Preterm Twins Born to a Mother with Miliary Tuberculosis: Importance of Early Recognition and Prompt Response in Infection Control to Manage Congenital Tuberculosis Exposure in a Neonatal Intensive Care Unit.

Delayed diagnosis of congenital tuberculosis (TB) in the neonatal intensive care unit (NICU) is a serious problem in terms of infection control. Here, we report our preemptive infection control activities implemented after the diagnosis of miliary TB in a mother of preterm twins (index twins, NB1 and NB2) in the NICU. In addition, we reviewed previous case reports of congenital TB exposure in the NICU setting. Immediately after diagnosing miliary TB in the mother, the index twins were isolated before their TB diagnosis and received preemptive anti-TB medication; contact investigations were also conducted. Eventually, NB1 was diagnosed with congenital TB at 29 days of age, and NB2 showed no definite evidence of TB. Through contact investigation, 11 of the 16 exposed infants received isoniazid prophylaxis and no positive tuberculin skin test results were obtained after 3 months. One of the 31 exposed healthcare workers showed new interferon-gamma release assay conversion. Moreover, our case showed a much shorter contagious period compared to that in previous reports (8 versus 17-102 days). This suggests that a high index of suspicion and prompt measures can help prevent congenital TB outbreaks and reduce the burden of infection control activities in the NICU.

Successful control of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae ST307 outbreak in a neonatal intensive care unit.

BACKGROUND: In this study, we evaluated the genetic relatedness of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-KPN) isolates from an outbreak in a neonatal intensive care unit (NICU) in August 2017, We implemented an active countermeasure to control this outbreak successfully. METHODS: The incidence of healthcare-associated ESBL-KPN bacteremia was evaluated before and after initiating enhanced infection control (IC) practices in January 2018. Surveillance cultures were set up and monitored for neonates, medical personnel, and NICU environments. Molecular analyses, including pulse-field gel electrophoresis (PFGE), sequence typing, and ESBL genotyping, were performed for the isolated KPN strains. RESULTS: After implementing the enhanced IC procedures, the healthcare-associated bacteremia rate decreased from 6.0 to 0.0 per 1000 patient-days. Samples from neonates (n = 11/15, 73.3%), medical personnel (n = 1/41, 2.4%), and medical devices and the environments (6/181, 3.3%) tested positive for ESBL-KPN in the surveillance cultures in December 2017. Active surveillance cultures revealed that 23 of 72 neonates who were screened (31.9%) were colonized with ESBL-KPN between January and March 2018. All the isolates demonstrated closely related PFGE patterns and were identified as ST307 strain carrying the CTX-M-15 gene. CONCLUSIONS: Contaminated NICU environments and medical devices, as well as transmission by medical personnel, appeared to be the source of the outbreak of ESBL-KPN infection. We employed an enhanced IC strategy during January-March 2018 and successfully controlled the clonal outbreak of CTX-M-15-positive KPN. ST307 has emerged as an important bacteremia-causing pathogen in the NICU and should be carefully monitored.

The difference in hand hygiene compliance rate between unit-based observers and trained observers for World Health Organization checklist and optimal hand hygiene.

BACKGROUND: Hand hygiene (HH) is crucial to prevent healthcare-associated infections and the spread of multidrug-resistant organisms. The monitoring of HH compliance may be affected by observer expertise. A sufficient duration of HH is necessary to remove microorganisms. The aim of this study was to measure compliance with both the World Health Organization (WHO) checklist and optimal HH as reported by unit-based observers and infection control nurses (ICN). METHODS: Optimal HH was defined as adhering to the exact duration and following a six-step procedure. The disparity in compliance with the WHO checklist and optimal HH was analyzed among each profession, unit, and indication, covering a period of 3 years. RESULTS: There was a statistically significant difference in WHO checklist compliance (94.4% vs. 87.0%, p<0.01) and optimal HH rate (86.3% vs. 42.4%, p<0.01) between unit-based observers and ICN. The optimal HH rate was especially lower for doctors (30.1%), in the intensive care units (39.4%), and before clean and aseptic procedures (37.0%) as observed by ICN. CONCLUSIONS: Although the overall WHO checklist HH rate was reported to be higher than 90%, optimal HH was only half this rate. More education and awareness of the significance of HH, as well as adherence to the optimal HH procedures, are needed to prevent hospital-acquired infections.

