016/0196-6553(94)90005-1 Get rights and content

Abstract

Background: Nosocomial bloodstream infection is an important cause of morbidity and mortality among neonates. From September 1 through December 5, 1990 (epidemic period), gram-negative bacteremia developed in 26 neonates after their admission to the neonatal intensive care unit (NICU) of Hospital General, a 1000-bed public teaching hospital in Guatemala with a 16-bed NICU. Twenty-three of the 26 patients (88%) died.

Methods: To determine risk factors for and modes of transmission of gram-negative bacteremia in the NICU, we conducted a cohort study of NICU patients who had at least one blood culture drawn at least 24 hours after admission to the NICU and performed a microbiologic investigation in the NICU.

Results: The rate of gram-negative bacteremia was significantly higher among patients born at Hospital General, delivered by cesarian section, and exposed to selected intravenous medications and invasive procedures in the NICU during the 3 days before the referent blood culture was obtained. During the epidemic period, the hospital's chlorinated well-water system malfunctioned; chlorine levels were undetectable and tap water samples contained elevated microbial levels, including total and fecal coliform bacteria. Serratia marcescens was identified in 81% of case-patient blood cultures ( $1316$ ) available for testing and from 57% of NICU personnel handwashings ( $47$ ). Most S. marcescens blood isolates were serotype 03: H 12 (46%) or 014: H12 (31%) and were resistant to ampicillin (100%) and gentamicin (77%), the antimicrobials used routinely in the NICU.

Conclusions: We hypothesize that gram-negative bacteremia occurred after invasive procedures were performed on neonates whose skin became colonized through bathing or from hands of NICU personnel.

