Characterization of an outbreak due to extended-spectrum β-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit
Background: The epidemiological–microbiological characteristics and effective intervention measures in an outbreak due to extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae in a neonatal intensive care unit are described.
Materials and methods: Cases from June 22, 2018 to February 11, 2019 were analyzed. Microbiological analysis of intestinal carriage of ESBL-producing K. pneumoniae and environmental samples was conducted. Strain relationships were studied by pulsed-field gel electrophoresis (PFGE).
Results: A 35-week outbreak affecting 41 patients, with eight infected, 33 colonized, and two deceased patients occurred. Two stages of the outbreak were observed with differences in the frequency of intestinal carriage of ESBL-producing K. pneumoniae. The same genetic subtype was seen in patient strains and was different from strains isolated from the environment. Deficiencies in contact precautions, hand hygiene, and handling of breast milk were observed.
Conclusions: A monoclonal outbreak by ESBL-producing K. pneumoniae that occurred in two phases and the different control measures in each of the stages is described. Effective control measures are mainly based on improving compliance with standard precautions and contact precautions, and other complementary measures are described such as proper handling of breast milk, periodic carriage studies, and the generation of three patient cohorts.
Magill SS, O’Leary E, Janelle SJ, Dumyati G, Nadle J, Wilson LE. et al. Changes in prevalence of health care–associated infections in U.S. Hospitals. N Engl J Med 2018; 379(18): 1732–44. doi: 10.1056/NEJMoa1801550
Giannoni E, Agyeman PKA, Stocker M, Posfay-Barbe KM, Heininger U, Spycher BD et al. Neonatal sepsis of early onset, and hospital-acquired and community-acquired late onset: A prospective population-based cohort study. J Pediatr 2018; 201: 106–14.e4. doi: 10.1016/j.jpeds.2018.05.048
Li X, Xu X, Yang X, Luo M, Liu P, Su K et al. Risk factors for infection and/or colonization with extended-spectrum β-lactamase-producing bacteria in the neonatal intensive care unit: a meta-analysis. Int J Antimicrob Agents 2017; 50(5): 622–8. doi: 10.1016/j.ijantimicag.2017.06.027
Johnson J, Quach C. Outbreaks in the neonatal ICU. Curr Opin Infect Dis 2017; 30(4): 395–403. doi: 10.1097/QCO.0000000000000383
Das P, Singh AK, Pal T, Dasgupta S, Ramamurthy T, Basu S. Colonization of the gut with gram-negative bacilli, its association with neonatal sepsis and its clinical relevance in a developing country. J Med Microbiol. 2011; 60, 1651–1660. doi: 10.1099/jmm.0.033803-0
Kanamori H, Weber DJ, Rutala WA. Healthcare outbreaks associated with a water reservoir and infection prevention strategies. Clin Infect Dis 2016; 62: 1423–1435. doi: 10.1093/cid/ciw122
Knothe H, Shah P, Krcmery V, Antal M, Mitsuhashi S. Transferable resistance to cefotaxime, cefoxitin, cefamandole and cefuroxime in clinical isolates of Klebsiella pneumoniae and Serratia marcescens. Infection 1983; 11(6): 315–7. doi: 10.1007/BF01641355
Ministerio de salud. Informe de vigilancia de infecciones asociadas a la atención en salud. August 2018. Chile. Available from: http://web.minsal.cl/infeccionesintrahospitalarias
Stapleton PJM, Murphy M, McCallion N, Brennan M, Cunney R, Drew RJ. Outbreaks of extended spectrum beta-lactamase producing Enterobacteriaceae in neonatal intensive care units: A systematic review. Arch Dis Child Fetal Neonatal Ed 2016; 101(1): F72–8. doi: 10.1136/archdischild-2015-308707
