Designed to protect neonates from staph infections caused by both resistant and susceptible strains, the draft includes recommendations open to comment until Nov. 6, 2019.

Methicillin-resistant S. aureus (MRSA) has caused numerous NICU outbreaks, but the CDC points out that drug-susceptible S. aureus also poses a threat to this frail patient population.

“While MRSA has long been the focus of prevention efforts due to the difficulty in treating and eradicating it, recent studies have demonstrated that methicillin-sensitive S. aureus (MSSA) has morbidity and mortality equal to MRSA and occurs more frequently in NICU patients,” state the guidelines, which were issued by the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC).

“There are a few recommendations that are specific to MRSA and then some unresolved issues related to MSSA because that data is still accumulating,” says Erin Stone, MA, a member of the CDC division of healthcare quality promotion who works with HICPAC. “There is an emerging evidence base and our goal was to highlight the evidence where recommendations could be formulated, and to highlight gaps in the evidence as well.”

The recommendations and key statements in the draft guidelines include the following, which are accompanied by Stone’s comments and explanations from the text. The term “S. aureus” includes both MSSA and MRSA. In addition to recommendations, there are categories of “conditional” recommendations and “no recommendation.”

Draft Recommendations

Recommendation 2.1.A.1. Perform active surveillance testing for S. aureus colonization in NICU patients when there is an increased incidence of S. aureus infection, or in an outbreak setting. (Recommendation)

“That is specific to infections and includes both MRSA and MSSA,” Stone says. “If providers see an increase in Staph aureus infections — MRSA or MSSA — then they could conduct active surveillance testing for Staph aureus in general for colonization to then implement appropriate infection prevention and control measures.”

The risks include, as cited in other recommendations, “unintended consequences, such as decreased healthcare personnel-patient contact, in other populations,” the CDC guidelines stated. “This literature search did not identify studies suggesting harm from use of contact precautions in NICU populations,” the CDC concluded.

Recommendation 2.1.A.2. Perform active surveillance testing for MRSA colonization in NICU patients when there is evidence of ongoing healthcare-associated transmission within the unit. (Recommendation)

The use of active surveillance testing for MSSA colonization in NICU patients to detect ongoing healthcare-associated MSSA transmission is an unresolved issue. (No Recommendation)

“MSSA is an unresolved issue based on the evidence,” Stone says. “If you see ongoing transmission of MRSA — that could be colonization or infection — you would then conduct active surveillance testing for MRSA. MSSA is not there yet.”

However, the recommendation could be subject to change pending public comments and a final literature review before the draft is finalized, Stone says.

“To date, no studies indicate that conducting active surveillance for MSSA colonization will lead to subsequent interventions that will reduce MSSA transmission, so it is possible that the resource cost of testing and of any interventions prompted by positive tests for colonization may outweigh the benefits,” the CDC stated. “Recent studies suggest, however, that active surveillance testing may lead to subsequent interventions that can decrease MSSA infections.”

Recommendation 2.1.A.4. If active surveillance testing for S. aureus colonization is implemented for NICU patients, test at regular intervals to promptly identify newly colonized patients. (Recommendation)

“Implementation of routine active surveillance testing for S. aureus colonization will enable facilities to identify colonized patients promptly and guide implementation of appropriate infection prevention and control measures to reduce person-to-person transmission,” the CDC draft stated.

Recommendation 2.1.A.5. If active surveillance testing for S. aureus colonization in NICU patients is implemented, consider testing outborn infants or infants transferred from other newborn care units on admission to promptly identify newly admitted colonized patients. (Conditional Recommendation)

“Outborn infants are infants born at another facility or infants transferred from other units within the same facility,” Stone says. “Conditional recommendations are more to ‘consider’ this intervention. It means that the CDC and HICPAC have determined that the benefits of the approach are likely to exceed the harms.”

Recommendation 2.1.B.1. If active surveillance for S. aureus colonization in NICU patients is performed, use culture-based or polymerase chain reaction detection methods. (Recommendation)

“If this recommendation is followed, facilities will be able to select the assay that best fits facility considerations and the needs at hand,” the CDC states. “While PCR offers marginally increased sensitivity over culture for detecting S. aureus, culture has the advantage of having isolates available for molecular typing and susceptibility tests.”

Recommendation 2.1.B.2. If active surveillance for S. aureus colonization of NICU patients is performed, collect samples from at least the anterior nares of NICU patients. (Recommendation)

“The anterior nares have the highest yield for identifying S. aureus colonization,” the CDC draft stated. “Collecting samples from the axilla, rectum, and umbilicus can increase the yield.”

Recommendation 2.1.C.1. Consider targeted decolonization for S. aureus-colonized NICU patients in addition to the implementation of, and adherence to, appropriate infection prevention and control measures in an outbreak setting, when there is ongoing healthcare-associated transmission, or an increase in the incidence of infection. (Conditional Recommendation)

“Implementing targeted decolonization could result in a reduction in the S. aureus colonization rate of NICU patients, which then may result in a reduction in S. aureus transmission and infection in NICUs,” the CDC stated. “[However], if targeted decolonization were conducted for S. aureus-colonized NICU patients, harms could include significant systemic absorption of decolonizing agents, increased resistance to the decolonizing agent, and adverse skin reactions.”

The draft is one of four sections that will comprise the full “Guideline for Infection Prevention and Control in NICU Patients.” HICPAC previously published a section on Clostridioides difficile (C. diff), but found insufficient evidence to make infection control recommendations. HICPAC concluded that the evidence was not sufficient to make evidence-based recommendations about the following issues:

  • Characteristics of NICU patients at high risk for clinically relevant C. diff infection (CDI) who would warrant diagnostic testing for C. diff;
  • The optimal assay or series of assays for detecting CDI among NICU patients;
  • The significance of a positive C. diff test in a NICU patient.2

“The third section will be on central line-associated bloodstream infections in NICU patients.” Stone says. “That is in progress. We hope to finalize that and open that up for public comment early next year. The final section will be respiratory illnesses in NICU patients.”

REFERENCES

  1. Centers for Disease Control and Prevention. Draft guideline for prevention and control of infections in neonatal intensive care unit patients: Draft recommendations for the prevention and control of Staphylococcus aureus in neonatal intensive care unit patients. 84 FR 46014. Fed Reg Sept. 3, 2019. Available at: https://bit.ly/2kEC7lT. Accessed Sept. 12, 2019.
  2. Centers for Disease Control and Prevention. Clostridioides difficile in neonatal intensive care unit patients: A systematic review. Aug. 30, 2018. Available at: https://bit.ly/2lGPtyo. Accessed Sept. 12, 2019.