Infection Control & Hospital Epidemiology (2018), 39, 1436–1441 doi:10.1017/ice.2018.260
Original Article
Reassessing the need for active surveillance of extended-spectrum beta-lactamase–producing Enterobacteriaceae in the neonatal intensive care population
Xiaoyan Song PhD, CIC1,2, Lamia Soghier MD, MEd1,2, Tara Taylor Floyd MPH, BSN1,
Tracie R. Harris MT (ASCP), CIC1, Billie L. Short MD1,2 and Roberta L. DeBiasi MD, MS1,2 1Children’s National Health System, Washington, DC and 2The George Washington University School of Medicine and Health Sciences, Washington, DC
Abstract
Objective: To determine the continued need for active surveillance to prevent extended-spectrum β-lactamase–producing Enterobacter- iaceae (ESBL-E) transmission in a neonatal intensive care unit (NICU). Design: This retrospective observational study included patients with ESBL-E colonization or infection identified during their NICU stay at our institution between 1999 and March 2018. Active surveillance was conducted between 1999 and March 2017 by testing rectal swab specimens collected upon admission and weekly thereafter. The overall incidence rates, of ESBL-E colonization or infection (including hospital acquired) before and after active surveillance were calculated. The cost associated with active surveillance was then estimated. Results: Overall, 171 NICU patients were found to have ESBL-E colonization or infection, and 150 of those patients (87.7%) were detected by active surveillance. The overall incidence rate was 1.4 per 100 patient admissions. The hospital-acquired incidence rate was 0.41 per 1,000 patient days, and this rate had decreased since 2002, with an average of 6 cases detected annually. A significant decrease was observed in 2009 when the unit moved to a new single-bed unit featuring private rooms. Active surveillance was discontinued with no increase in the number of infections. Of the 150 ESBL-E colonized patients, 14 (9.3%) subsequently developed an infection. Active surveillance resulted in a total of 50,950 specimen collections and a cost of $127,187 for processing, an average of $848 to detect 1 ESBL-E colonized patient. Conclusion: ESBL-E transmission and infection in our NICU remains uncommon. Active surveillance may have contributed to the decline of ESBL-E transmission when used in conjunction with contact precautions and private rooms, but its relatively high cost could be prohibitive.
(Received 8 July 2018; accepted 24 September 2018; electronically published October 22, 2018)
Extended-spectrum β-lactamases (ESBLs) are enzymes that confer resistance to most β-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam.1 Since they were first described in 1983 in Germany, ESBL-producing Enterobacteriaceae (ESBL-E) have increasingly been identified as pathogens and have become endemic in many healthcare settings and communities.2,3 Multiple global surveillance programs have documented increasing ESBL-E prevalence worldwide4–6 in both adult and pediatric populations.7 This surveillance, combined with a lack of effective treatments for ESBL-E infections and the potential risk of transmission among patients in hospital settings, have led to the development of strategies to monitor and control ESBL-E colonization and transmission. The rise of ESBL-E prevalence in pediatric patients is con-
cerning. Although well characterized in adults, the epidemiology, risk factors, outcome, therapies, and control measures for ESBL-E
Author for correspondence: Xiaoyan Song, Children’s National Health System,
West Wing 3.5 Suite 100, 111 Michigan Ave NW, Washington, DC 20010. E-mail:
xsong@cnmc.org
Cite this article: Song X, et al. (2018). Reassessing the need for active surveillance of
extended-spectrum beta-lactamase–producing Enterobacteriaceae in the neonatal intensive care population. Infection Control & Hospital Epidemiology 2018, 39, 1436–1441. doi: 10.1017/ice.2018.260
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
in pediatric patients has remained largely unknown. The limited data in this population have primarily been generated by studies of outbreaks in pediatric intensive care units or neonatal intensive care units (NICUs). During outbreaks, vehicle-based transmission (eg, through artificial nails of hospital staff) or vector-based transmission (eg, cockroach infestations) have contributed to the spread of pathogens.8,9 These differ from risk factors described in non-outbreak settings, where patient characteristics including younger gestational age, low birth weight, prolonged mechanical ventilation, length of hospital stay, invasive devices, and antibiotic use independently increase a patient’s risk for ESBL-E coloniza- tion or infection.10,11 ESBL-E infections have been associated with poor outcomes as measured by prolonged hospital stay, delay in effective therapy, and mortality.12–14 Patients with ESBL-E rectal colonization have an increased risk for developing ESBL-E infections.15,16 Of the myriad of strategies to prevent transmission of ESBL-E
among hospitalized patients, active surveillance to identify and isolate patients colonized with ESBL-E has been a common practice, especially in high-risk populations such as NICU patients. Active surveillance continues to be the recommendation of the Centers for Disease Control and Prevention as a core prevention strategy.17 This strategy was first introduced in the
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