Expanding PVL positive MRSA healthcare-associated infections outbreak in a newborns unit, caused by hospital hygiene shortcomings

Open access

Abstract

A prolonged outbreak of Healthcare-Associated Infections (HCAIs) evolved since December 2013, in a Newborns Unit from Hospital A, sited in the North-Eastern development region, Romania. A first cluster consisted of 19 cases, of which 18 infections in newborns and 1 labour infectious complication in a mother. Except for five cases declared and treated in the Neonatology Unit as hospital-acquired infections, the other cases were discharged and further required rehospitalisation and treatment.

Eight of these innitialy discharged cases were readmitted to the Pediatric Surgery Unit and two others to the Pediatrics Unit of Hospital B, while three others were readmitted to three hospitals: one to the Pediatrics Unit of Hospital C, and other two to Hospital A and Hospital D, respectively. The mother with the labour infectious complication was readmitted to the Gynecology Unit of the Hospital A.

A number of fifteen Staphylococcus aureus (S. aureus) strains isolated from the HCAI first episode and 8 strains from 7 HCWs were received by „Cantacuzino” Institute, Nosocomial Infections and Antibiotic Resistance Laboratory from the County Public Health Directorate, for confirmation and molecular typing.

After a first round of interventions for infection control, a second episode bursted in Hospital A and our laboratory received six other S. aureus isolates from newborns, hospital environment, and HCWs.

Public Health interventions based on epidemiologic data and molecular microbiology results were finally successful. The evolution of all cases was favorable.

An important factor favoring the outbreak was the moving of the Birth Unit of Hospital A to an innapropriate location for an 18-month interval, more than innitially estimated, in relation to rehabilitation of the ward.

We considered to report this episode taking into account the unusual evolution, the risk of multiresistant bacterial strains spreading, and multiple unwanted consequences caused by shortcomings in providing appropriate hygiene conditions.

1. Polak JD, Ringler N, Daugherty B. Unit Based Procedures: Impact on the Incidence of Nosocomial Infections in the Newborn Intensive Care Unit. Newborn Infant Nurs Rev. 2004 Mar;4(1):38-45. DOI: 10.1053/j.nainr.2003.12.001

2. Pereira Reginatto F, Silva ISB. The main neonatal dermatological findings: a review. EMJ Dermatol. 2016 Aug;4(1):111-8.

3. Drăgulescu EC, Buzea M, Codiță I. Molecular Analysis of Community-Acquired Staphylococcus aureus strains isolated from Skin and Soft-Tissue Infections in Romania. Romanian Biotechnological Letters. Published online ahead of print. DOI: 10.26327/RBL2017.106

4. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 3.1, 2013. http://www.eucast.org

5. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 4.0, 2014. http://www.eucast.org

6. Leclercq R. Mechanisms of resistance to macrolides and lincosamides: nature of the resistance elements and their clinical implications. Clin Infect Dis. 2002 Feb;34(4):482-92. DOI: 10.1086/324626

7. Milheirico C, Oliveira DC, de Lencastre H. Update to the multiplex PCR strategy for assignment of mec element types in Staphylococcus aureus. Antimicrob Agents Chemother. 2007 Sep;51(9):3374-7. DOI: 10.1128/AAC.00275-07

8. Harmsen D, Claus H, Witte W, Rothganger J, Claus H, Turnwald D, et al. Typing of methicillin-resistant Staphylococcus aureus in a university hospital setting by using novel software for spa repeat determination and database management. J Clin Microbiol. 2003 Dec;41(12):5442-8. DOI: 10.1128/JCM.41.12.5442-5448.2003

9. Murchan S, Kaufmann ME, Deplano A, de Ryck R, Struelens M, Zinn CE, et al. Harmonization of pulsed-field gel electrophoresis protocols for epidemiological typing of strains of methicillin-resistant Staphylococcus aureus: a single approach developed by consensus in 10 European laboratories and its application for tracing the spread of related strains. J Clin Microbiol. 2003 Apr;41(4):1574-85. DOI: 10.1128/JCM.41.4.1574-1585.2003

10. Tenover FC, Arbeit RD, Goering RV, Mickelsen PA, Murray BE, Persing DH, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol. 1995 Sep;33(9):2233-9.

11. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997 Jul;10(3):505-20.

