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Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016 Erika Van Schalkwyk, Samantha Iyaloo, Serisha D

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Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016 Erika Van Schalkwyk, Samantha Iyaloo, Serisha D SYNOPSIS Large Outbreaks of Fungal and Bacterial Bloodstream Infections in a Neonatal Unit, South Africa, 2012–2016 Erika van Schalkwyk, Samantha Iyaloo, Serisha D. Naicker, Tsidiso G. Maphanga, Ruth S. Mpembe, Thokozile G. Zulu, Mabatho Mhlanga, Sibongile Mahlangu, Motlatji B. Maloba, Grace Ntlemo, Kgomotso Sanyane, Dini Mawela, Nelesh P. Govender In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at http://www.medscape.org/journal/eid; and (4) view/print certificate. For CME questions, see page 1399. Release date: June 14, 2018; Expiration date: June 14, 2019 Learning Objectives Upon completion of this activity, participants will be able to: • Describe the background of Candida krusei infection among neonates • Assess the clinical picture and prognosis of C. krusei candidemia among neonates • Distinguish risk factors for C. krusei candidemia among neonates • Analyze results of an environmental study in the neonatal intensive care unit (NICU) to find the source of C. krusei CME Editor Jean Michaels Jones, BSN, Technical Writer/Editor, Emerging Infectious Diseases. Disclosure: Jean Michaels Jones has disclosed no relevant financial relationships. CME Author Charles P. Vega, MD, FAAFP, Health Sciences Clinical Professor, University of California, Irvine, Department of Family Medicine; Associate Dean for Diversity and Inclusion, University of California, Irvine, School of Medicine; Executive Director, University of California, Irvine, Program in Medical Education for the Latino Community, Irvine, California. Disclosure: Charles P. Vega, MD, FAAFP, has disclosed the following relevant financial relationships: served as an advisor or consultant for Johnson and Johnson Pharmaceutical Research & Development, LLC; served as a speaker or a member of a speakers bureau for Shire Pharmaceuticals. Authors Disclosure: Erika van Schalkwyk, MD, MPH; Samantha Iyaloo, MBChB, MPH; Serisha D. Naicker, MSc; Tsidiso G. Maphanga, MSc; Ruth S. Mpembe, BTech; Thokozile G. Zulu, BS; Mabatho Mhlanga, BTech; Sibongile Mahlangu, BSc, MBChB, DTM&H, MMed; Motlatji B. Maloba, MD, FCPathSA(Micro); Grace Ntlemo, MBChB; Kgomotso Sanyane, MMed; Dini Mawela, MBChB, MMed; and Nelesh P. Govender, MBBCh, MMed, MSc, have disclosed no relevant financial relationships. Sibongile Mahlangu, BSc, MBChB, DTM&H, MMed, intends to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States and investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States. Author affiliations: University of Pretoria, Pretoria, South Africa Makgato Health Sciences University, Pretoria (S. Mahlangu, (E. van Schalkwyk); National Institute for Communicable M.B. Maloba, G. Ntlemo, K. Sanyane, D. Mawela); University of Diseases, Johannesburg, South Africa (E. van Schalkwyk, the Witwatersrand, Johannesburg, (N.P. Govender); University of S. Iyaloo, S.D. Naicker, T.G. Maphanga, R.S. Mpembe, T.G. Zulu, Cape Town, Cape Town, South Africa (N.P. Govender) M. Mhlanga, N.P. Govender); National Health Laboratory Service, DOI: https://doi.org/10.3201/eid2407.171087 Johannesburg (S. Mahlangu, M.B. Maloba, G. Ntlemo); Sefako 1204 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 7, July 2018 Page 1 of 1 Bloodstream Infections in a Neonatal Unit Candidemia is a major cause of healthcare-associated in- Methods fections. We describe a large outbreak of Candida krusei bloodstream infections among infants in Gauteng Prov- Outbreak Setting ince, South Africa, during a 4-month period; a series of Hospital A is a 1,500-bed public-sector hospital in a semi- candidemia and bacteremia outbreaks in the neonatal unit urban area of South Africa that serves as a referral center followed. We detected cases by using enhanced labora- for 9 hospitals in 3 provinces in the region. The metropoli- tory surveillance and audited hospital wards by environ- mental sampling and epidemiologic studies. During July– tan area had a population of ≈3.1 million in 2014 (15). The October 2014, among 589 patients, 48 unique cases of C. infant mortality rate was estimated at 19.3/1,000 live births krusei candidemia occurred (8.2% incidence). Risk factors in Gauteng in 2014 (16), and the