title: VEB-1 extended-spectrum β-lactamase-producing multidrug-resistantProteus mirabilissepsis outbreak in a neonatal intensive care unit in India: clinical and diagnostic implications.
abstract: BACKGROUND
  Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, multidrug-resistant (MDR) pathogens, are increasingly implicated in nosocomial outbreaksworldwide, particularly in neonatal intensive care units (NICUs).Proteus mirabilisis an uncommon nosocomial pathogen causing sepsis in neonates.
  
  
  METHODS
  We report an outbreak of ESBL-positive MDRP. mirabilissepsis involving five babies within 10 days in a NICU, which was promptly detected and managed. The aim of this study was to characterize the molecular mechanism of resistance to third-generation cephalosporins (3GCs) in the bacteria. Surveillance cultures were collected from health-care personnel (hand swabs, urine) and the surrounding patient-care environment. Ribotyping was performed to determine the clonality of the strain. ThirteenP. mirabiliswere recovered from the blood cultures of the five babies and surveillance cultures. Twelve isolates were positive for the VEB-1 ESBL type, and were susceptible only to ciprofloxacin and carbapenems. There was an unusual phenotypic synergy observed between the 3GCs and imipenem/cefoxitin. The source of infection was traced to a contaminated multidose vial. The outbreak was associated with a high mortality (80 %). A change of empirical antibiotic policy to ciprofloxacin, with strict infection control measures, brought the outbreak to an abrupt end.
  
  
  CONCLUSIONS
  This is believed to be the first report of a nosocomial outbreak of VEB-1 ESBL-producingP. mirabilissepsis in neonates from India. The present report of infection due to VEB-1-producingP. mirabilis, an uncommon pathogen for an epidemic in a neonatal unit, highlights the growing significance of such Gram-negative bacteria as a cause of infections in newborns. Epidemic spread in a neonatal unit of an ESBL-producingProteusspecies, which also had an intrinsically reduced susceptibility to imipenem, and resistance to colistin and tigecycline, can be a threatening situation and can result in high neonatal mortality unless recognized and controlled in a timely manner.
authors.affiliation: Department of Microbiology, VMMC and Safdarjang Hospital , New Delhi 110029 , India.
authors.forename: Sarika
authors.initials: S
authors.lastname: Jain
authors.affiliation: Department of Microbiology, VMMC and Safdarjang Hospital , New Delhi 110029 , India.
authors.forename: Rajni
authors.initials: R
authors.lastname: Gaind
authors.affiliation: Department of Microbiology, VMMC and Safdarjang Hospital , New Delhi 110029 , India.
authors.forename: Charu
authors.initials: C
authors.lastname: Kothari
authors.affiliation: Department of Pediatrics, VMMC and Safdarjang Hospital , New Delhi 110029 , India.
authors.forename: Rachna
authors.initials: R
authors.lastname: Sehgal
authors.affiliation: Department of Microbiology, Vallabhbhai Patel Chest Institute , New Delhi , India.
authors.forename: A
authors.initials: A
authors.lastname: Shamweel
authors.affiliation: Department of Microbiology, Vallabhbhai Patel Chest Institute , New Delhi , India.
authors.forename: S S
authors.initials: SS
authors.lastname: Thukral
authors.affiliation: Department of Pediatrics, VMMC and Safdarjang Hospital , New Delhi 110029 , India.
authors.forename: Harish K
authors.initials: HK
authors.lastname: Chellani
keywords: Infection control; Neonatal sepsis; Outbreak; Proteus mirabilis; VEB-1 ESBL