12. Boyce JM, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol. 1997 Sep;18(9):622-7. DOI: 10.1086/502213

13. Albrich WC, Harbarth S. Health-care workers: source, vector, or victim of MRSA? Lancet Inf Dis. 2008 May;8(5):289-301. DOI: 10.1016/S1473-3099(08)70097-5

14. Rammelkamp CH Jr, Mortimer EA Jr, Wolinsky E. Transmission of streptococcal and staphylococcal infections. Ann Intern Med. 1964 May;60(5):753-8. DOI: 10.7326/0003-4819-60-5-753

15. Mernelius S. Infection control of Staphylococcus aureus - spa typing to elucidate transmission. Thesis. 2015;1-95.

16. Sherertz RJ, Bassetti S, Bassetti-Wyss B. “Cloud” Health-Care Workers. Emerg Infect Dis. 2001 Apr;7(2):241-4. DOI: 10.3201/eid0702.010218

17. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

18. Chan GJ, Lee ACC, Baqui AH, Tan J, Black RE. Risk of Early-Onset Neonatal Infection with Maternal Infection or Colonization: A Global Systematic Review and Meta-Analysis. PLoS Medicine. 2013 Aug;10(8):e1001502. DOI: 10.1371/journal.pmed.1001502

19. Remington JS, Klein JO, Wilson ChB, Nizet V, Maldonado YA. Infectious Diseases of the Fetus and Newborn Infant, 7th Edition, by Saunders, an imprint of Elsevier Inc. 2011;1-1273.

20. Folden DV, Machayya JA, Sahmoun AE, Beala JR, Holzmana GS, Helgerson SD, et al. Estimating the proportion of community-associated methicillin-resistant Staphylococcus aureus: two definitions used in the USA yield dramatically different estimates. J Hosp Infect. 2005 Jun;60:329-32. DOI: 10.1016/j.jhin.2004.12.025

21. Otter JA, French GL. Nosocomial transmission of community associated methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2006 Dec; 6(12):753-5. DOI: 10.1016/S1473-3099(06)70636-3

22. Glaser P, Martins-Simões P, Villain A, Barbier M, Tristan A, Bouchier C, et al. Demography and intercontinental spread of the USA300 community-acquired methicillin-resistant Staphylococcus aureus lineage. mBio. 2016 Feb;7(1):e02183-15. DOI: 10.1128/mBio.02183-15

23. Carrel M, Perencevich EN, David MZ. USA300 Methicillin-Resistant Staphylococcus aureus, United States, 2000–2013. Emerg Infect Dis. 2015 Nov;21(11):1973 -1980. DOI: 10.3201/eid2111.150452

24. Healy CM, Hulten KG, Palazzi DL, Campbell JR, Baker CJ. Emergence of new strains of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit. Clin Infect Dis. 2004 Nov;39(10):1460-6. DOI: 10.1086/425321

25. Pfaller MA, Herwaldt LA. The clinical microbiology laboratory and infection control: emerging pathogens, antimicrobial resistance, and new technology. Clin Infect Dis. 1997 Jun;25(4):858-70. DOI: 10.1086/515557

26. Azarian T, Cook RL, Johnson JA, Guzman N, McCarter YS, Gomez N, et al. Whole-Genome Sequencing for Outbreak Investigations of Methicillin-Resistant Staphylococcus aureus in the Neonatal Intensive Care Unit: Time for Routine Practice? Infect Control Hosp Epidemiol. 2015 Jul;36(7):777-85. DOI: 10.1017/ice.2015.73

27. Edgeworth JD, Yadegarfar G, Pathak S, Batra R, Cockfield JD, Wyncoll D, et al. An outbreak in an intensive care unit of a strain of methicillin-resistant Staphylococcus aureus sequence type 239 associated with an increased rate of vascular access device-related bacteremia. Clin Infect Dis. 2007 Feb;44(4):493-501. DOI: 10.1086/511034

28. Oliveira D, Santos-Sanches I, Mato R, Tamayo M, Ribeiro G, Costa D, et al. Virtually all methicillin resistant Staphylococcus aureus (MRSA) infections in the largest Portuguese teaching hospital are caused by two internationally spread multiresistant strains: the ‘Iberian’ and the ‘Brazilian’ clones of MRSA. Clin Microbiol Infect. 1998 Jul;4(7):373-84. DOI: 10.1111/j.1469-0691.1998.tb00081.x

29. Kuroda M, Ohta T, Uchiyama I, Baba T, Yuzawa H, Kobayashi I, et al. Whole genome sequencing of meticillin-resistant Staphylococcus aureus. Lancet. 2001 Apr;357(9264):1225-40. DOI: 10.1016/S0140-6736(00)04403-2

30. Diep BA, Gill SR, Chang RF, Phan TH, Chen JH, Davidson MG, et al. Complete genome sequence of USA300, an epidemic clone of community-acquired meticillin-resistant Staphylococcus aureus. Lancet. 2006 Mar;367(9512):731-39. DOI: 10.1016/S0140-6736(06)68231-7