Management of carbapenem-resistant Acinetobacter baumannii epidemic in an intensive care unit using multifaceted intervention strategy.

BACKGROUND/AIMS: We evaluated the effects of a multifaceted intervention for controlling a carbapenem-resistant Acinetobacter baumannii (CRAB) epidemic in an intensive care unit (ICU) with no restrictions on carbapenem use. METHODS: This study was conducted in a medical ICU between April 2012 and June 2016. The baseline infection control programs included surveillance cultures, contact precautions, and environmental cleaning. However, increases in the detection of CRAB isolates beginning in May 2013 led to the implementation of a new protocol, consisting of universal glove and gown use with daily chlorhexidine bathing for all patients in combination with baseline programs. The efficacy of the intervention was subjected to interrupted time series (ITS) analysis. RESULTS: The multifaceted intervention led to a decrease in the incidence of CRAB from 17.65 to 0.89 cases per 1,000 patient-days, during the study period (p < 0.001). ITS analysis revealed a significant change in the trend of CRAB incidence (-0.413, p < 0.001). Over this same period, mean monthly use of carbapenems increased from 143.54 ± 95.73 to 204.95 ± 78.43 doses per 1,000 patient-days (p = 0.018). CONCLUSION: Our multifaceted intervention reduced the incidence of CRAB acquisition in an ICU where carbapenem use was not restricted.

The effect of targeted decolonization on methicillin-resistant Staphylococcus aureus colonization or infection in a surgical intensive care unit.

BACKGROUND: The effect of decolonization on the control of methicillin-resistant Staphylococcus aureus (MRSA) may differ depending on intensive care unit (ICU) settings and the prevalence of antiseptic resistance in MRSA. METHODS: This study was conducted in a 14-bed surgical ICU over a 40-month period. The baseline period featured active surveillance for MRSA and institution of contact precautions. MRSA decolonization via chlorhexidine baths and intranasal mupirocin was implemented during a subsequent 20-month intervention period. Pre-post and interrupted time series analysis were used to evaluate changes in the clinical incidence of hospital-acquired MRSA colonization or infection. MRSA isolates were tested for the presence of qacA/B genes and mupirocin resistance. RESULTS: In pre-post analysis, the clinical incidence of MRSA significantly decreased by 61.6% after implementation of decolonization (P < .001). Meanwhile, interrupted time series analysis showed decreases in both the level (ß = -0.686; P = .210) and trend (ß = -0.011; P = .819) of clinical MRSA incidence, but these changes were not statistically significant. Of 169 MRSA isolates, 64 (37.8%) carried the qacA/B genes, and 22 (13.0%) showed either low- (n = 20) or high-level (n = 2) resistance to mupirocin. Low-level mupirocin resistance significantly increased from 0%-19.4% during the study period. CONCLUSION: Although decolonization using antiseptic agents was helpful to decrease hospital-acquired MRSA rates, the emergence of antiseptic resistance should be monitored.

Successful control of carbapenem-resistant Acinetobacter baumannii in a Korean university hospital: a 6-year perspective.

BACKGROUND: This study evaluated the effect of infection control interventions on the incidence of carbapenem-resistant Acinetobacter baumannii (CRAB) in a tertiary hospital over a 6-year period. METHODS: Multiple interventions, including cohorting, promotion of hand hygiene, active surveillance in the intensive care units, and environmental cleaning, were implemented from 2007 through 2009 (period 1). From 2009 through 2012 (period 2), infection control programs were enhanced by the introduction of an onsite education and hand hygiene campaign in preparation for hospital accreditation. To assess the efficacy of the infection control intervention programs, the nosocomial incidence density of CRAB, consumption of alcohol-based hand gel, and consumption of antimicrobials during the study period were measured. RESULTS: The incidence density of CRAB increased from 0.35 to 0.46 per 1000 patient-days (PD) during period 1, but decreased to 0.06 per 1000 PD in period 2 (P = .011). The consumption of alcohol-based hand gel increased from 5.6 L to 11.9 L per 1000 PD during the study period (P < .001). There was a significant association between the incidence density of CRAB and carbapenem use (P = .008). CONCLUSIONS: Education for infection control programs, hand hygiene campaign, and the judicious use of carbapenem may decrease the nosocomial incidence of CRAB.