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An Epidemic of Gastroenteritis and Mild Necrotizing Enterocolitis in Two Neonatal Units of a University Hospital in Rome, Italy

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An Epidemic of Gastroenteritis and Mild Necrotizing Enterocolitis in Two Neonatal Units of a University Hospital in Rome, Italy Epidemiol. Infect. (2004), 132, 455–465. f 2004 Cambridge University Press DOI: 10.1017/S0950268804002006 Printed in the United Kingdom An epidemic of gastroenteritis and mild necrotizing enterocolitis in two neonatal units of a University Hospital in Rome, Italy A. FAUSTINI1*,F. FORASTIERE1, P. GIORGI ROSSI 2 AND C. A. PERUCCI 1 1 Department of Epidemiology Local Health Authority RME, Rome, Italy 2 Agency for Public Health, Lazio, Rome, Italy (Accepted 22 December 2003) SUMMARY In the summer of 1999 a cluster of 18 cases of necrotizing enterocolitis (NEC) occurred in a University Hospital in Rome, Italy. The cases presented with mild clinical and radiological signs, and none died. Seventy-two per cent had a birth weight of >2500 g, 66.7% had a gestational age of >37 weeks, 30% presented with respiratory diseases and/or hypoglycaemia. All cases occurred within 10 days of birth and between 5 and 7 days after two clusters of diarrhoea (14 cases). The NEC outbreak had two phases; most cases in the first phase occurred in the at-risk unit, whereas those in the second phase occurred in the full-term unit. In the multivariate analysis, invasive therapeutic procedures, pathological conditions and formula feeding were associated with NEC. Although no predominant common bacteria were isolated, we suggest an infective origin of this outbreak. INTRODUCTION the immaturity of the gastrointestinal tract or to a host-defence mechanism [10]. Another factor associ- Neonatal necrotizing enterocolitis (NEC) is a serious ated with NEC is modality of feeding: NEC occurs gastrointestinal disease characterized by abdominal less frequently in infants who are fed, those fed hu- distension, gastrointestinal haemorrhage, ileus (gas- man breast milk or those on a careful feeding regimen tric residuals), intestinal necrosis and pneumatosis (i.e. a diluted formula slowly increased in concen- intestinalis [1]. The incidence of the disease in the tration) [9, 11–14]. The third important factor in the neonatal period has been reported as between 1 and pathogenesis of this disease is the presence of patho- 5% of admissions in neonatal intensive care units, gens or imbalance in the intestinal microbial flora. and between 0.3 and 2.4 cases per 1000 live births in While it is generally agreed that NEC does not occur population-based studies [2]. NEC generally occurs as without bacterial colonization of the gastrointestinal sporadic cases, but it also occurs in temporal and tract, no single bacterial agent, bacterial product, or geographic clusters, and a few important outbreaks virus has been consistently identified as a cause of have been reported [3]. The mortality rate varies be- NEC [15], nor is the relationship between gastro- tween 9 and 28% [2]. enteritis and NEC clear [16–20]. The aetiology and pathogenesis of the disease are In the summer of 1999, 14 cases of NEC were re- still unclear. Most studies indicate that prematurity is ported in a University Hospital in Rome, the first case the most important risk factor [4–9], probably due to occurred on 6 June in a 2-day-old child and the last case occurred on 8 July in a child born on the 1 July. * Author for correspondence: Dr A. Faustini, Department of The results of the epidemiological investigation of this Epidemiology, Via di S. Costanza n.53, 00198 Rome, Italy. outbreak follow. Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.14, on 01 Oct 2021 at 02:57:52, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268804002006 456 A. Faustini and others MATERIALS AND METHODS from rectum, apnoea, shock, hypotension or radio- graphs positive for pneumatosis intestinalis; a sus- Setting of the outbreak pected case of NEC (stage I) is a baby with at least Forty cases of NEC were diagnosed in newborns two of the following clinical signs: abdominal disten- (45 000 births per year) between January 1997 and sion, gastric retention, haemoglobin-positive stools or June 1999 in the Lazio region (including the city of a radiological finding of persistent intestinal disten- Rome) with an incidence of 0.1/1000 per year. The sion. The onset date of NEC was defined as the date incidence rate ranged from 0.04 to 0.37/1000 per year in which the first clinical or radiological sign was in the different hospitals of the region; no epidemic detected. A case of gastroenteritis (or diarrhoea) was was detected before July 1999. At the time of the defined as a baby with more than three stool emis- outbreak there were three neonatal units at the Uni- sions per day for at least three consecutive days [22]. versity Hospital: the Neonatal Intensive Care Unit (NICU), the