Prolonged outbreak of clonal, mupirocin-resistant methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit: association with personnel and a possible environmental reservoir, analyzed using whole genome sequencing.

BACKGROUND: Outbreaks of MRSA occur in NICUs and may be difficult to control. We describe an outbreak of mupirocin-resistant MRSA, molecular epidemiology of isolates and control. METHODS: Medical record review of personnel contact with infants. MRSA isolates were analyzed by whole genome sequencing (WGS); single nucleotide polymorphisms (SNPs) were identified. RESULTS: A 31-month outbreak of MRSA infection occurred. Weekly colonization surveillance of infants was initiated; initial prevalence was 45%. Isolates exhibited high level mupirocin-resistance. There were 3 periods of increased colonization and new infections despite implementation of multiple infection prevention interventions. During the second period, an analysis identified a frontline staff member associated with newly colonized infants whose nasal culture grew the clonal MRSA. A marked reduction in colonization followed removal from patient contact. WGS of isolates from years 1-3 showed clonality with maximum SNP differences of 33. Importantly, the year 3 isolates were more closely related to the early year 1 isolates (15-20 SNP differences) than to the late year 1 or year 2 isolates (18-33 SNP differences). DISCUSSION/CONCLUSIONS: During a recrudescent MRSA outbreak due to a clonal strain, both contact with a colonized staff member and a putative environmental or personnel reservoir were associated with MRSA acquisition.

Reducing ventilator-associated pneumonia through advanced oral-dental care: a 48-month study.

OBJECTIVE: To determine the effect of implementing a comprehensive oral and dental care system and protocol on the rate of ventilator-associated pneumonia. METHODS: Patients more than 18 years old receiving mechanical ventilation for more than 48 hours in a medical intensive care unit at a university-affiliated medical center were studied in 2 consecutive 24-month periods. Patients in the group studied before the intervention (n = 779) had no oral assessments, no suctioning of the subglottic space, no toothbrushing, and suctioning of secretions in the oral cavity as needed. The group studied during the intervention (n = 759) included patients treated under a protocol whereby the oral cavity was assessed, deep suctioning was done every 6 hours, oral tissue cleansing was done every 4 hours or as needed, and toothbrushing was done twice daily. RESULTS: Compliance with protocol components exceeded 80%. The groups did not differ significantly in age, sex, or severity of illness. The rate of ventilator-associated pneumonia was 12.0 per 1000 ventilator days before the intervention and decreased to 8.0 per 1000 ventilator days during the intervention (P = .06). Duration of mechanical ventilation and length of stay in the intensive care unit differed significantly between groups, as did mortality. CONCLUSION: Our findings suggest that use of advanced tools, a comprehensive oral care protocol, and staff compliance with the protocol can significantly reduce rates of ventilator-associated pneumonia and associated costs.