A study by US and Indian researchers suggests that the presence of indwelling devices and prior antibiotic exposure are associated with increased risk of healthcare-associated bloodstream infections (BSIs) in newborns in low-resource settings.
The prospective study, published this week in JAMA Network Open by a Johns Hopkins University School of Medicine–led research team, examined data on neonates admitted to one of three neonatal intensive care units (NICUs) in Pune, India, from May 2017 through July 2019. The newborns were followed from admission until discharge, transfer, or death. The primary outcome was healthcare-associated BSIs, defined as positive blood culture on or after admission day 3.
Like many other low- and middle-income countries (LMICs) grappling with high levels of antimicrobial resistance (AMR), India has reported high rates of infections among hospital-born neonates, with rates 3- to 20-fold higher than observed in high-income countries, the study authors note. Their aim was to identify some of the drivers of these high neonatal healthcare-associated infection rates.
“Identification of neonates at highest risk for health care–associated infection events is paramount to guide the development of targeted interventions to prevent health care–associated infections and, thus, reduce the burden of neonatal morbidity and mortality in LMICs,” the study authors wrote.
27% of newborns with BSIs died before discharge
Among the 6,410 newborns (median gestational age, 34 weeks; 55.5% male) included in the study, the incidence of healthcare-associated BSIs was 6.09 per 1,000 patient-days. Most BSIs (202 [54.2%]) occurred during days 3 to 7 of admission. Among the 373 newborns (5.8%) with healthcare-associated BSIs, 101 (27.1%) died before discharge.
Of the 412 bacterial isolates collected, most (273 [66.3%]) were gram-negative organisms, and 85.5% of the 236 tested gram-negative isolates were resistant to third- or fourth-generation cephalosporins, while 44.8% were resistant to carbapenems. The most frequently isolated organisms were Klebsiella spp (124 [30.1%) of all isolates), Acinetobacter spp (47 [11.4%]), and Citrobacter spp (41 [10%]).
Identification of neonates at highest risk for health care–associated infection events is paramount to guide the development of targeted interventions to prevent health care–associated infections and, thus, reduce the burden of neonatal morbidity and mortality in LMICs.
Increased risk of healthcare-associated BSIs was associated with central venous catheters (hazard ratio [HR], 2.35; 95% confidence interval [CI], 1.55 to 3.57), respiratory support (HR, 3.09; 95% CI, 2.86 to 3.34), or urinary catheters (HR, 2.24; 95% CI, 1.48 to 3.40) within 3 days preceding infection. Among 3,339 newborns admitted for 7 days or longer, antibiotic exposure during the first week of admission was associated with a nearly threefold increase in the risk of health care–associated BSIs (adjusted HR, 2.82; 95% CI, 1.26 to 6.32).
The study authors say that, given the observed high burden of resistant gram-negative healthcare-associated BSIs, the limited treatment options for such infections, and the high associated morbidity and mortality, strategies to reduce infection risk in NICUs in LMICs are “of paramount importance.” They suggest implementation of infection prevention and control (IPC) measures and antimicrobial stewardship interventions should be critical components of this effort.
“NICUs should address BSI prevention through improvements in IPC practices, with a focus on risk associated with indwelling devices,” the authors concluded. “It will be important for future studies to explore drivers of high antibiotic use to tailor stewardship programs to local context.“
