CDC updates guidance for S. aureus in NICU, with several ‘unresolved’ issues

The CDC updated its recommendations for the prevention and control of Staphylococcus aureus in the NICU based on a systematic review of literature published through August 2019.

It left several issues “unresolved,” making no recommendations on the following:

• Using active surveillance testing to detect ongoing health care-associated transmission of methicillin-sensitive S. aureus (MSSA);

• The use of universal decolonization for S. aureus-colonized NICU patients;

• The optimal decolonization agent or combination of agents for S. aureus-colonized NICU patients;

• The appropriate procedures to allow the discontinuation of contact precautions for patients with a history of MRSA.

In response, Ibukunoluwa C. Akinboyo, MD, a pediatric infectious diseases specialist at Duke Children’s Health Center Infectious Diseases Clinic, and colleagues composed a white paper for the Society for Healthcare Epidemiology of America (SHEA) to “serve as [a] companion document to the CDC guidelines on the same topic and help answer practical questions.”

Ibukunoluwa C. Akinboyo

“The white paper by SHEA and the CDC guidelines reflect common challenges faced by health care personnel in this environment, but hospital epidemiologists and infection prevention practitioners in specific health care settings can help address more nuanced issues by reviewing the available literature for unique clinical situations,” Akinboyo told Healio.

Akinboyo and colleagues offered answers to seven questions, including whether family members and visitors should wear personal protective equipment (PPE) when visiting an infant on contact precautions for MRSA. In answering that question, they said, “Family members/visitors should perform proper hand hygiene before entering and exiting the NICU, and before and after making contact with an infant. Health care personnel may choose to allow visitors not to wear personal protective equipment (PPE).”

In other guidance, they said contact precautions “are not necessary for infants of MRSA-colonized or infected parents” and that parents colonized with MRSA “do not need to wear PPE, as long as drainage is contained, the infection site is covered and strict hand hygiene is practiced.”

Other guidance included recommendations for MRSA-discordant twins, high-risk groups who are likely to remain colonized with MRSA, active surveillance, decolonization, and pre-emptive contact precautions for patients screened for MRSA on admission.

They said there is no optimal decolonization regimen for infants colonized with S. aureus, but that intranasal mupirocin twice daily for 5 to 7 days is an acceptable method.

In an outbreak, they suggested applying preemptive contact precautions while S. aureus surveillance results are pending.

“For NICU providers, these are practical recommendations for managing hospitalized infants at risk for S. aureus,” Akinboyo said. “Pediatricians can use the recommendations to provide anticipatory guidance for expectant parents visiting infants hospitalized in the NICU.”

Recommendations from the CDC include:

• Perform active surveillance testing for S. aureus colonization in NICU patients when there is an increased incidence of S. aureus or an outbreak;

• Perform active surveillance testing for MRSA colonization in NICU patients when there is evidence of ongoing health care-associated transmission within the unit.

• If active surveillance testing for S. aureus colonization is implemented in NICU patients, continue to test at regular intervals to identify newly colonized patients.

• If active surveillance testing for S. aureus colonization is performed, either culture-based or PCR detection methods are acceptable.

• If active surveillance testing for S. aureus colonization is performed, collect samples from at least anterior nares from patients in the NICU.

The CDC also included two conditional recommendations:

• If active surveillance testing for S. aureus colonization is implemented in patients in the NICU, consider testing outborn infants or infants transferred from other newborn care units to identify newly admitted colonized patients.

• Consider targeted decolonization for S. aureus-colonized patients in the NICU, in addition to the implementation of, and adherence to, appropriate infection prevention and control measures in an outbreak setting, or when there is ongoing health care-associated transmission, or an increase in the incidence of infection.

“S. aureus still causes a significant number of neonatal infections,” Akinboyo said. “Understanding practices that can decrease S. aureus transmission within shared units from caregivers and from siblings should help clinicians improve clinical management of neonates and the bonding environment for families.”

References:

• Akinboyo IC, et al. Infect Control Hosp Epidemiol. 2020:doi.10.1017/ice/2020.51.

• CDC. NICU: S. aureus guidelines. https://www.cdc.gov/infectioncontrol/guidelines/NICU-saureus/index.html. Accessed Sept. 23, 2020.

• CDC. Recommendations for prevention and control of infections in neonatal intensive care unit patients: Staphylococcus aureus. https://www.cdc.gov/infectioncontrol/pdf/guidelines/NICU-saureus-h.pdf. Accessed Sept. 23, 2020.