Bacterial contamination of neonatal intensive care units: How safe are the neonates?

BACKGROUND: Intensive care units (ICU) are essential healthcare facility for life threatening conditions. Bacterial contamination of objects/instruments in ICU is an important source of nosocomial infections. This study is aimed to determine the level of bacterial contamination of instruments/objects which are commonly touched by healthcare workers and frequently come in contact with the neonates. METHODS: This hospital based prospective study was conducted in neonatal intensive care unit (NICU) of Manipal Teaching Hospital, Pokhara, Nepal. A total of 146 samples collected from surfaces of incubators, radiant warmers, suction tips, ventilators, stethoscopes, door handles, weighing machines, mothers' beds, phototherapy beds, laryngoscope, telephone sets, blood pressure machine, etc. formed the material of the study. Isolation, identification and antibiotic susceptibility of the bacterial isolates was performed by standard techniques. Blood culture isolates from NICU patients during the study period were compared with the environmental isolates. RESULTS: Out of 146 samples, bacterial growth was observed in 109. A total of 119 bacterial isolates were retrieved from 109 samples. Three common potential pathogens isolated were Escherichia coli (n = 27), Klebsiella species (n = 21) and Staphylococcus aureus (n = 18). Majority of E. coli and Klebsiella isolates were from incubators, suction tips and mothers' beds. Majority of S. aureus isolates were cultured from radiant warmers. Among S. aureus isolates, 33.3% (6/18) were methicillin resistant. Majority of the bacterial isolates were susceptible to gentamicin and amikacin. Common potential pathogens isolated from blood culture of NICU patients were S. aureus and Klebsiella species. CONCLUSION: High degree of bacterial contamination of objects/instruments in NICU was recorded. Isolation of potential pathogens like E. coli, Klebsiella species and S. aureus is a major threat of nosocomial infections. Blood culture data of NICU reflects possibility of nosocomial infections from contaminated sites. Gentamicin and amikacin may be used for empirical therapy in suspected cases of nosocomial infections in NICU.

Detection and characterization of ESBL-producing Enterobacteriaceae from the gut of healthy chickens, Gallus gallus domesticus in rural Nepal: Dominance of CTX-M-15-non-ST131 Escherichia coli clones.

The surge in the prevalence of drug-resistant bacteria in poultry is a global concern as it may pose an extended threat to humans and animal health. The present study aimed to investigate the colonization proportion of extended-spectrum ß-lactamase (ESBL) and carbapenemase-producing Enterobacteriaceae (EPE and CPE, respectively) in the gut of healthy poultry, Gallus gallus domesticus in Kaski district of Western Nepal. Total, 113 pooled rectal swab specimens from 66 private household farms and 47 commercial poultry farms were collected by systematic random sampling from the Kaski district in western Nepal. Out of 113 pooled samples, 19 (28.8%) samples from 66 backyard farms, and 15 (31.9%) from 47 commercial broiler farms were positive for EPE. Of the 38 EPE strains isolated from 34 ESBL positive rectal swabs, 31(81.6%) were identified as Escherichia coli, five as Klebsiella pneumoniae (13.2%), and one each isolate of Enterobacter species and Citrobacter species (2.6%). Based on genotyping, 35/38 examined EPE strains (92.1%) were phylogroup-1 positive, and all these 35 strains (100%) had the CTX-M-15 gene and strains from phylogroup-2, and 9 were of CTX-M-2 and CTX-M-14, respectively. Among 38 ESBL positive isolates, 9 (23.7%) were Ambler class C (Amp C) co-producers, predominant were of DHA, followed by CIT genes. Two (6.5%) E. coli strains of ST131 belonged to clade C, rest 29/31 (93.5%) were non-ST131 E. coli. None of the isolates produced carbapenemase. Twenty isolates (52.6%) were in-vitro biofilm producers. Univariate analysis showed that the odd of ESBL carriage among commercial broilers were 1.160 times (95% CI 0.515, 2.613) higher than organically fed backyard flocks. This is the first study in Nepal, demonstrating the EPE colonization proportion, genotypes, and prevalence of high-risk clone E. coli ST131 among gut flora of healthy poultry. Our data indicated that CTX-M-15 was the most prevalent ESBL enzyme, mainly associated with E. coli belonging to non-ST131clones and the absence of carbapenemases.

Low rate of gut colonization by extended-spectrum ß-lactamase producing Enterobacteriaceae in HIV infected persons as compared to healthy individuals in Nepal.

