Infection Control & Hospital Epidemiology
Table 1. Characteristics of Patients With the First ESBL-E Colonization Detected by Active Surveillance Between September 2005 and 2016
Variable Gender
Female Male Age
≤1 week 1–2 weeks 2–3 weeks >3 weeks
Birth weight <750 g
751–1,000 g 1,001–1,500 g 1,501–2,500 g >2,500 g Unknown
8 8 7
25
1 4 4 6
29 4
Length of stay after admission ≤1 week 1–2 weeks 2–3 weeks >3 weeks
19 7 4
18
Delivery method C-section
Vaginal delivery Unknown
20 26 2
readmitted after a recent hospitalization. cStatistical significance.
Estimated direct cost for active surveillance
During the study period, the estimated NICU admission rate was ~700 admissions per year with a daily occupancy of 45 beds per day, resulting in a total of 14,914 patient days annually. Given that a rectal swab was collected upon admission and weekly during hospitalization, ~50,950 specimens were collected and processed for ESBL-E surveillance. Given that active surveillance detected 150 patients with an ESBL-E pathogen, the positive detection rate was ~3 per 1,000 specimens collected. Further- more, by applying $11.37 per specimen for confirmed positive or $2.47 per specimen for confirmed negative specimens, we esti- mated that the total direct cost of processing these specimens was $127,187.00, accounting for both supply cost and laboratory technicians. Using the active surveillance approach, it cost an average of $848 to detect 1 patient colonized with ESBL-E.
3 1 4
39
11 10 6 9 6 5
28 4 1
14
22 21 4
11 9
11 64
12 14 10 15 35 9
47 11 5
32
42 47 6
>.05 <.05c >.05
Group 1a (N = 48)
21 27
Group 2b (N=47)
14 33
Total (N=95)
35 60
P Value >.05 Discussion
In this study, we analyzed ESBL-E active surveillance data sys- tematically collected in a level IV NICU for 19 years. Until now, most of our knowledge about ESBL-E in NICUs in US hospitals has come from reports involving an outbreak. In this study, we sought to determine the incidence of ESBL-E colonization and infection in a NICU where transmission of ESBL-E pathogens remains at an endemic level using the largest dataset available in this population. In this patient cohort, the incidence rate for ESBL-E coloni-
zation was 1.4 per 100 patient admissions. Of these ESBL-E– colonized patients, ~10% had 1 or more subsequent positive ESBL-E cultures from specimens collected from other sources following a clinical concern of infection. Both of these numbers were substantially lower than the incidence rate of 2.2 per 100 patient admissions and the 25% rate of progression from colo- nization to infection observed in adult ICU patients in the United States and in NICUs outside the United States.22–24 Overall, in this study, ESBL-E colonization was detected at a rate of 3 per 1,000 specimens submitted. Factors potentially contributing to the low ESBL-E incidence rate and detection rate could include the reliance on rectal swab samples only for testing, as well as the use of traditional culture methods, which have the potential to fail to accurately detect the presence of an ESBL in all strains of E. coli and K. pneumoniae.1 The rise of antimicrobial resistance, combined with the lack of
>.05
aPatients admitted from home or from an outside hospital after staying for ≤48 h. bPatients transferred from another healthcare facility following ≥48 h hospitalization or
new antibiotics in the developmental pipeline, have led to a significant health threat to humans. Over the past several dec- ades, both gram-positive and gram-negative bacterial organisms have exhibited resistance to first-line antibiotics or to multiple classes of antibiotics. Infections caused by these resistant organisms have fewer effective therapies, and therefore were linked to increased morbidity and mortality. Once a resistant organism emerges, strategies to prevent its spread are limited to early identification and early isolation, which are accomplished by active surveillance, followed by institution of strict contact precautions. These strategies have been repeatedly proven cost- effective in reducing transmission and infection of multidrug- resistant gram-positive pathogens, such as methicillin-resistant S. aureus and vancomycin-resistant Enterococcus in multiple clinical studies conducted nationally and internationally.25–28 Amid rising incidences and outbreaks of multidrug-resistant gram-negative bacteria in 2006 (including ESBL-E), the Centers for Disease Control and Prevention recommended the use of these 2 strategies in high-risk patient populations to prevent their transmission in healthcare settings.29 These measures continue to be recommended by a joint working group in the United King- dom after an extensive review of evidence published over a 70- year span.17 Nonetheless, this study reveals a low rate of EBSL-E colonization detected by active surveillance and a low rate of progression from colonization to infection in NICU patients, suggesting that the benefits of ESBL-E active surveillance in NICUs with endemic ESBL-E transmission might be offset by the high costs associated with laboratory testing and contact isolation practices.
Importantly, the ESBL-E transmission rate in the CNHS NICU
steadily declined over the 19-year study period. Previous studies conducted in NICUs with a baseline ESBL-E prevalence rate as high as 24% have shown that active surveillance in con- junction with contact precautions is effective in reducing trans- mission risk.23 As demonstrated by a single-center, retrospective,
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