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Active Surveillance Cultures and Decolonization to Reduce Staphylococcus aureus Infections in the Neonatal Intensive Care Unit

  • Victor O. Popoola (a1), Elizabeth Colantuoni (a2), Nuntra Suwantarat (a3), Rebecca Pierce (a4), Karen C. Carroll (a4), Susan W. Aucott (a5) and Aaron M. Milstone (a1) (a3) (a6)...



Staphylococcus aureus is a common cause of healthcare-associated infections in neonates.


To examine the impact of methicillin-susceptible S. aureus (MSSA) decolonization on the incidence of MSSA infection and to measure the prevalence of mupirocin resistance.


We retrospectively identified neonates admitted to a tertiary care neonatal intensive care unit (NICU) from April 1, 2011, through September 30, 2014. We compared rates of MSSA-positive cultures and infections before and after implementation of an active surveillance culture and decolonization intervention for MSSA-colonized neonates. We used 2 measurements to identify the primary outcome, NICU-attributable MSSA: (1) any culture sent during routine clinical care that grew MSSA and (2) any culture that grew MSSA and met criteria of the National Healthcare Safety Network’s healthcare-associated infection surveillance definitions. S. aureus isolates were tested for mupirocin susceptibility. We estimated incidence rate ratios using interrupted time-series models.


Before and after the intervention, 1,523 neonates (29,220 patient-days) and 1,195 neonates (22,045 patient-days) were admitted to the NICU, respectively. There was an immediate reduction in the mean quarterly incidence rate of NICU-attributable MSSA-positive clinical cultures of 64% (incidence rate ratio, 0.36 [95% CI, 0.19–0.70]) after implementation of the intervention, and MSSA-positive culture rates continued to decrease by 21% per quarter (incidence rate ratio, 0.79 [95% CI, 0.74–0.84]). MSSA infections also decreased by 73% immediately following the intervention implementation (incidence rate ratio, 0.27 [95% CI, 0.10–0.79]). No mupirocin resistance was detected.


Active surveillance cultures and decolonization may be effective in decreasing S. aureus infections in NICUs.

Infect. Control Hosp. Epidemiol. 2016;37(4):381–387


Corresponding author

Address correspondence to Aaron M. Milstone, MD, MHS, Johns Hopkins Department of Pediatric Infectious Diseases, 200 N Wolfe St/Rubenstein 3141, Baltimore, MD 21287 (