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Water supply infrastructure problems are different in LMICs as compared to high-income countries (World Health Organization and UNICEF, 2015). Pegues, et al. discusses contributions to the outbreak in a hospital in Guatemala City, Guatemala included limited supply of and low quality antiseptics and lack of sinks in addition to the malfunctioning of the well-water chlorination system, all concerns that may be especially applicable in other LMICs (Pegues et al., 1994). Problems may be particularly acute in small facilities in rural areas where sources may not be in the building or may be unreliable, forcing staff to collect water from distant sources and store water in the facility, which may introduce additional contamination (Bain et al., 2014; Shields et al., 2015).
Water is an important, overlooked, and controllable source of nosocomial infection. Hospitalized neonates and their mothers are particularly vulnerable to nosocomial waterborne infections. Our objectives through this systematic review were to: investigate water sources, reservoirs, and transmission routes that lead to nosocomial waterborne infections in neonates and their mothers; establish patient risk factors; compile measures for controlling outbreaks and recommended strategies for prevention; and identify information gaps to improve guidelines for reporting future outbreaks.
We searched PubMed, Web of Science, Embase, and clinicaltrials.gov. Peer-reviewed studies reporting contaminated water as a route of transmission to neonates and/or their mothers were included.
Twenty-five studies were included. The most common contaminated water sources in healthcare facilities associated with infection transmission were tap water, sinks, and faucets. Low birthweights, preterm or premature birth, and underlying disease increased neonatal risk of infection. Effective control measures commonly included replacing or cleaning faucets and increased or alternative methods for hand disinfection, and recommendations for prevention of future infections highlighted the need for additional surveillance.
The implementation of control measures and recommended prevention strategies by healthcare workers and managing authorities of healthcare facilities and improved reporting of future outbreaks may contribute to a reduction in the incidence of nosocomial waterborne infections in neonates and their mothers.
Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications
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Therefore, investing in improving HH compliance among staff is an important intervention to control outbreaks of MDR-GNBs.154–164 Although the isolated impact of improving HH on MDR-GNB acquisitions is difficult to quantify owing to methodologic complexities resulting primarily from the inconsistencies of outcome measurements,165 HH is efficacious, even when conclusive data are limited or unavailable.162 A recent modeling analysis in the ICU setting demonstrated that HH is the most efficient measure in controlling ESBL acquisitions.
Antimicrobial activity of copper against organisms in aqueous solution: A case for copper-based water pipelines in hospitals?
2013, American Journal of Infection Control
An association exists between water of poor quality and health care-associated infections. Copper shows microbiocidal action on dry surfaces; it is necessary to evaluate its antimicrobial effect against organisms in aqueous solution.
The objective was to determine the in vitro antimicrobial activity of copper against common nosocomial pathogens in aqueous solution.
Copper and polyvinyl chloride containers were used. Glass was used as control material. Fourteen organisms isolated from hospital-acquired infections, and 3 control strains were tested. Inocula were prepared by direct suspension of colonies in saline solution and water in each container tested. Bacterial counts in colony-forming units (CFU)/mL were determined at the beginning of the experiment; at 30 minutes; and at 1, 2, 24, and 48 hours.
Organisms in glass and polyvinyl chloride remained viable until the end of the experiment. Organisms in copper showed a reduction from more than 100,000 CFU/mL to 0 CFU/mL within the first 2 hours of contact (F > 4.29, P < .001).
Copper containers show microbiocidal action on organisms in aqueous solution. Copper may contribute to the quality of water for human use, particularly in hospitals.
Microbial contamination of a disinfectant-soaked unwoven cleaning cloth
2012, Journal of Hospital Infection
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Pipettes were used to transfer 1 mL of undiluted or diluted samples to trypticase soy agar (TSA). Disinfectant for the soaking of oral aspiration tubes was diluted 10- and 100-fold in polypeptone solution containing 2% Tween 80 and 0.07% lecithin to de-activate the disinfectant.10 Pipettes were used to transfer 1 mL of undiluted or diluted samples to prepared TSA containing 2% Tween 80 and 0.07% lecithin.
In December 2009, a 76-year-old male patient developed pneumonia due to Burkholderia cepacia whilst in an intensive care unit at a Japanese university hospital. During the subsequent environmental investigation to find the source, B. cepacia with an identical DNA type was found in his denture storage solution. Open packets of unwoven rayon cloths soaked in 0.2% alkyldiaminoethylglycine hydrochloride, used for environmental cleaning, were shown to be contaminated with B. cepacia, Alcaligenes xylosoxidans, Pseudomonas fluorescens and Pseudomonas aeruginosa. B. cepacia of a different DNA type was found in five of 42 samples from sealed packets of cloths.
An outbreak of Klebsiella pneumoniae late-onset sepsis in a neonatal intensive care unit in Guatemala
2012, American Journal of Infection Control
Gram-negative bloodstream infections are an important cause of neonatal mortality. In October 2009, we investigated a Klebsiella spp outbreak in a neonatal intensive care unit in Guatemala.
Probable cases were defined as a Klebsiella spp isolated from blood in neonates aged <28 days in the neonatal intensive care unit between October 1 and November 10, 2009; confirmed cases were identified as Klebsiella pneumoniae. Clinical data were abstracted from medical charts. K pneumoniae isolates were genotyped by pulsed-field gel electrophoresis (PFGE) and tested for antimicrobial susceptibility. Infection control practices were inspected.
There were 14 confirmed cases. The median age at onset of infection was 3 days (range, 2-8 days). Nine patients died (64%). K pneumoniae isolates were resistant to multiple antimicrobials. PFGE revealed 2 distinct clusters. Breaches in infection control procedures included inappropriate intravenous solution use and inadequate hand hygiene and contact precautions.
We report a K pneumoniae outbreak with high neonatal mortality in Guatemala. PFGE clustering suggested a common source possibly related to reuse of a single-use intravenous medication or solution. The risk for K pneumoniae bloodstream infections in neonates in low-resource settings where sharing of solutions is common needs to be emphasized.
Efficacy of an infection control programme in reducing nosocomial bloodstream infections in a Senegalese neonatal unit
2011, Journal of Hospital Infection
Citation Excerpt :
Infection is the leading cause of these deaths.1 Neonates requiring intermediate or intensive care in developing countries are at high risk for hospital-acquired neonatal infections due to overcrowding, shortages of nursing and medical staff, lack and improper use of basic supplies and equipment, overuse of antibiotics, and insufficient knowledge of infection control practices and antimicrobial use.2–9 In low-resource countries, many pathogens in neonatal hospital-acquired infections are Gram-negative rods; Klebsiella pneumoniae is the main pathogen, followed by Staphylococcus aureus.2,4,8,10–14
Neonatal nosocomial infections are public health threats in the developing world, and successful interventions are rarely reported. A before-and-after study was conducted in the neonatal unit of the Hôpital Principal de Dakar, Senegal to assess the efficacy of a multi-faceted hospital infection control programme implemented from March to May 2005. The interventions included clustering of nursing care, a simple algorithm for empirical therapy of suspected early-onset sepsis, minimal invasive care and promotion of early discharge of neonates. Data on nosocomial bloodstream infections, mortality, bacterial resistance and antibiotic use were collected before and after implementation of the infection control programme. One hundred and twenty-five infants were admitted immediately before the programme (Period 1, January–February 2005) and 148 infants were admitted immediately after the programme (Period 2, June–July 2005). The two groups of infants were comparable in terms of reason for admission and birth weight. After implementation of the infection control programme, the overall rate of nosocomial bloodstream infections decreased from 8.8% to 2.0% (P = 0.01), and the rate of nosocomial bloodstream infections/patient-day decreased from 10.9 to 2.9/1000 patient-days (P = 0.03). Overall mortality rates did not differ significantly. The proportion of neonates who received antimicrobial therapy for suspected early-onset sepsis decreased significantly from 100% to 51% of at-risk infants (P < 0.001). The incidence of drug-resistant bacteria was significantly lower after implementation of the programme (79% vs 12%; P < 0.001), and remained low one year later. In this neonatal unit, simple, low-cost and sustainable interventions led to the control of a high incidence of bacterial nosocomial bloodstream infections, and the efficacy of these interventions was long-lasting. Such interventions could be extended to other low-income countries.

