Abstract:
BACKGROUND. Rates of healthcare-associated infections (HAIs) among babies born in developing countries are higher than among those
born in resource-rich countries, as a result of suboptimal infection prevention and control (IPC) practices. Following two reported deaths
of neonates with carbapenem-resistant Klebsiella pneumoniae bloodstream infections (BSIs), we conducted an outbreak investigation in a
neonatal unit of a regional hospital in Gauteng Province, South Africa.
OBJECTIVES. To confirm an outbreak of K. pneumoniae BSIs and assess the IPC programme in the neonatal unit.
METHODS. We calculated total and organism-specific BSI incidence risks for culture-confirmed cases in the neonatal unit for baseline
and outbreak periods. We conducted a clinical record review for a subset of cases with K. pneumoniae BSI that had been reported to
the investigating team by the neonatal unit. An IPC audit was performed in different areas of the neonatal unit. We confirmed species
identification and antimicrobial susceptibility, and used polymerase chain reaction for confirmation of carbapenemase genes and pulsedfield
gel electrophoresis (PFGE) for typing of submitted clinical isolates.
RESULTS. From January 2017 to August 2018, 5 262 blood cultures were submitted, of which 11% (560/5 262) were positive. Of 560 positive
blood cultures, 52% (n=292) were positive for pathogenic organisms associated with healthcare-associated BSIs. K. pneumoniae comprised
the largest proportion of these cases (32%; 93/292). The total incidence risk of healthcare-associated BSI for the baseline period (January
2017 - March 2018) was 6.8 cases per 100 admissions, and that for the outbreak period (April - September 2018) was 10.1 cases per
100 admissions. The incidence risk of K. pneumoniae BSI for the baseline period was 1.6 cases per 100 admissions, compared with 5.0 cases
per 100 admissions during the outbreak period. Average bed occupancy for the entire period was 118% (range 101 - 133%), that for the
baseline period was 117%, and that for the outbreak period was 121%. In a subset of 12 neonates with K. pneumoniae bacteraemia, the
median (interquartile range (IQR)) gestational age at birth was 27 (26 - 29) weeks, and the median (IQR) birth weight was 1 100 (880 -
1 425) g. Twelve bloodstream and 31 colonising K. pneumoniae isolates were OXA-48-positive. All isolates were genetically related by PFGE
analysis (89% similarity). Inadequate IPC practices were noted, including suboptimal adherence to aseptic technique and hand hygiene
(57% overall score in the neonatal intensive care unit), with poor monitoring and reporting of antimicrobial use (pharmacy score 55%).
CONCLUSIONS. Overcrowding and inadequate IPC and antimicrobial stewardship contributed to a large outbreak of BSIs caused by genetically
related carbapenemase-producing K. pneumoniae isolates in the neonatal unit.