31. DeLeo FR, Otto M, Kreiswirth BN, Chambers HF. Community-associated meticillin-resistant Staphylococcus aureus. Lancet. 2010 Sep;375(9725):1557-68 DOI: 10.1016/S0140-6736(09)61999-1

32. Boyle-Vavra S, Ereshefsky B, Wang CC, Daum RS. Successful multiresistant community-associated methicillin-resistant Staphylococcus aureus lineage from Taipei, Taiwan, that carries either the novel Staphylococcal chromosome cassette mec (SCCmec) type VT or SCCmec type IV. J Clin Microbiol. 2005 Sep;43(9):4719-30. DOI: 10.1128/JCM.43.9.4719-4730.2005

33. Diep BA, Otto M. The role of virulence determinants in community-associated MRSA pathogenesis. Trends Microbiol. 2008 Aug;16(8):361-9. DOI: 10.1016/j.tim.2008.05.002

34. Krziwanek K, Luger C, Sammer B, Stumvoll S, Stammler M, Metz-Gercek S, et al. PVL-positive MRSA in Austria. Eur J Clin Microbiol Infect Dis. 2007 Dec;26(12):931-5. DOI: 10.1007/s10096-007-0391-4

35. Witte W, Strommenger B, Cuny Ch, Heuck D, Nuebel U. Methicillin-resistant Staphylococcus aureus containing the Panton-Valentine leucocidin gene in Germany in 2005 and 2006. J Antimicrob Chemother. 2007 Dec;60(6):1258-63. DOI: 10.1093/jac/dkm384

36. Nashev D, Bizeva L, Toshkova K. First cases of infections caused by Panton-Valentine leukocidin positive community-acquired methicillin-resistant Staphylococcus aureus in Bulgaria. Euro Surveill. 2007 Jun;12(26):pii=3225.

37. Daskalaki M, Rojo P, Marin-Ferrer M, Barrios M, Otero JR, Chaves F. Panton–Valentine leukocidin-positive Staphylococcus aureus skin and soft tissue infections among children in an emergency department in Madrid, Spain. Clin Microbiol Infect. 2010;16(1):74-77. DOI: 10.1111/j.1469-0691.2009.02830.x

38. Orendi JM, Coetzee N, Ellington MJ, Boakes E, Cookson BD, Hardy KJ, et al. Community and nosocomial transmission of Panton-Valentine leucocidin-positive community-associated meticillin-resistant Staphylococcus aureus: implications for healthcare. J Hospital Infect. 2010 Jun;75(4):258-64. DOI: 10.1016/j.jhin.2010.03.023

39. Sanchini A, Spitoni MG, Monaco M, Raglio A, Grigis A, Petro W, et al. Outbreak of skin and soft tissue infections in a hospital newborn nursery in Italy due to community-acquired meticillin-resistant Staphylococcus aureus USA300 clone. J Hospital Infect. 2013;83:36-40. DOI: 10.1016/j.jhin.2012.09.017

40. Kaïret K, Ho E, Van Kerkhoven D, Boes J, Van Calenbergh S, Pattyn L, et al. USA300, A strain of community-associated methicillin-resistant Staphylococcus aureus, crossing Belgium’s borders: outbreak of skin and soft tissue infections in a hospital in Belgium. Eur J Clin Microbiol Infect Dis. 2017 May;36(5):905-9. DOI: 10.1007/s10096-016-2883-6

41. Sassi M, Felden B, Revest M, Tattevin P, Augagneur Y, Donnio P-Y. An outbreak in intravenous drug users due to USA300 Latin-American variant community-acquired methicillin-resistant Staphylococcus aureus in France as early as 2007. Eur J Clin Microbiol Infect Dis. 2017 Dec;36(12):2495-501. DOI: 10.1007/s10096-017-3092-7

42. Huang E, Gurzau AE, Hanson BM, Kates AE, Smith TC, Pettigrew MM, et al. Detection of livestock-associated methicillin-resistant Staphylococcus aureus among swine workers in Romania. J Infect Public Health. 2014 Jul-Aug;7(4):323-32. DOI: 10.1016/j.jiph.2014.03.008

43. Szekely E, Enache LS, Marinescu S, Ungvari E, Toth A, Paszti J. Fatal sepsis due to community-associated methicillin resistant Staphylococcus aureus – a case report. Rev Rom Med Lab. 2010 Jun;18(2/4):29-33.

