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Patient screening for resistant bacteria

Authors

Giannoni E, Tissières P Helder O, Mader S, Thiele N, Borghesi A

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Patient screening for multidrug-resistant bacteria in neonatal intensive care units (NICUs) is part of infection prevention and control programmes.

Rationale

The goal is to reduce the incidence of infections caused by multidrug-resistant bacteria in NICUs. Active surveillance consists of performing screening cultures to identify asymptomatic infants colonised with multidrug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and Gram-negative pathogens expressing extended spectrum β-lactamases and carbapenemases. Identification of patients colonised by MDRO allows the adoption of contact precautions and cohorting of patients and decontamination, in order to minimise the likelihood of progression from colonisation to invasive infection and the spread to other patients. The benefit of active surveillance and associated interventions is well documented in the adult ICUs (1), and during outbreaks. (2) However, the benefit of screening all NICU patients for MDRO is more controversial. While some studies have shown a reduction in colonisation by MDRO (3,4), there was significant variation in timing of screening, anatomic sites sampled, isolation protocols, and decolonisation strategies. (5,6) Furthermore, cost effectiveness of active surveillance is questionable (7), treatments used for decontamination may not be totally harmless in newborns (8), and other infection prevention strategies focusing on hand hygiene and promotion of feeding with breast milk may be more efficient. (9,10) The impact of screening all infants admitted to the NICU for MDRO is likely to depend on the local epidemiology of nosocomial infections and resistance patterns, on NICU organisation and implementation of basic infection prevention practices. Therefore, a uniform approach for screening MDRO may not be applicable to all European NICUs, and policies regarding screening should be part of infection prevention and control programmes developed by each institution.

Benefits

Short-term benefits

  • Reduced risk and containment of outbreaks due to multi-resistant bacteria (2,9,10)

Long-term benefits

  • Reduced mortality and improved neurodevelopmental outcome (2,11)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents and family are informed by healthcare professionals about practices to reduce the incidence of nosocomial infections. (9,10) A (Moderate quality)
B (High quality)
Patient information sheet
       
For healthcare professionals    
2. A unit guideline on screening for multi-resistant bacteria and regarding measures that need to be taken in the event of a positive screening is adhered to by all healthcare professionals. B (High quality) Guideline
       
3. Training on infection prevention practices are attended by all responsible healthcare professionals. (2,9,10) A (High quality)
B (High quality)
Training documentation
       
4. Frequent contact with dedicated infection control teams to discuss specific cases is ensured. B (High quality) Guideline
       
For neonatal unit    
5. A unit guideline on screening for multi-resistant bacteria and regarding measures that need to be taken in the event of a positive screening is available and regularly updated. (2,9,10) A (Moderate quality)
B (High quality)
Guideline
       
For hospital    
6. Training on infection prevention practices and frequent contact with dedicated infection control teams to discuss specific cases is ensured. B (High quality) Guideline, training documentation
       
7. Resources for infection prevention and control are available, including microbiology laboratories with ability to perform identification, susceptibility testing and rapid notification of results to clinicians, ability to monitor local epidemiology of nosocomial infections, and strategies for management of outbreak. (2,9,10) A (High quality) Guideline, audit report
       
For health service    
8. A national guideline on screening for multi-resistant bacteria, and regarding measures that need to be taken in the event of a positive screening is available and regularly updated. B (High quality) Guideline
       
9. Initiatives to contain antibiotic-resistant pathogens are supported. (9,10) A (Moderate quality) Audit report
       

Where to go

Further development Grading of evidence
For parents and family  
N/A  
For healthcare professionals  
N/A  
For neonatal unit and hospital  
  • Update policies based on changes in the local epidemiology of nosocomial infections and new evidence from the literature.
B (Moderate quality)
For health service  
N/A  
   

Getting started

Initial steps
For parents and family
  • Parents and family are verbally informed by healthcare professionals about infection prevention practices.
For healthcare professionals
N/A
For neonatal unit
  • Develop and implement a guideline on screening for multi-resistant bacteria, and regarding measures that need to be taken in the event of a positive screening.
  • Develop information material on infection prevention and control for parents.
For hospital
N/A
For health service
  • Develop and implement a national guideline on screening for multi-resistant bacteria, and regarding measures that need to be taken in the event of a positive screening.
 

