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An Outbreak of Serratia marcescens in a Moroccan Neonatal Intensive Care Unit.

1. Introduction

Nosocomial infections in neonatal intensive care unit still represent a public health problem by the morbidity and mortality that they engender. The most incriminated pathogens are Enterobacteriaceae that belong to the Gramnegative bacillus (GNB) family, especially in developing countries, and they can represent 51.5% of the cases [1]. Among the GNB, Serratia marcescens (S. marcescens) is a ubiquitous opportunistic pathogen, whose eradication of the environment is very difficult [2]. Nosocomial infections with S. marcescens are rare in newborns and often described as outbreaks [2, 3]. Infection can occur in the newborn as pneumonia, bacteremia, conjunctivitis, urinary tract infections, and even gastroenteritis. The outcome of these infections is often serious, with a heavy morbidity and mortality; whence, the importance of initiating, as soon as the diagnosis of this germ is made, controls measures before the propagation which can be spectacular.

The aim of this study is to share our experience of nosocomial infections due to this germ, to show the gravity of this germ, with a review of the literature.

2. Patients and Methods

This is a descriptive retrospective study, performed in the neonatal intensive care unit (NICU) of Mohammed VI University Medical Hospital, Marrakesh, Morocco. During the epidemic period of this germ, July and August 2016, the population in our study included neonates hospitalized in the NICU, whose postnatal age ranged from 0 to 28 days with the diagnosis of nosocomial infection of S. marcescens, which was made by the positivity of bacteriological samples at least 48 hours after admission to our NICU. Data collection was done using an individual record.

The literature review was done on PubMed including writings describing Serratia marcescens outbreaks in neonates in the NICU.

3. Results

We collected eight cases, which were included during the study period, July and August 2016, which corresponded to the epidemic period of S. marcescens bacteremia.

The epidemic began in early July 2016 in a premature 33.9 GA admitted for hyaline membrane disease, which showed after 3 days of his hospitalization signs of sepsis with isolation of Serratia marcescens in the blood culture, and other cases were diagnosed throughout the July period.

The mean gestational age of our patients was 36 weeks (wk), with extremes ranging from 33.2 to 40.8 wk. Newborns were premature in 75% of cases. The sex ratio (boy/girl) was 3. The weight ranged from 1130 grams to 3600 grams with an average weight of 1853 grams. Hyaline membrane disease was the most diagnosis of hospitalization in 62.5% of cases and neonatal pulmonary infection in 37.5% of cases (Table 1).

On admission, all patients were treated with ceftriaxone and gentamicin antibiotics, and 87.5% of cases were artificially ventilated. The diagnosis of nosocomial infection was made over an average of 7 days of hospitalization, with extremes ranging from 3 days to 12 days. The diagnosis was made in the presence of clinical signs and/or biological abnormalities on the hemogram or ascension C-reactive protein with S. marcescens-positive blood cultures. Isolated S. marcescens strains were susceptible in 75% of cases to 3rd generation cephalosporins and all susceptible to imipenem, to ciprofloxacin, and to aminoglycosides (amikacin and gentamicin), but all were resistant to colistin (Table 2). After diagnosis of nosocomial S. marcescens infection, all patients were treated with imipenem and amikacin. The outcome was favorable in 37.8% of the cases, and the death was reported in 62.5%. The average hospital stay was 22.75 days, with extremes ranging from 12 days to 34 days.

4. Discussion

Nosocomial infections in neonatal intensive care units are a public health problem because of their heavy consequences on morbidity and mortality and the important cost they generate [1]. S. marcescens has emerged as a currently recognized pathogen for nosocomial infection in neonates, especially in epidemic form [4], which has also been reported in our experience. We collected 8 cases of S. marcescens bacteremia for 2 months. A similar report was published in 2010 by Gulcin Bayramoglu et al., comprising 9 cases, in neonatal intensive care unit over a period of 36 days [5].

Bacteriologically, Serratia is a Gram-negative bacillus belonging to the Enterobacteriaceae family, saprophytic genus, and widely found in the environment.

In S. marcescens outbreaks, sources of contamination reported in the literature were different: catheters, heparin solution, dialysis machine, propofol, liquid soap [6-11], and of course the manual transmission due to lack hospital hygiene.

The statistically significant risk factors of infection nosocomial to Serratia according to Al Jarousha and coworkers were low birth weight less than 1500 g, gestational age greater than 37 weeks, and mechanical ventilation [4]. Other risk factors that are common to all nosocomial infections are long hospital stay, antibiotic prescription, and the use of invasive methods: umbilical catheter, intubation, bladder catheterization, and parenteral nutrition [12]. However, our population was 75% premature and 87.5% artificially ventilated, the average weight recovered was 1850 g, and only one newborn had an umbilical vein catheter.