A worldwide increase in the gastrointestinal colonization by extended-spectrum ß-lactamase (ESBL)-producing bacteria has been observed. Their prevalence amongst Healthy People Living with HIV (HPLWH) has not been investigated adequately. The aim of this study was to determine and compare the rates of and risk factors for intestinal carriage and acquisition of extended-spectrum ß-lactamase producing Enterobacteriaceae (ESBL-E) and carbapenemase-producing Enterobacteriaceae (CPE) among healthy people living with HIV (HPLWH) and healthy HIV negative population in the community. A cross-sectional study was conducted. Rectal swabs from HPLWH (n = 119) and HIV negative individuals (n = 357) from the community were screened for ESBL and CPE. Phenotypically confirmed ESBL-E strains were genotyped by multiplex PCR. The risk factors associated with ESBL-E colonization were analyzed by a multivariable conditional logistic regression analysis. Specimen from 357 healthy volunteers (213 female and 144 male) and 119 HPLWH (82 female and 37 male) with a median age of 30 [IQR 11-50] years were included in the study. ESBL colonization were found in 45 (37.82% [CI 29.09, 47.16]) and 246 (68.91% [CI 63.93, 73.49]), HPLWH and healthy HIV negative participants respectively. HPLWH had lower ESBL carriage rate (odds ratio 0.274 [CI 0.178, 0.423]) compared to healthy HIV negative subject's (p<0.01). In this study, no carbapenemase-producing bacteria were isolated.CTX-M-15 type was the most predominant genotype in both groups. Livestock contact and over-the-counter medications were significantly associated with a higher ESBL-E carriage rate among healthy subjects. This is the first study in Nepal that has demonstrated a high rate of gut colonization by ESBL-E in the community, predominantly of blaCTX-M-15 genotype. This study divulges the low fecal carriage rate of ESBL producing bacteria in HPLWH group compared to healthy individuals in western Nepal. The factors responsible for this inverse relationship of HIV status and gut colonization by ESBL-E are unidentified and require further large-scale study.

Bacterial contamination of frequently touched objects in a tertiary care hospital of Pokhara, Nepal: how safe are our hands?

Background: Objects frequently touched by patients and healthcare workers in hospitals harbor potential pathogens and may act as source of infectious agents. This study aimed to determine the bacterial contamination of common hospital objects frequently touched by patients, visitors and healthcare workers. Methods: A total of 232 samples were collected from various sites like surface of biometric attendance devices, elevator buttons, door handles, staircase railings, telephone sets and water taps. Isolation, identification and antibiotic susceptibility testing of the isolates was performed by standard microbiological techniques. Biofilm forming ability of the S. aureus isolates was tested by a microtitre plate method. Results: A total of 232 samples were collected and 219 bacterial isolates were recovered from 181 samples. Staphylococcus aureus was the most common bacterial isolate (44/219). Majority of S. aureus isolates were recovered from elevator buttons, biometric attendance devices and door handles. Among the S. aureus isolates, 36.3% (16/44) were methicillin resistant Staphylococcus aureus (MRSA) while remaining were methicillin sensitive Staphylococcus aureus (MSSA). Out of 44 S. aureus isolates, 12 (29.5%) were multidrug resistant and 14 (31.8%) were biofilm producers. The majority of MRSA isolates 62.5% (10/16) were biofilm producers. Acinetobacter was the most common Gram negative isolate followed by E coli and Pseudomonas species. Conclusions: High bacterial contamination of frequently touched objects with variety of potential pathogens and normal flora was detected. S. aureus was the most common bacterial isolate. Biofilm forming ability offers additional survival advantage to the organisms on these objects. Present study highlights the need of improved hand hygiene among healthcare workers and regular cleaning/disinfection of sites of frequent public contact.

Onychomycosis due to Candida parapsilosis in a Child with Ventricular Septal Defect: An Unusual Predisposition.

Candida parapsilosis is emerging as a potential pathogen for onychomycosis. A 4-year-old male child with perimembranous ventricular septal defect (VSD) was admitted with features of cystitis and was treated with broad spectrum antibiotics. Two weeks later, he developed yellowish discoloration of nails of both hands. The sloughed out nail, on microscopy, showed numerous yeast forms that were identified as Candida parapsilosis by both phenotypic and genotypic methods. Antifungal sensitivity testing of the isolate was performed by microbroth dilution method in accordance with CLSI guidelines. Patient was successfully treated with topical amphotericin B and oral fluconazole. Thus, one should have a high index of suspicion of C. parapsilosis onychomycosis, especially when the patient is in the paediatric age group, presenting with unusual predisposing condition like congenital heart disease, and is on broad spectrum antibiotics.

Streptococcus pneumoniae and Haemophilus species colonization in health care workers: the launch of invasive infections?

BACKGROUND: Streptococcus pneumoniae and Haemophilus influenzae are important human pathogens. The risk of airborne and droplet-transmitted respiratory tract infections in healthcare workers (HCW) is substantial. The aim of this study was to determine the extent of oropharyngeal colonization with S. pneumoniae and Haemophilus spp. their antibiogram and risk factors of colonization in HCW at a tertiary care center, Western Nepal. METHODS: During 3 month period, 100 oropharyngeal swab specimens were collected from HCW of Manipal Teaching Hospital and 50 from non HCW from community. All the 150 specimens were screened for Haemophilus spp. and S. pneumoniae by standard techniques. Serotyping of H. influenzae type b was done by using specific antiserum. Antibiotic sensitivity patterns of isolates were determined by modified Kirby Bauer disc diffusion method. Association between the groups was analyzed using the Pearson χ(2) test and Fisher exact test. A forward step logistic regression model was used to identify significant predictors for colonization. RESULT: Sixty-five percent of HCW were colonized with S. pneumoniae and/or Haemophilus species compared to 32 % of non-HCW. Health care workers had odd ratio (OR) 3.946 [CI (1.916, 8.128)] times more tendency of colonization compared to non-HCW (P < 0.05). Pneumococcal colonization was observed high among smokers (81.5 %). Amongst HCW, post graduate resident doctors had higher rate of colonization (83.3 %) followed by interns (64.9 %), least being amongst the laboratory workers (58.3 %). CONCLUSION: The higher rate of colonization amongst HCW raises the possibility of occupational risk as well as horizontal spread of infections.