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American Journal of Infection Control

Abstract

References (29)

The colonization of patients in an intensive care unit with gram-negative flora: the significance of the oral route

J Hosp Infect

Bacterial colonization of neonates admitted to an intensive care environment

J Pediatr

Analysis of bacterial infections in a neonatal intensive care unit

J Hosp Infect

Sepsis neonatorum

N Engl J Med

Infections in newborn infants in a special care unit

Ann Clin Lab Sci

Nosocomial infections in a newborn intensive-care unit: results of forty-one months of surveillance

N Engl J Med

Epidemiology of nosocomial infections in pediatric patients

Pediatr Infect Dis J

Epidemic of Serratia marcescens bacteremia and meningitis in a neonatal unit in Mexico City

Infect Control Hosp Epidemiol

Nosocomial Klebsiella infection in a neonatal unit: identification of risk factors for gastrointestinal colonization

Infect Control

Nosocomial infections due to kanamycin-resistant, [R]-factor carrying enteric organisms in an intensive care nursery

Pediatrics

Outbreak of amikacin-resistant Enterobacteriaceae in an intensive care nursery

Pediatrics

Serotyping of Serratia marcescens: evaluation of LeMinor's H-immobilization test and description of three new flagella H antigens

J Clin Microbiol

Edwards and Ewing's identification of Enterobacteriaceae

Performance standards for antimicrobic disc susceptibility test

Cited by (33)

A systematic review of nosocomial waterborne infections in neonates and mothers

Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications

Antimicrobial activity of copper against organisms in aqueous solution: A case for copper-based water pipelines in hospitals?

Microbial contamination of a disinfectant-soaked unwoven cleaning cloth

An outbreak of Klebsiella pneumoniae late-onset sepsis in a neonatal intensive care unit in Guatemala

Efficacy of an infection control programme in reducing nosocomial bloodstream infections in a Senegalese neonatal unit

ArticleEpidemic gram-negative bacteremia in a neonatal intensive care unit in Guatemala☆

Abstract

J Hosp Infect

J Pediatr

J Hosp Infect

Sepsis neonatorum

N Engl J Med

Infections in newborn infants in a special care unit

Ann Clin Lab Sci

Nosocomial infections in a newborn intensive-care unit: results of forty-one months of surveillance

N Engl J Med

Epidemiology of nosocomial infections in pediatric patients

Pediatr Infect Dis J

Epidemic of Serratia marcescens bacteremia and meningitis in a neonatal unit in Mexico City

Infect Control Hosp Epidemiol

Nosocomial Klebsiella infection in a neonatal unit: identification of risk factors for gastrointestinal colonization

Infect Control

Nosocomial infections due to kanamycin-resistant, [R]-factor carrying enteric organisms in an intensive care nursery

Pediatrics

Outbreak of amikacin-resistant Enterobacteriaceae in an intensive care nursery

Pediatrics

Serotyping of Serratia marcescens: evaluation of LeMinor's H-immobilization test and description of three new flagella H antigens

J Clin Microbiol

Edwards and Ewing's identification of Enterobacteriaceae

Performance standards for antimicrobic disc susceptibility test

Article
Epidemic gram-negative bacteremia in a neonatal intensive care unit in Guatemala☆