44. Alexandrescu V, Codiță I, Băețel A, Drăgulescu E-C, Coldea I-L. Caz letal de gripă sezonieră suprainfectată cu S. aureus rezistent la meticilină producător de leucocidină Panton-Valentine – România, 2009 [Engl. Seasonal flu fatal case superinfected with Methicillin-Resistant S. aureus producing Panton-Valentine Leukocidin – Romania, 2009]. Bacteriol Virusol Parazitol Epidemiol. 2010 Apr-Jun;55(2):107-108.

45. Ionescu B, Ionescu D, Gheorghe I, Curuțiu C, Banu O, Bleotu C, et al. Virulence patterns of Staphylococcus aureus hospital strains isolated in Bucharest, Romania. Rom Biotech Letters. 2015 May-Jun;20(3):10536-46.

46. Vremeră T, Iancu LS, Năstase EV, Logigan C, Miftode EG, Mereuță AI, et al. Triplex real-time PCR for detection of methicillin-resistant Staphylococcus aureus and Panton-Valentine leukocidin in North-East Romania. Rev Med Chir Soc Med Nat Iasi. 2012 Oct-Dec;116(4):1171-6.

47. Vremeră T, Iancu LS, Logigan C, Năstase E, Miftode E, Enache E, et al. Use of real time PCR for testing Staphylococcus aureus isolates from the Iasi Infectious Diseases Hospital. Rev Med Chir Soc Med Nat Iasi. 2011 Jul;115(3):927-33.

48. Dorobăț OM, Bădicuț I, Tălăpan D, Tenea C, Rafila A. Antibiotic resistance of Gram-positive cocci isolated in 2008. Bacteriol Virusol Parazitol Epidemiol. 2010 Apr-Jun;55(2):83-92.

49. Ionescu R, Mediavilla JR, Chen L, Grigorescu DO, Idomir M, Kreiswirth BN, et al. Molecular Characterization and Antibiotic Susceptibility of Staphylococcus aureus from a Multidisciplinary Hospital in Romania. Microb Drug Resist. 2010 Dec;16(4):263-72. DOI: 10.1089/mdr.2010.0059

50. Kock R, Becker K, Cookson B, Van Gemert-Pijnen JE, Harbarth S, Kluytmans J, et al. Methicillin-resistant Staphylococcus aureus (MRSA): burden of disease and control challenges in Europe. Euro Surveill. 2010 Oct;15(41):19688. DOI: 10.2807/ese.15.41.19688-en

51. Năstase E, Dorneanu O, Vremeră T, Logigan C, Miftode E, Dorobăț CM. MecA and pvl genes detection in Staphylococcus aureus strains isolated from lower respiratory tract infections. Rev Med Chir Soc Med Nat Iasi. 2010 Oct-Dec;114(4):1162-8.

52. Nica M, Biolan T, Dascălu A, Mozes E, Toderan A, Calistru P, et al. Bacterial strains isolated from systemic infections and reported for evaluation and antibiotic resistance surveillance by the “Dr. Victor Babes” Clinical Hospital for Infectious and Tropical Diseases, Bucharest. Bacteriol Virusol Parazitol Epidemiol. 2010 Apr-Jun;55(2):161-8.

53. Szekely E, Lorinczi L, Bilca D, Fodor E, Soki J, Sabău M. Incidence, antibiotic resistance and clonal relations of MRSA strains isolated from a Romanian university hospital. Acta Microbiol Immunol Hung. 2008 Mar;55:1-13. DOI: 10.1556/AMicr.55.2008.1.1

54. Dorneanu O, Miftode E, Vremera T, Năstase E, Filip O, Luca V. Prevalence and characteristics of Staphylococcus aureus isolated from infections in Northeast Romania. J Prev Med. 2006 Jun;14(3-4):66-70.

55. Coman G, Cîrlan M, Petraru E, Dahorea C, Butnaru F. Antibiotic resistance phenotypes of S. aureus from pediatric infections. Rev Med Chir. 2002 Jan;106:46-52.

56. Grigore L, Dumitrescu V, Sfartz S, Codiță I. The antibiotic resistance of Staphylococcus aureus strains isolated in units with an elevated nosocomial risk and in outpatient facilities in 1995. Bacteriol Virusol Parazitol Epidemiol. 1997 Jan-Mar;42:51-4.

