ABSTRACT
BACKGROUND: Although hospital-acquired infections appear to be a growing threat to the survival of newborns in the developing world, the epidemiology of this problem remains poorly characterized. METHODS: During a 10-month period, we conducted prospective longitudinal surveillance for colonization and bloodstream infection caused by gram-negative rods among all infants hospitalized in the 2 largest neonatal intensive care units in Manila, the Philippines. We determined antibiotic susceptibilities and calculated adjusted odds ratios for risk factors for bacteremia by means of multivariate logistic regression. RESULTS: Of 1,831 neonates enrolled during a 10-month period, 1,017 (55.5%) became newly colonized and 358 (19.6%) became bacteremic with a drug-resistant gram-negative rod, most commonly Klebsiella species, Enterobacter species, Acinetobacter species, and Pseudomonas aeruginosa. Of the invasive isolates, 20% were resistant to imipenem, 41% to trimethoprim-sulfamethoxazole, 52% to amikacin, 63% to ampicillin-sulbactam, 67% to ceftazidime, and 80% to tobramycin. The factors significantly associated with an increased risk of bacteremia were mechanical ventilation and prematurity. Additionally, colonization with a drug-resistant gram-negative rod was an independent risk factor for bacteremia (odds ratio, 1.4 [95% confidence interval, 1.0-1.9]). CONCLUSIONS: Colonization with a drug-resistant gram-negative rod was an independent risk factor for sepsis. If our data are typical, the unusually high intensity of colonization pressure and disease caused by multidrug-resistant gram-negative rods at these 2 neonatal intensive care units indicates an emerging healthcare crisis in the developing world. Improved infection control methods are therefore critically needed in developing countries.
Subject(s)
Bacteremia/epidemiology , Carrier State/epidemiology , Drug Resistance, Multiple, Bacterial , Gram-Negative Bacteria/drug effects , Gram-Negative Bacterial Infections/epidemiology , Infant, Premature, Diseases/epidemiology , Intensive Care Units, Neonatal , Anti-Bacterial Agents/pharmacology , Bacteremia/microbiology , Carrier State/microbiology , Female , Gram-Negative Bacteria/classification , Gram-Negative Bacteria/isolation & purification , Gram-Negative Bacterial Infections/microbiology , Humans , Infant, Extremely Low Birth Weight , Infant, Low Birth Weight , Infant, Newborn , Infant, Premature , Infant, Premature, Diseases/microbiology , Male , Microbial Sensitivity Tests , Philippines/epidemiology , Risk FactorsABSTRACT
BACKGROUND: The growing burden of neonatal mortality associated with hospital-acquired neonatal sepsis in the developing world creates an urgent need for cost-effective infection-control measures in resource-limited settings. METHODS: Using a before-and-after comparison design, we measured how rates of staff hand-hygiene compliance, colonization with drug-resistant pathogens (defined as ceftazidime- and/or gentamicin-resistant gram-negative bacilli and drug-resistant gram-positive cocci), bacteremia, and overall mortality changed after the introduction of a simplified package of infection-control measures at 2 neonatal intensive care units (NICUs) in Manila, The Philippines. RESULTS: Of all 1827 neonates admitted to the NICU, 561 (30.7%) arrived from delivery already colonized with drug-resistant bacteria. Of the 1266 neonates who were not already colonized, 578 (45.6%) became newly colonized with drug-resistant bacteria. Of all 1827 neonates, 358 (19.6%) became bacteremic (78.2% were infected with gram-negative bacilli) and 615 (33.7%) died. Of 2903 identified drug-resistant colonizing bacteria, 85% were drug-resistant gram-negative bacilli (predominantly Klebsiella species, Pseudomonas species, and Acinetobacter species) and 14% were methicillin-resistant Staphylococcus aureus. Contrasting the control period with the intervention period at each NICU revealed that staff hand-hygiene compliance improved (NICU 1: relative risk, 1.3; 95% confidence interval 1.1-1.5; NICU 2: relative risk, 1.6; 95% confidence interval, 1.4-2.0) and that overall mortality decreased (NICU 1: relative risk, 0.5; 95% confidence interval, 0.4-0.6; NICU 2: relative risk, 0.8; 95% confidence interval, 0.7-0.9). However, rates of colonization with drug-resistant pathogens and of sepsis did not change significantly at either NICU. DISCUSSION: Nosocomial transmission of drug-resistant pathogens was intense at these 2 NICUs in The Philippines; transmission involved mostly drug-resistant gram-negative bacilli. Infection-control interventions are feasible and are possibly effective in resource-limited hospital settings.