antenatal HIV prevalence for candidemia on multivariable analyses were necrotiz- was 28% (17). ing enterocolitis, birthweight <1,500 g, receipt of paren- The neonatal unit at hospital A has 55 beds, compris- teral nutrition, and receipt of blood transfusion. Despite ing 14 intensive-care beds, 20 high-care beds, and a nursery initial interventions, outbreaks of bloodstream infection area that has 15 cots and 6 beds for surgical patients. The caused by C. krusei, rarer fungal species, and bacterial ward is largely of open-plan design: it has areas not fully pathogens continued in the neonatal unit through July 29, separated by floor-to-ceiling divisions. An average of 154 2016. Multiple factors contributed to these outbreaks; the patients are admitted to the unit every month. The unit is most functional response is to fortify infection prevention often overcrowded, and infants share cots when capacity and control. is exceeded. Fluconazole is not routinely used as prophy- laxis but was used as first-line treatment for suspected or n August 4, 2014, the National Institute for Commu- confirmed fungemia and other invasive fungal infections Onicable Diseases (NICD) received a report of 11 neo- before this outbreak. Amphotericin B deoxycholate was the nates infected with candidemia from a university-affiliated other systemic antifungal agent available for therapeutic hospital in Gauteng Province, South Africa. A large out- use; penicillin G and amikacin were used as empiric ther- break of candidemia caused by Candida krusei ensued over apy for suspected bacteremia. The unit protocol requires 4 months in the neonatal unit. We investigated to identify that blood culture samples be collected for every admit- the possible source and mode of transmission of the out- ted neonate at birth and for all infants in whom sepsis is break, to identify risk factors for the development of can- suspected. A confirmatory blood culture specimen is com- didemia, and to recommend control measures. After this pleted before appropriate treatment is initiated. All speci- outbreak, and despite the initial interventions, a series of mens are referred to an onsite hospital laboratory with a full >4 outbreaks of bacterial and fungal bloodstream infections microbiology service. (BSI) lasting until July 29, 2016, occurred. We investigated the first outbreak extensively; we report the results of this First Outbreak and subsequent investigations. Candidemia may result in substantial long-term ill- Case Definition ness among hospitalized premature neonates, and report- For the outbreak investigation, we defined a case-patient ed crude mortality rates are 32%–46% (1–3). In a recent as any neonate admitted to the neonatal unit during July 1– point prevalence survey among hospitalized adults and October 31, 2014, whose blood sample was positive for C. children in the United States, Candida was the leading krusei. Any specimen positive for C. krusei from the same pathogen causing BSI (4). C. krusei, a less common cause patient within 30 days of the first positive specimen was con- of BSI, is intrinsically resistant to fluconazole, a first-line sidered to be part of a single case. We defined a neonate as antifungal agent (5). an infant <28 days of age; however, infants remaining in the Known risk factors for candidemia among neonates in- unit or whose sample tested positive for candidemia beyond clude very low birthweight (VLBW), prematurity, central the 28th day of life were also included in this investigation. venous catheter use, necrotizing enterocolitis (NEC), total parenteral nutrition (TPN), and prior or prolonged broad- Baseline Data Extraction, Confirmation of the Outbreak, and spectrum antibacterial drug use, among others (1,2,6–10). Identification of Cases Worldwide, outbreaks of candidemia in neonatal intensive We extracted data for all cases of laboratory-confirmed care units (NICUs) are often caused by C. parapsilosis and candidemia during January 2012–December 2013 from associated with suboptimal adherence to infection preven- the National Health Laboratory Service (NHLS) Corporate tion and control practices (5,11–13). In South Africa, C. Data Warehouse (CDW), which archives demographic and parapsilosis is the most common Candida species among laboratory data from patients whose diagnostic laboratory neonates; 2% of candidemia case-patients among all age tests are performed
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