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1. Chu, A, Hageman, JR, Schreiber, M, Alexander, K. Antimicrobial therapy and late onset sepsis. NeoReviews 2012;13:e94e102.
2. Stoll, BJ, Hansen, N, Fanaroff, AA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002;110:285291.
3. Shane, AL, Hansen, NI, Stoll, BJ, et al. Methicillin-resistant and susceptible Staphylococcus aureus bacteremia and meningitis in preterm infants. Pediatrics 2012;129:e914e922.
4. Popoola, VO, Budd, A, Wittig, SM, et al. MRSA transmission and infections in a neonatal intensive care unit despite active surveillance cultures and decolonization—challenges for infection prevention. Infect Control Hosp Epidemiol 2014;35:412418.
5. Klevens, RM, Edwards, JR, Richards, CL Jr, et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep 2007;122:160166.
6. Payne, NR, Carpenter, JH, Badger, GJ, Horbar, JD, Rogowski, J. Marginal increase in cost and excess length of stay associated with nosocomial bloodstream infections in surviving very low birth weight infants. Pediatrics 2004;114:348355.
7. Sohn, AH, Garrett, DO, Sinkowitz-Cochran, RL, et al. Prevalence of nosocomial infections in neonatal intensive care unit patients: results from the first national point-prevalence survey. J Pediatr 2001;139:821827.
8. Stoll, BJ, Hansen, NI, Adams-Chapman, I, et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA 2004;292:23572365.
9. Schlapbach, LJ, Aebischer, M, Adams, M, et al. Impact of sepsis on neurodevelopmental outcome in a Swiss national cohort of extremely premature infants. Pediatrics 2011;128:e348e357.
10. Hornik, CP, Fort, P, Clark, RH, et al. Early and late onset sepsis in very-low-birth-weight infants from a large group of neonatal intensive care units. Early Hum Dev 2012;88:S69S74.
11. Hocevar, SN, Edwards, JR, Horan, TC, Morrell, GC, Iwamoto, M, Lessa, FC. Device-associated infections among neonatal intensive care unit patients: incidence and associated pathogens reported to the National Healthcare Safety Network, 2006-2008. Infect Control Hosp Epidemiol 2012;33:12001206.
12. Huang, YC, Lien, RI, Su, LH, Chou, YH, Lin, TY. Successful control of methicillin-resistant Staphylococcus aureus in endemic neonatal intensive care units—a 7-year campaign. PLoS One 2011;6:e23001.
13. Nelson, MU, Bizzarro, MJ, Baltimore, RS, Dembry, LM, Gallagher, PG. Clinical and molecular epidemiology of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit in the decade following implementation of an active detection and isolation program. J Clin Microbiol 2015;53:24922501.
14. Gerber, SI, Jones, RC, Scott, MV, et al. Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement. Infect Control Hosp Epidemiol 2006;27:139145.
15. Popoola, VO, Milstone, AM. Decolonization to prevent Staphylococcus aureus transmission and infections in the neonatal intensive care unit. J Perinatol 2014;34:805810.
16. Carey, AJ, Duchon, J, Della-Latta, P, Saiman, L. The epidemiology of methicillin-susceptible and methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit, 2000-2007. J Perinatol 2010;30:135139.
17. Kuint, J, Barzilai, A, Regev-Yochay, G, Rubinstein, E, Keller, N, Maayan-Metzger, A. Comparison of community-acquired methicillin-resistant Staphylococcus aureus bacteremia to other staphylococcal species in a neonatal intensive care unit. Eur J Pediatr 2007;166:319325.
18. Graham, PL 3rd, Morel, AS, Zhou, J, et al. Epidemiology of methicillin-susceptible Staphylococcus aureus in the neonatal intensive care unit. Infect Control Hosp Epidemiol 2002;23:677682.
19. Ericson, JE, Popoola, VO, Smith, PB, et al. Burden of invasive Staphylococcus aureus infections in hospitalized infants [published online October 19, 2015]. JAMA Pediatr 2015:18.
20. Milstone, AM, Budd, A, Shepard, JW, et al. Role of decolonization in a comprehensive strategy to reduce methicillin-resistant Staphylococcus aureus infections in the neonatal intensive care unit: an observational cohort study. Infect Control Hosp Epidemiol 2010;31:558560.
21. Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN). Surveillance definitions for specific types of infections. CDC website. Published 2013. Accessed November 7, 2013.
22. Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing: 24th informational supplement. CLSI document. Wayne, PA: CLSI, 2014:M100S24.
23. Suwantarat, N, Carroll, KC, Tekle, T, Ross, T, Popoola, VO, Milstone, AM. Low prevalence of mupirocin resistance among hospital-acquired methicillin-resistant Staphylococcus aureus isolates in a neonatal intensive care unit with an active surveillance cultures and decolonization program. Infect Control Hosp Epidemiol 2015;36:232234.
24. Linden, A. itsa: Stata module for conducting interrupted time series analysis for single and multiple groups. Linden Consulting website. Published 2014.
25. Khoury, J, Jones, M, Grim, A, Dunne, WM Jr, Fraser, V. Eradication of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit by active surveillance and aggressive infection control measures. Infect Control Hosp Epidemiol 2005;26:616621.
26. Calfee, DP, Salgado, CD, Milstone, AM, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:S108S132.
27. Nelson, MU, Bizzarro, MJ, Dembry, LM, Baltimore, RS, Gallagher, PG. One size does not fit all: why universal decolonization strategies to prevent methicillin-resistant Staphylococcus aureus colonization and infection in adult intensive care units may be inappropriate for neonatal intensive care units. J Perinatol 2014;34:653655.
28. Delaney, HM, Wang, E, Melish, M. Comprehensive strategy including prophylactic mupirocin to reduce Staphylococcus aureus colonization and infection in high-risk neonates. J Perinatol 2013;33:313318.
29. Hitomi, S, Kubota, M, Mori, N, et al. Control of a methicillin-resistant Staphylococcus aureus outbreak in a neonatal intensive care unit by unselective use of nasal mupirocin ointment. J Hosp Infect 2000;46:123129.
30. Walker, ES, Vasquez, JE, Dula, R, Bullock, H, Sarubbi, FA. Mupirocin-resistant, methicillin-resistant Staphylococcus aureus: does mupirocin remain effective? Infect Control Hosp Epidemiol 2003;24:342346.
31. Miller, MA, Dascal, A, Portnoy, J, Mendelson, J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996;17:811813.
32. Jones, JC, Rogers, TJ, Brookmeyer, P, et al. Mupirocin resistance in patients colonized with methicillin-resistant Staphylococcus aureus in a surgical intensive care unit. Clin Infect Dis 2007;45:541547.
33. Choudhury, S, Krishnan, PU, Ang, B. Prevalence of high-level mupirocin resistance among meticillin-resistant Staphylococcus aureus isolates in a tertiary care hospital in Singapore. J Hosp Infect 2012;82:5657.
34. You, JH, Chan, CY, Wong, MY, Ip, M. Active surveillance and decolonization of methicillin-resistant Staphylococcus aureus on admission to neonatal intensive care units in Hong Kong: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2012;33:10241030.
35. Carey, AJ. War on Staphylococcus aureus . J Perinatol 2014;34:803804.
36. Huang, SS, Septimus, E, Kleinman, K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013;368:22552265.

Active Surveillance Cultures and Decolonization to Reduce Staphylococcus aureus Infections in the Neonatal Intensive Care Unit

  • Victor O. Popoola (a1), Elizabeth Colantuoni (a2), Nuntra Suwantarat (a3), Rebecca Pierce (a4), Karen C. Carroll (a4), Susan W. Aucott (a5) and Aaron M. Milstone (a1) (a3) (a6)...


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