At-Risk Unit (ARU) for low birth weight and low gestational age babies who were not Microbiological tests acutely ill, and the Full-Term Unit (FTU). The NICU Stool samples from babies with diarrhoea were col- was in a separate building, the other two units were lected in only three cases and were tested for Salmo- next to each other, divided only by a double glass nella and Shigella; stool samples from babies with door, beyond which disposable aprons, masks and NEC were cultured for enteropathogen bacteria, only gloves were required before entering the ARU. The after antibiotic therapy was administered. Blood cul- same paediatric staff cared for babies in the two tures were not done. The follow-up of discharged units. All babies born in the hospital were admitted newborns also included cultures tested for entero- to the FTU or ARU. Sick children from other hospi- bacteria. tals were admitted to the NICU but not to the other units. Early in July 1999 a cluster of NEC cases was ob- Reliability study of radiological diagnosis served, a few of these presented diarrhoea. There were In a separate study on reliability of radiological no suspected cases diagnosed in the NICU. On 3 July diagnosis, the radiographs of 13 children diagnosed the maternity ward stopped admitting new patients, with NEC were reviewed independently by three but those already hospitalized delivered there. On expert radiologists blind with regard to their clinical this date 32 babies were already hospitalized in non- condition and previous radiological diagnosis. These critical units (14 in the FTU and 18 in the ARU). data were compared with the original radiological A total of 221 live births occurred during the period findings. When two reviewers reported the presence of 1 June to 5 July 1999, of these 161 were in the FTU intramural gas, the radiological diagnosis was con- and 54 in the ARU (in six cases the information was firmed as pneumatosis or stage II NEC; when two missing). reviewers reported the presence of at least two signs All hospital records of the 221 newborns, those of among meteorism, loops distension and oedema in their mothers, and registers reporting delivery, nurs- the bowel wall, the radiological diagnosis of NEC was ing and feeding practices were reviewed to find all confirmed as stage I. cases of NEC and gastroenteritis and to analyse the possible associated factors. For children discharged in the period 1 June to 5 July, a follow-up was done Data analysis through a telephone questionnaire after 5 July; the Both overall and unit-specific daily attack rates were questionnaire requested information about the child’s calculated for diarrhoea and for NEC, according to health and gastroenteritis in other family members onset date. Among the 221 live births in the Univer- since the mother’s hospitalization. sity Hospital from 1 June 1999, newborns with a diagnosis of NEC or gastroenteritis were compared with their contemporaries in the neonatal unit who Case definitions did not present any sign of these syndromes. According to the case definition proposed by Bell [21], Among the variables potentially associated with a definite case of NEC (stage II) is a baby with one of NEC, we analysed maternal factors (nationality, the following intestinal or systemic signs: frank blood age at delivery, pre-eclampsia, hypertension, sepsis, Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.14, on 01 Oct 2021 at 02:57:52, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268804002006 Outbreak of necrotizing enterocolitis 457 13.0 12.0 11.0 3 10.0 4 9.0 1 8.0 7.0 6.0 2 . 2 Attack rate (%) 5 0 2 2 1 1 4.0 3.0 1 1 1 1 11 11 1 1 1 1 1 1 2.0 1.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 June July Fig. 1. Daily attack rate (%) for necrotizing enterocolitis (NEC) and diarrhoea, in live births in two neonatal units, from June to July 1999, Rome, Italy. Number of cases are shown on the top of columns. &, NEC; %, diarrhoea. genito-urinary tract infection), delivery and newborn was 18.5% (10/54) in the ARU and 5.0% (8/161) in characteristics (sex, birth weight, gestational age, the FTU. Nine of the 18 cases were male; the mean delivery type, 5-min Apgar score, neonatal unit, and age of onset was 1.3 days (range 0–6 days); the mean the first method of feeding), perinatal diseases (hypo- delay of diagnosis was 3.4 days (range 0–14 days). glycaemia, asphyxia, respiratory distress, hyaline There were 12 cases of gastroenteritis, 2 additional membrane disease, polycythaemia, congenital heart cases of NEC presented diarrhoea among the first diseases), and invasive procedures before the onset of symptoms, with a total cumulative incidence of 7.7%; symptoms (tracheal intubation, intravenous infusions, diarrhoea lasted between 3 and 8 days; all cases of surfactant administration, blood transfusion, use of gastroenteritis except one occurred in the ARU; the umbilical vessel catheters or vesical catheters).
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