Haller S, Eller C, Hermes J, Kaase M, Steglich M, Radonić A, et al. What caused the outbreak of ESBL-producing Klebsiella pneumoniae in a neonatal intensive care unit, Germany 2009 to 2012? Reconstructing transmission with epidemiological analysis and whole-genome sequencing. BMJ Open. 2015; 5(5): 1–9. doi: 10.1136/bmjopen-2014-007397
Corbella M, Caltagirone M, Gaiarsa S, Mariani B, Sassera D, Bitar I, et al. Characterization of an outbreak of extended-spectrum β-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit in Italy. Microb Drug Resist. 2018;24(8):1128–36. doi: 10.1089/mdr.2017.0270
Rettedal S, Löhr IH, Natås O, Giske CG, Sundsfjord A, Øymar K. First outbreak of extended-spectrum β-lactamase-producing Klebsiella pneumoniae in a Norwegian neonatal intensive care unit; associated with contaminated breast milk and resolved by strict cohorting. Apmis 2012; 120(8): 612–21. doi: 10.1111/j.1600-0463.2012.02879.x
Leigh G. Donowitz, Frederic J. Marsik, Karen A. Fisher, Richard P. Wenzel, Contaminated breast milk: A source of Klebsiella bacteremia in a newborn intensive care unit. Reviews of Infectious Diseases, 1981; 3(4): 716–20. doi: 10.1093/clinids/3.4.716
Dorota P, Chmielarczyk A, Katarzyna L, Piotr M, Lauterbach J, et al. Klebsiella pneumoniae in breast milk-a cause of sepsis in neonate. Arch Med 2017, 9: 1. doi: 10.21767/1989-5216.1000189
Gray J, Arvelo W, McCracken J, Lopez B, Lessa FC, Kitchel B, et al. An outbreak of Klebsiella pneumoniae late-onset sepsis in a neonatal intensive care unit in Guatemala. Am J Infect Control 2012; 40(6): 516–20. doi: 10.1016/j.ajic.2012.02.031
González RAC, Gil GF, Solórzano RM, Cruz GJ, Puig PJ, Suárez SM, et al. Brote por Klebsiella pneumoniae multiresistente y productora de β-lactamasa de espectro extendido en una unidad de alto riesgo neonatal. Rev chil infectol 2011; 28: 28–34. doi: 10.4067/S0716-10182011000100005.
Aranega-Bou P, George RP, Verlander NQ, Paton S, Bennet A, Moore G, TRACE investigators group. Carbapenem-resistant Enterobacteriaceae dispersal from sinks is linked to drain position and drainage rates in laboratory model system. J Hosp Infect 2019; 102:63–69. doi: 10.1016/j.jhin.2018.12.007
De Geyter D, Blommaert L, Verbraeken N, Sevenois M, Huyghens L, Martini H et al. The sink as a potential source of transmission of carbapenemase-producing Enterobacteriaceae in the intensive care unit. Antimicrob Resist Infect Control 2017; 6: 24. doi: 10.1186/s13756-017-0182-3
Sahly H, Navon-Venezia S, Roesler L, Hay A, Carmeli Y, Podschun R, et al. Extended-spectrum β-lactamase production is associated with an increase in cell invasion and expression of fimbrial adhesins in Klebsiella pneumoniae. Antimicrob Agents Chemother 2008; 52(9): 3029–34. doi: 10.1128/AAC.00010-08
Löhr IH, Hülter N, Bernhoff E, Johnsen PJ, Sundsfjord A, Naseer U. Persistence of a pKPN3-like CTX-M-15-encoding IncFIIK plasmid in a Klebsiella pneumonia ST17 host during two years of intestinal colonization. PLoS One 2015; 10(3): 1–16. doi: 10.1371/journal.pone.0116516
Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; 29th ed. CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2019.
de Oliveira Garcia D, Doi Y, Szabo D, Adams-Haduch JM, Vaz TM, Leite D, et al. Multiclonal Outbreak of Klebsiella pneumoniae Producing Extended-Spectrum-Lactamase CTX-M-2 and Novel Variant CTX-M-59 in a Neonatal Intensive Care Unit in Brazil. Antimicrob Agents Chemother 2008 May; 52(5): 1790–1793. doi: 10.1128/AAC.01440-07
Calbo E, Garau J. The changing epidemiology of hospital outbreaks due to ESBL-producing Klebsiella pneumoniae: the CTX-M-15 type consolidation. Future Microbiol 2015; 10(6): 1063–75. doi: 10.2217/fmb.15.22
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