In our study, we isolated Serratia in blood cultures. This germ could be responsible for septicemia, pneumonia, conjunctivitis, urinary tract infections, and even gastroenteritis in newborns. In a study by Morillo et al., the clinical manifestations found in the ascending order were pneumonia, conjunctivitis, septicemia, and finally urinary tract infection [13]. Cerebromeningeal complications have recently been reported to be more frequent with Serratia marcescens, namely, meningitis, brain abscess, and empyema, and it is recommended to perform systematically brain imaging and more particularly transfontanellar ultrasound even in the absence of neurological signs [14].

With regard to the resistance of S. marcescens to antibiotics, high resistance to cephalosporins is often reported which can reach up to 100% [13, 15]. In our study, the cephalosporin resistance rate was lower and all strains were sensitive to imipenem and ciprofloxacin, which is consistent with the results reported by Al Jarousha who reported a sensitivity of 90% to imipenem and 76% to ciprofloxacin [4]. As for colistin, all our isolated strains were resistant concordant with the results of Buffet-Battailon et al. [16] and those of Adjide et al. [15]. In addition to the resistance of Serratia to antibiotics, its severity is clear in light of the high mortality rates reported, which varies from 14.3% to 62.5% of cases [4, 5, 14, 15, 17-20] but in our study, we have a higher rate which was 62.5% (Table 3).

To cope with these epidemics, a number of measures were taken as soon as the first case is diagnosed, mainly the education of medical and paramedical staff on the importance of hand hygiene, the use of double protection by gloves, the technical and geographical isolation of the infected patients, and the disinfection of any surface or equipment likely to be contaminated. We achieved all these measures, which allowed a control of the epidemic at the end of August 2016.

5. Conclusion

Nosocomial infections with Serratia marcescens are beginning to take a large scale in neonatal intensive care unit, often in epidemic form. They are responsible for significant morbidity and mortality and pose the problem of acquiring antibiotic resistance. For this reason, prevention is the best method to fight them.

Data Availability

The data used to support the findings of this study are available from the corresponding author upon request.

https://doi.org/ 10.1155/2018/4867134

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References

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Abderrahim Harouchi, CHU Ibn Rochd, Casablanca, Maroc," Journal de Pediatrie et de Puericulture, vol. 26, no. 1, pp. 11-18, 2013.

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[3] S. Ktari, F. Mahjoubi, B. Mnif, H. Kallel, M. Bouaziz, and A. Hammami, "Investigation de trois epidemies d'infections nosocomiales a Serratia marcescens survenues dans le service de reanimation-CHU de Sfax Tunisie," La Tunisie Medicale, vol. 88, no. 7, pp. 501-506, 2010.

[4] A. M. Kh. Al Jarousha, I. A. El Qouqa, A. H. N. El Jadba, and A. S. Al Afifi, "An outbreak of Serratia marcescens septicaemia in neonatal intensive care unit in Gaza City, Palestine," Journal of Hospital Infection, vol. 70, no. 2, pp. 119-126, 2008.

[5] G. Bayramoglu, K. Buru, U. Dinc, M. Mutlu, G. Yilmaz, and Y. Aslan, "Investigation of an outbreak of Serratia marcescens in a neonatal intensive care unit," Journal of Microbiology, Immunology and Infection, vol. 44, no. 2, pp. 111-115, 2011.

[6] E. R. Van der Vorm and C. Woldring-Zwaan, "Source, carriers, and management of a Serratia marcescens outbreak on a pulmonary unit," Journal of Hospital Infection, vol. 52, no. 4, pp. 263-267, 2002.

[7] G. Perotti, M. E. Bernardo, M. Spalla, C. Matti, M. Stronati, and L. Pagani, "Rapid control of two outbreaks of Serratia marcescens in a Northern Italian neonatal intensive care unit," Journal of Chemotherapy, vol. 2, pp. 56-60, 2007.

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[10] B. Henry, C. Plante-Jenkins, and K. Ostrowska, "An outbreak of Serratia marcescens associated with the anesthetic agent propofol," American Journal of Infection Control, vol. 29, no. 5, pp. 312-315, 2001.

[11] T. Tanaka, H. Takahashi, J. M. Kobayashi, T. Ohyama, and N. Okabe, "A nosocomial outbreak of febrile bloodstream infection caused by heparinized-saline contaminated with Serratia marcescens, Tokyo, 2002," Japanese Journal of Infectious Diseases, vol. 57, no. 5, pp. 189-192, 2004.

