The Laboratory of Medical Microbiology at the University of Antwerp, Belgium, plays a crucial role in the NeoIPC project, acting as the central microbiology laboratory for its various studies, including the NeoIPC Colonisation Surveillance and NeoDeco.
Recently, we had the opportunity to speak with Surbhi Malhotra-Kumar, Director of the Laboratory of Medical Microbiology. She discussed the factors driving hospital-acquired infections in neonatal intensive care units (NICUs), the challenges posed by antimicrobial resistance (AMR), and the Laboratory’s role in the NeoDeco study, which will explore innovative infection prevention practices such as optimised kangaroo care, crucial to reduce the burden of AMR in NICUs.
Could you explain the factors that contribute to the presence of bacteria responsible for hospital-acquired infections in NICUs, and how these are typically transmitted between newborns?
There are various factors that contribute to the presence, persistence and transmission of bacteria, or pathogens, in a NICU. Infants can acquire pathogens through cross-transmission between infants, between infant and caregiver, or due to contamination of medical equipment or other materials in the NICU environment, such as cots and sinks. Along with these routes come a variety of factors that influence the risk of transmission. A high turnover of infants, a large number of different visitors, poor hand hygiene, high workload, inadequately trained staff, and lack or insufficient disinfection procedures or difficult-to-clean surfaces are common examples of factors that increase the risk of transmission and thus contribute to the persistence of pathogens in NICUs.
It’s important to note that not all infants that acquire a pathogen actually become sick. Those without clinical symptoms act as “reservoirs”, sometimes carrying the pathogen for prolonged periods and thus contributing to its persistence and transmission in the NICU.
Antimicrobial resistance (AMR) is a growing concern in NICUs. Could you explain what causes it, what contributes to its rise, and why it poses such a significant challenge in these settings?
Low birth weight infants admitted to NICUs have fragile skin and mucosal barrier defenses and are immunologically immature, making them highly susceptible and more vulnerable to bacterial infections. This is why they often rely on antibiotics for treatment. Antibiotics are, therefore, some of the most commonly prescribed drugs in NICUs.
The frequent use of antibiotics, however, can pose some problems. When bacteria are continuously being exposed to antibiotics, they may find ways to adapt themselves to survive the antibiotics and develop resistance, called antimicrobial resistance (AMR). Especially problematic is the ability of bacteria to spread the genetic elements causing resistance to the same type or even different types of bacteria. Moreover, these genetic elements could even confer resistance to multiple antibiotics at the same time, further expanding the problem. Antibiotic resistance is obviously a huge advantage for bacteria in an environment of high antibiotic use, such as in NICUs, and outbreaks of resistant bacteria are common and often prolonged in neonatal intensive care wards.
When bacteria are resistant to antibiotics or to multiple antibiotics at the same time, there are fewer effective treatment options available, which complicates the management. This can result in the need for heavier, often more expensive treatments, which are also associated with more severe side effects. And while there may be some specific treatment options that are still effective, determining which options those are takes valuable time during which an infant is not receiving adequate therapy. Overall, the lack of appropriate treatment or the delayed instauration of effective therapy can result in severe illness or worsen the clinical outcome of infection.
Why are infection prevention and control (IPC) measures important?
A traditional, simple and important way to combat the spread of resistant bacteria is to reduce the number of infections, because fewer infections means fewer drugs are prescribed. IPC measures, such as hand hygiene and proper cleaning of equipment, are often very simple but also highly effective methods to prevent infections and reduce the spread of resistant bacteria. For IPC measures to be very effective, it is of utmost importance that they are very carefully adhered to. Effective implementation of IPC measures can lead to less antibiotic use, which, in turn, is beneficial in reducing the spread of AMR.
With the NeoDeco study, NeoIPC is looking to find out if implementing optimised kangaroo care in a NICU can work as an IPC practice and reduce resistant bacterial colonisation. What role will your Laboratory play in this study?
Within NeoDeco, the Laboratory of Medical Microbiology will support the participating NICUs during the collection, storage and shipping of samples, as well as analyse all collected stool samples for the presence of resistance genes, which are genetic elements pointing towards the colonisation of infants with resistant bacteria. By doing this, we aim to investigate the overall burden of colonisation with resistant bacteria among NICUs in Europe and whether the implementation of optimised kangaroo care can reduce this burden.
Additionally, we will conduct a number of sub-studies to learn more about the transmission routes of bacteria in NICUs by investigating the presence of resistant bacteria on surfaces in the environment. We will also check environmental and infant samples for resistance to biocides. Biocides, like antiseptics and disinfectants, are used in IPC measures to clean the skin of infants and health professionals before procedures or to disinfect surfaces and any equipment that may harbour bacteria. Finally, we aim to investigate the microbiological impact of kangaroo care on the infant by examining the bacteria present on the infant and comparing them with bacteria on the caregiver.
What aspect of the NeoDeco study excites you the most?
Skin-to-skin contact, or kangaroo care, is a safe intervention in neonates that has been shown to have several beneficial effects such as reducing infection and mortality. NeoDeco will take the intervention forward to not only quantify the effect on decreasing resistant bacterial colonisation, but also understand the mechanisms underlying these benefits. In short, we will scientifically evaluate kangaroo care, and optimise and standardise it as an IPC intervention.
If proven to be effective, optimised kangaroo care will be established as a safe and low-cost IPC intervention that could be implemented anywhere in the world. We as a project and team aim to improve neonatal care globally. This is not only the focus of the NeoIPC project but also the focus of our Lab: to help reduce the burden of infectious diseases.