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Background

Infections due to multi-drug resistant Enterobacteriaceae (MDR-E) are a global challenge, especially on low resource setting (LRS) neonatal units with high mortality in preterm neonates. Maternal MDR-E carriage is a risk-factor for neonatal carriage in HIC but the contribution towards acquisition in LRS is unknown. We aimed to characterise neonatal MDR-E carriage and explore associations with maternal carriage via detailed clinical, microbiological and genomic analyses.

Methods

This cross-sectional study at the Gambian teaching hospital involved weekly collection of skin/peri-anal swabs from neonates <2000g and <24h, with maternal recto-vaginal swabs. We conducted conventional microbiology for Enterobacteriaceae and isolates were whole genome sequenced (Illumina platform) to identify sequence types. Antibiotic resistance gene carriage was determined using abriccate with MDR diagnosed if genes coded for resistance to >=3 antimicrobial classes. Maximum likelihood phylogenetic trees were generated from core aligned SNPs using RAxML

Results

137 swabs from 34 neonates and 23 mothers, (21 dyads) yielded 135 Enterobacteriaceae. 82% of isolates had genotypic MDR, mostly K pneumoniae (98%, 43/44) and E coli (84%, 42/50). 22%(17/34) of neonates carried ≥1 MDR-E at admission rising to 85% (11/13) by 7d. K pneumoniae and E coli strains were heterogeneous with no evidence of clonal outbreaks. Paired E coli (6 dyads) and K pneumoniae (5 dyads) were unrelated on SNP-distance analysis. Two or more antibiotic resistance genes were identified in all K pneumoniae (median 13.5 genes) and E coli (median 7.5 genes) with wide diversity of ESBL, AMP-C, fluoroquinolone and septrin resistant genes.

Fig1. Phylogeny trees for K.pneumoniae (top) and Escherichia coli (bottom) isolates

Conclusions

Our results suggest rapid acquisition of MDR-E during hospitalization without genomic evidence of maternal transmission. Environmental surveillance is required for insights to guide infection prevention strategies.

Clinical Trial Registration

Not applicable as no clinical trial is involved

Background

The influence of the neonatal intensive care unit (NICU) design on the acquisition of multidrug resistant organisms (MDRO) has not been well-documented. The aim of this study was to examine the effect of open bay unit (OBU) versus single room unit (SRU) design on the incidence of colonization and infection with MDRO and third generation cephalosporin resistant bacteria (3G-CRB) as well as the number of possible transmission events in infants admitted to the NICU.

Methods

All infants admitted to the NICU two years prior to and two years following transition from OBU to SRU were identified. Incidence of colonization, infection and possible transmission events of MDRO were compared between OBU and SRU periods.

Results

Analysis was performed in 1293 NICU infants, which identified 3.2% MDRO carriers including 2.3% extended-spectrum β-lactamase producing Enterobacterales carriers and 18.6% 3G-CRB carriers.

No difference was found in the incidence density per 1,000 patient-days (1.56 OBU, 2.63 SRU, n.s.) between the historic open ward and the new single room units. The MDRO infection rate was low (0.12%) and not found to be different between OBU and SRU infants. We did not find a decrease in possible transmission events per 1,000 patient-days after transition (0.62 OBU, 0.81 SRU, n.s.).

Conclusions

Transition from an open bay to a single room unit NICU was not associated with a reduction in colonization and infection rates or possible transmission events with MDRO in our hospital.