[12] M. Doaa and S. Omnia, "Bacterial nosocomial infections in neonatal intensive care unit, Zagazig University Hospital, Egypt," Egyptian Pediatric Association Gazette, vol. 62, no. 34, pp. 72-79, 2014.

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[20] Z. Walter, I. Soulake, D. Baud et al., "Management and investigation of a Serratia marcescens outbreak in a neonatal unit in Switzerland-the role of hand hygiene and whole genome sequencing-R1, ARIC-D-17-00143," Antimicrobial Resistance and Infection Control, vol. 6, no. 1, p. 125, 2017.

Abdellatif Daoudi, (1,2) Fatiha Benaoui, (1,2) Nadia El Idrissi Slitine, (1,2) Nabila Soraa, (3) and Fadl Mrabih Rabou Maoulainine (1,2)

(1) Neonatal Intensive Care Unit, Mother-Child Center, Mohammed VI University Medical Hospital of Marrakesh, Morocco

(2) Research Team Childhood, Health and Development, Faculty of Medicine and Pharmacy Cadi Ayyad University, Morocco

(3) Biology Laboratory, Mother-Child Unit, Mohammed VI University Medical Hospital of Marrakesh, Morocco

Correspondence should be addressed to Abdellatif Daoudi; abdellatif.daoudi90@gmail.com

Received 25 March 2018; Revised 30 July 2018; Accepted 13 September 2018; Published 1 November 2018

Academic Editor: Gabriel Dimitriou
Table 1: Patients' demographic data.

Patient   Diagnosis     Gestational   Weight      Method of
no.                     age (weeks)   (grams)      delivery

1         Neonatal
          pulmonary         40.8       3600       Caesarean
          infection

2         Hyaline           33.2       1130    Vaginal delivery
          membrane
          disease

3         Hyaline           33.9       1300    Vaginal delivery
          membrane
          disease

4         Neonatal          34.6       1800    Vaginal delivery
          pulmonary
          infection

5         Hyaline           35,3       1600    Vaginal delivery
          membrane
          disease

6         Prematurity       34.6       1400    Vaginal delivery

7         Prematurity       35.9       1800    Vaginal delivery

8         Neonatal           40        2200    Vaginal delivery
          pulmonary
          infection

Patient   Antibiotic    Mechanical     Umbilical
no.       prescription  ventilation  catheterization

1
              Yes           Yes           None

2             Yes           Yes           None

3             Yes           Yes           None

4             Yes           Yes           None

5             Yes           Yes           None

6             Yes           Yes           None

7             Yes          None           None

8             Yes           Yes           None

Patient   Day of infection    Outcome
no.        with Serratia
             marcescens
1
                 12          Favorable

2                 7          Favorable

3                 3            Death

4                 6          Favorable

5                 5            Death

6                 8            Death

7                 5            Death

8                11            Death

Table 2: Susceptibility to antibiotics of Serratia marcescens.

Antibiotic       Sensitivity     Sensitivity of S.       Resistance
                               marcescens Intermediary

Amoxicillin         None                None                100%
Piperacillin         75%                None                25%
Cefotaxime          87.5%               12.5%               None
Ceftazidime         87.5%               12.5%               None
Imipenem            100%                None                None
Ciprofloxacin       100%                None                None
Gentamicin          100%                None                None
Amikacin            100%                None                None
Colistin            None                None               100%

Table 3: Summary of outbreaks caused by S. marcescens reported in
the literature in comparison with our experience.

Series                              Country/city        Year

Al Jarousha et al. [4]             Palestine/Gaza       2008
Chemsi et al. [18]               Morocco/Casablanca     2013
Madide and Smith [14]          South Africa/Cape Town   2015
Polilli et al. [19]                Italy/Pescara        2011
Gulcin Bayramoglu et al. [5]       Turkey/Trabzon       2006
Walter Zingg et al. [20]         Switzerland/Geneva     2013
Our cases                        Morocco/Marrakesh      2016

Series                         Number of cases    Outcome

Al Jarousha et al. [4]               159          70 died
Chemsi et al. [18]                    9           5 died
Madide and Smith [14]                 5           3 died
Polilli et al. [19]                   6           2 died
Gulcin Bayramoglu et al. [5]          9              3
Walter Zingg et al. [20]             20          None died
Our cases                             8           5 died
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Article Details
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Title Annotation:Research Article
Author:Daoudi, Abdellatif; Benaoui, Fatiha; Slitine, Nadia El Idrissi; Soraa, Nabila; Maoulainine, Fadl Mra
Publication:Advances in Medicine
Article Type:Report
Geographic Code:6MORO
Date:Jan 1, 2018
Words:2389
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