57. Grundmann H, Aanensen DM, Van den Wijngaard CC, Spratt BG, Harmsen D, Friedrich AW, the European Staphylococcal Reference Laboratory Working Group. Geographic Distribution of Staphylococcus aureus Causing Invasive Infections in Europe: A Molecular-Epidemiological Analysis. PLoS Medicine. 2010 Jan;7(1):e1000215. DOI: 10.1371/journal.pmed.1000215

58. Oprea M, Drăgulescu EC, Coldea IL, Codiţă I, Szmal C, Străuţ M. Molecular characterization of Staphylococcus aureus isolates belonging of two most prevalent spa-types recovered from Romanian hospitals during 2006-2007. Clin Microbiol Inf. 2008 May;14 (Suppl. 7):S410–S411.

59. Szekely E, Man A, Mare A, Vas KE, Molnar S, Bilca D, et al. Molecular epidemiology and virulence factors of methicillin-resistant Staphylococcus aureus strains in a Romanian university hospital. Rom Rev Lab Med. 2012 Dec;20(4/4):371-82.

60. Grundmann H, Schouls LM, Aanensen DM, Pluister GN, Tami A, Chlebowicz M, et al, on behalf of the ESCMID Study Group on Molecular Epidemiological Markers and the European Staphylococcal Reference Laboratory Working Group. The dynamic changes of dominant clones of Staphylococcus aureus causing bloodstream infections in the European region: Results of a second structured survey. Euro Surveill. 2014 Dec;19(49):20987. DOI: 10.2807/1560-7917.ES2014.19.49.20987

61. Cîrlan M, Saad M, Coman G, Bilal NE, Elbashier AM, Kreft D, et al. International spread of major clones of methicillin resistant Staphylococcus aureus: nosocomial endemicity of multi locus sequence type 239 in Saudi Arabia and Romania. Infect Genet Evol. 2005 Jan;5:335-9. DOI: 10.1016/j.meegid.2004.09.005

62. Codiţă I, Oprea M, Szmal C, Drăgulescu EC, Traşcă M, Brehar Cioflec D, Chicin G, Şerban R, Pistol A. Panton-Valentine leukocidin positive, t008 spa-type meticillin-resistant Staphylococcus aureus in a Romanian western county hospital. Clin Microbiol Infect. 2008 May; 14 (Suppl. 7):S687.

63. Codiţă I, Drăgulescu EC, Lixandru BE, Coldea IL, Dinu S, Străuț M. Cluster of t127 spa type MRSA strains evolving in a Romanian newborns unit in 2010. Rom Rev Lab Med. 2011 Jun;Suppl.19 (2/4):S81-2.

64. Franco A, Hasman H, Iurescia M, Lorenzetti R, Stegger M, Pantosti A, et al. Molecular characterization of spa type t127, sequence type 1 methicillin-resistant Staphylococcus aureus from pigs. J Antimicrob Chemother. 2011 Jun;66(6):1231-5. DOI: 10.1093/jac/dkr115

65. Monecke S, Muller E, Dorneanu OS, Vremeră T, Ehricht R. Molecular Typing of MRSA and of Clinical Staphylococcus aureus Isolates from Iasi, Romania. PLoS ONE. 2014 May;9(5):e97833. DOI: 10.1371/journal.pone.0097833

66. Scheithauer S, Trepels-Kottek S, Häfner H, Keller D, Ittel T, Wagner N, et al. Healthcare worker-related MRSA cluster in a German neonatology level III ICU: A true European story. Int J Hyg Environ Health. 2014 Mar;217(2-3):307-11. DOI: 10.1016/j.ijheh.2013.07.006

67. Pammi M, Davis RJ, Gordon A, Starke J. Infant isolation and cohorting for preventing or reducing transmission of healthcare-associated infections in neonatal units. Cochrane Db Syst Rev. 2016;12:CD012458.

68. Lepelletier D, Corvec S, Caillon J, Reynaud A, Roze J-Ch, Gras-Leguen Ch. Eradication of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit: which measures for which success? Am J Infect Control. 2009 Apr;37(3):195-200. DOI: 10.1016/j.ajic.2008.09.024

69. Gerber S, Jones R, Scott M, Price J, Dworkin M, Filippell M, Rearick T, et al. Management of Outbreaks of Methicillin-Resistant Staphylococcus aureus Infection in the Neonatal Intensive Care Unit: A Consensus Statement. Infect Control Hosp Epidemiol. 2006 Feb;27(2):139-45. DOI: 10.1086/501216

Revista Romana de Medicina de Laborator

Romanian Journal of Laboratory Medicine

Journal Information


IMPACT FACTOR 2017: 0.400
5-year IMPACT FACTOR: 0.320



CiteScore 2017: 0.31

SCImago Journal Rank (SJR) 2017: 0.144
Source Normalized Impact per Paper (SNIP) 2017: 0.195

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 21 21 21
PDF Downloads 20 20 20