Extended spectrum beta-lactamase-producing Klebsiella pneumoniae outbreak reveals incubators as pathogen reservoir in neonatal care center

  • Lucile Cadot
  • Hélène Bruguière
  • Estelle Jumas-Bilak
  • Marie-Noëlle Didelot
  • Agnès Masnou
  • Gaëlle de Barry
  • Gilles Cambonie
  • Sylvie Parer
  • Sara Romano-BertrandEmail author
Original Article


In the context of a 3-month extended-spectrum beta-lactamase-producing Klebsiella pneumonia (ESBL-KP) outbreak in a neonatal care center (NCC), hygiene practices and hospital environment were investigated. ESBL-KP strains isolated from patients and environment were compared by molecular typing. The density of incidence of multi-drug-resistant bacteria (MDRB) was calculated from January 2014 to September 2016. The 3-month ESBL-KP outbreak involved 19 patients. Clinical strains from the 19 patients displayed the same molecular profile between them, and with a strain isolated from an incubator after cleaning. Furthermore, 52.4% of incubator mattresses were positive for diverse pathogens. Hygiene practices were acceptable except for external practitioners and parents. In addition to classical infection control (IC) measures, the replacement of mattresses and the improvement of incubators disinfection stopped the outbreak. The protocol of disinfection was revised and microbiological control was implemented. A significant decrease of MDRB incidence was concomitant (p value = 0.03219) but 3 months later, MDRB incidence increased again.

Conclusion: This investigation highlighted incubators and mattresses as critical materials associated to infectious risk in NCC. NCC and IC teams should implement efficient protocol for incubators disinfection and monitoring.

What is Known:

Environment in neonatal intensive care units is often suspected as reservoir for Enterobacteriaceae outbreaks but is scarcely investigated.

Incubators and mattresses offer wet and warm conditions suitable for pathogens multiplication, but microbiological survey is not performed routinely for assessing bacterial contamination.

What is New:

Incubators and mattresses serve as reservoir for pathogens and relay in outbreak.

An infection control protocol associating efficient disinfection and microbiology analysis is proposed.


Incubator mattress Outbreak Multi-drug-resistant bacteria Neonatal intensive care unit Molecular typing Steam-cleaner 



Beta-lactamase-producing Klebsiella pneumonia


Healthcare-associated infection


Infection control


Klebsiella pneumonia


Matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry


Multi-drug-resistant bacteria


Methicillin-resistant Staphylococcus aureus


Methicillin-susceptible Staphylococcus aureus


Neonatal care center


Neonatal intensive care unit


Neonatal kangaroo unit


Neonatal resuscitation unit


Pulsed field gel electrophoresis


Vancomycin-resistant Enterococcus


Authors’ contributions

LC wrote the first draft of the manuscript and provided environmental sampling and bacteriological analyses; HB made the audit observations and analyzed their results; EJB helped for the interpretation of results from bacteriological analyses; MND contributed to the survey of cases in the NCC wards; AM performed molecular typing on strains; GDB provided antibiotic consumption reports; GC diagnosed cases and contributed to their survey in the NCC wards; SP managed the audit study and the application of preventive measures; SRB managed the environmental investigation, the application of preventive measures, and the writing of the manuscript. All authors have seen and approved the submission of this version of the manuscript and take full responsibility for the manuscript. No authors received any grant or honorarium or payment for producing this manuscript.


This work was supported by the University Hospital of Montpellier and the association ADEREMPHA, Sauzet, France.

Compliance with ethical statements

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Supplementary material

431_2019_3323_MOESM1_ESM.docx (85 kb)
ESM 1 (DOCX 84 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Lucile Cadot
    • 1
  • Hélène Bruguière
    • 1
  • Estelle Jumas-Bilak
    • 2
  • Marie-Noëlle Didelot
    • 3
  • Agnès Masnou
    • 4
  • Gaëlle de Barry
    • 5
  • Gilles Cambonie
    • 6
  • Sylvie Parer
    • 2
  • Sara Romano-Bertrand
    • 2
    Email author
  1. 1.Département d’Hygiène HospitalièreCHU MontpellierMontpellierFrance
  2. 2.Hydrosciences Montpellier, IRD, CNRS, Univ Montpellier, Département d’Hygiène HospitalièreCHU MontpellierMontpellier cedex 5France
  3. 3.Laboratoire de BacteriologieCHU MontpellierMontpellierFrance
  4. 4.Hydrosciences Montpellier, IRD, CNRSUniv MontpellierMontpellierFrance
  5. 5.Pharmacie à Usage InterieurCHU MontpellierMontpellierFrance
  6. 6.Service de NéonatologieCHU MontpellierMontpellierFrance

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