Maryland NICU Still Taking Action After Pseudomonas Exposure

Alicia Ault

August 18, 2016

A hospital in the Washington, DC, suburbs is treating the plumbing and disinfecting the neonatal intensive care unit (NICU) after three neonates tested positive for the potentially deadly Pseudomonas aeruginosa bacteria.

Prince George's Hospital Center shut down its NICU on August 9 after nasal swabs of the three infants indicated exposure to the bacteria, according to a report in the Washington Post. Nine babies in the NICU at that time were transferred to Children's Hospital National Medical Center in Washington, DC.

The facility would not respond to specific questions from Medscape Medical News about whether the bacteria was detected through routine surveillance or because of concerns after the earlier deaths of two neonates. The hospital has not released the cause of those deaths or a determination of how the other neonates were exposed to P aeruginosa.

In a statement, the hospital said that "results of continuous water sampling and testing revealed the presence of Pseudomonas in one patient care area outside the NICU." That has led to disinfection and plumbing treatment in the unit, as well as new water filtration in the NICU and hospital-wide water treatment, said the statement.

"We are taking a very methodical and collaborative approach to our investigation and remediation and will follow the science where it leads us," said Sherry Perkins, executive vice president and chief operating officer of Dimensions Healthcare System, in the statement. Dimensions owns Prince George's Hospital Center, which is located in Cheverly, Maryland.

The hospital is transferring current inpatient high-risk pregnancies to a partner hospital and says infants born at high risk will be stabilized and transferred.

The Maryland Department of Health and Mental Hygiene was notified of the P aeruginosa cases on August 7 and is assisting with "disease control, case management, and remediation," a spokesman told Medscape Medical News. The Maryland Institute for Emergency Medical Services systems and the Centers for Medicare & Medicaid Services have been on site and are monitoring the investigation, according to Dimensions.

Uncommon in NICU

Although P aeruginosa is common in the hospital, finding it in the NICU is "a bit odd," William Schaffner, MD, an infectious diseases specialist at Vanderbilt University, Nashville, Tennessee, and medical director at the National Foundation for Infectious Diseases, told Medscape Medical News.

Pseudomonas is "not commonly seen in the NICU," agreed Aaron Milstone, MD, associate hospital epidemiologist at Johns Hopkins Hospital, Baltimore, Maryland.

The bacteria is especially dangerous to those with a compromised immune system, causing urinary tract or bloodstream infections. It enters through catheters, ventilators, or central lines.

The Centers for Disease Control and Prevention (CDC) estimates that 51,000 healthcare-associated P aeruginosa infections occur in the United States annually. Thirteen percent ― 6000 ― of the infections are multidrug-resistant. Some 400 people die from P aeruginosa infections each year.

Water is a known source of P aeruginosa, which is why NICUs generally use sterile water for certain activities, Dr Milstone said.

Even so, no societies or organizations have issued guidelines or recommendations for testing water for the pathogen or for routinely testing the environment or patients for P aeruginosa, he said.

Johns Hopkins Hospital, however, is "pretty aggressive in treating our water," said Dr Milstone, noting that it adds chlorine dioxide to water that has already been treated by the local authorities. He said the extra expense is worth it for Hopkins, as it has many vulnerable patients, including transplant recipients.

The CDC has not issued specific infection control or water treatment recommendations for the bacteria, but it is "an important pathogen to conduct surveillance on," said Matthew Crist, MD, MPH, a medical officer in the CDC's Division of Healthcare Quality Promotion.

"For a given NICU, it would not be a very common occurrence," Dr Crist told Medscape Medical News. Even so, 15 outbreaks in NICUs have been recorded, he said.

When P aeruginosa is detected, infectious diseases detectives usually look to water or a "product that was locally or nationally distributed that should have been sterile but was not," said Dr Schaffner.

Once colonization occurs in a single patient, "the usual way bacteria would spread would be via the hands of the caregivers," Dr Schaffner said. Gloves might protect the healthcare worker, but not the patient. "It doesn't take but an occasional lapse to permit the transmission of bacteria," he said.

Both Dr Schaffner and Dr Milstone said that it appears that Prince George's Hospital Center acted quickly and appropriately to prevent further spread ― and perhaps any illness — once the pathogen was discovered.

Early recognition and early intervention are key to preventing infection, Dr Milstone said.

Dr Schaffner, Dr Milstone, and Dr Crist have disclosed no relevant financial relationships.

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