Sources

  1. Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, et al. Targeted versus Universal Decolonization to Prevent ICU Infection. N Engl J Med. 2013 Jun 13;368(24):2255–65.
  2. Stapleton PJM, Murphy M, McCallion N, Brennan M, Cunney R, Drew RJ. Outbreaks of extended spectrum beta-lactamase-producing Enterobacteriaceae in neonatal intensive care units: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2016 Jan;101(1):F72-78.
  3. Pierce R, Lessler J, Popoola VO, Milstone AM. Meticillin-resistant Staphylococcus aureus (MRSA) acquisition risk in an endemic neonatal intensive care unit with an active surveillance culture and decolonization programme. J Hosp Infect. 2017 Jan;95(1):91–7.
  4. Rybczynska H, Melander E, Johansson H, Lundberg F. Efficacy of a once-a-week screening programme to control extended-spectrum beta-lactamase-producing bacteria in a neonatal intensive care unit. Scand J Infect Dis. 2014 Jun;46(6):426–32.
  5. Milstone AM, Song X, Coffin S, Elward A, Society for Healthcare Epidemiology of America’s Pediatric Special Interest Group. Identification and eradication of methicillin-resistant Staphylococcus aureus colonization in the neonatal intensive care unit: results of a national survey. Infect Control Hosp Epidemiol. 2010 Jul;31(7):766–8.
  6. Popoola VO, Budd A, Wittig SM, Ross T, Aucott SW, Perl TM, et al. Methicillin-resistant Staphylococcus aureus transmission and infections in a neonatal intensive care unit despite active surveillance cultures and decolonization: challenges for infection prevention. Infect Control Hosp Epidemiol. 2014 Apr;35(4):412–8.
  7. Macnow T, O’Toole D, DeLaMora P, Murray M, Rivera K, Whittier S, et al. Utility of surveillance cultures for antimicrobial resistant organisms in infants transferred to the neonatal intensive care unit. Pediatr Infect Dis J. 2013 Dec;32(12):e443-450.
  8. Nelson MU, Bizzarro MJ, Dembry LM, Baltimore RS, Gallagher PG. One size does not fit all: why universal decolonization strategies to prevent methicillin-resistant Staphylococcus aureus colonization and infection in adult intensive care units may be inappropriate for neonatal intensive care units. J Perinatol Off J Calif Perinat Assoc. 2014 Sep;34(9):653–5.
  9. Patel SJ, Saiman L. Antibiotic resistance in neonatal intensive care unit pathogens: mechanisms, clinical impact, and prevention including antibiotic stewardship. Clin Perinatol. 2010 Sep;37(3):547–63.
  10. Pelat C, Kardaś-Słoma L, Birgand G, Ruppé E, Schwarzinger M, Andremont A, et al. Hand Hygiene, Cohorting, or Antibiotic Restriction to Control Outbreaks of Multidrug-Resistant Enterobacteriaceae. Infect Control Hosp Epidemiol. 2016 Mar;37(3):272–80.
  11. Schlapbach LJ, Aebischer M, Adams M, Natalucci G, Bonhoeffer J, Latzin P, et al. Impact of sepsis on neurodevelopmental outcome in a Swiss National Cohort of extremely premature infants. Pediatrics. 2011 Aug;128(2):e348-357.

November 2018 / 1st edition / next revision: 2023

Recommended citation
EFCNI, Giannoni E, Tissières P et al., European Standards of Care for Newborn Health: Patient screening for resistant bacteria. 2018.

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