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Xiaoyan Song et al
Fig. 1. Hospital-acquired ESBL-E infection and colonization incidence rate in the neonatal intensive care unit at Children’s National Health System, 1999–March 2017. Hospital- acquired was defined as the detection of ESBL-E for the first time from a specimen collected for either active surveillance or clinical diagnosis after patient being admitted for 48 hours or longer. The center line was calculated as the average incidence rate.
acquired ESBL-E colonization and/or infection rate, while Poisson regression was conducted to examine the statistical significance of the changes over time. Our institutional review board approved this study.
Results
Between 1999 and March 2017, a total of 171 NICU patients were found to have ESBL-E infection or colonization on admission (n = 60; 35.1%) or to have acquired the organism during the hospitalization (n = 111, 64.9%). The overall incidence rate of ESBL-E colonization or infection was estimated to be 1.4 per 100 patient admissions, or 1.2 per 1,000 patient days. The overall hospital-acquired ESBL-E incidence rate was estimated to be 0.41 per 1,000 patient days, and this rate had declined since 2002 (Poisson regression coefficient, −0.08; 95% confidence interval [CI], −0.13 to −0.33; P = .009) (Fig. 1), with an average of 6 cases detected annually. A significant decline as indicated by a central- line shift on the U chart, was observed in 2009 when the unit moved into its current single-bed unit featuring private patient rooms. Active surveillance using rectal swabs identified 150 patients (87.7%) colonized with ESBL-E. The remaining 21 patients were identified from specimens collected from tracheal aspirates (n = 12), urine (n = 4), abdominal fluid (n = 1), eye (n = 1), blood (n = 1), ventilator fluid (n = 1), and a wound (n = 1) in symptomatic patients when clinicians suspected neonatal sepsis or pneumonia. Of the 150 patients that were colonized with EBSL-E as indicated by the positive surveillance result, 14 (9.3%) progressed to develop 1 or more subsequent infections caused by the same ESBL-E species found in the rectal swab specimens collected for active surveillance. These infections included urinary
tract infection (n = 7), bacteremia (n = 6), eye infection (n = 1), meningitis (n = 1), and complications following ven- triculoperitoneal shunt and intestinal atresia repair procedures (n = 2). With a total of 35 infections in this cohort, the incidence rate of ESBL-E infection was 0.13 per 1,000 patient days. Klebsiella pneumoniae (43.4%) was the most frequently iden-
tified ESBL-E by active surveillance, followed by Escherichia coli (25.8%) and Serratia marcescens (6.9%). In contrast, Serratia marcescens (37.5%), K. oxytoca (20.8%), and E. coli (20.8%) were the 3 most common ESBL-E pathogens detected among speci- mens collected for clinical diagnosis. Between April 2017 and March 2018 after active surveillance
was discontinued, 4 patients were found to have ESBL-E in spe- cimens collected for clinical diagnosis including tracheal aspirates (n = 3) for pneumonia and drainage (n = 1) for cellulitis. Of the 3 patients with a tracheal aspirate specimen growing ESBL-E, only 1 patient was clinically treated for a new onset of pneumonia. Thus, with 2 infections in this cohort, the incidence rate of ESBL-E infection was 0.10 per 1,000 patient days.
Epidemiology
Of the 95 patients who screened positive for ESBL-E between September 2005 and March 2017, 60 (63.2%) were male, 25 (26.3%) had a birth weight <1,000 g, and 47 (49.5%) were the product of a vaginal delivery. Of these 95 patients, 47 (49.5%) were transferred after a 48-hour or longer hospitalization at another healthcare facility or were readmitted after a recent hospitalization at CNHS. Except for birthweight, these 47 patients had similar characteristics compared to the remaining 48 patients who were admitted from home or from another healthcare facility with <48 hours at that facility (Table 1).
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