Besiedelung von gesunden Schwangeren und Neugeborenen mit multiresistenten Erregern (MRE) und Staphylococcus aureus (SA)

Adler, Alexandra (2018): Besiedelung von gesunden Schwangeren und Neugeborenen mit multiresistenten Erregern (MRE) und Staphylococcus aureus (SA): Relevanz gesundheitsökonomischer Aspekte sowie verschiedener Abstrichorte. Dissertation, LMU München: Medizinische Fakultät

Abstract

Background The prevalence of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase producing Escherichia coli (ESBL-E) in the hospital environment is increasing. So far, there is little data on the prevalence and importance of such colonization in pregnant women and their newborns at the moment of birth. In the context of the QARKS study (quality assurance of antibiotic resistant colonization in children and pregnant women), a risk assessment of the presence of antibiotic-resistant bacteria in pregnant women and newborns was done and the need for prevention concepts was evaluated. Due to the special importance in the context of limited supplies, this thesis deals with the costs of hospitalization as well as the significance of sampling locations with regard to MRE colonization. Methods The QARKS study was conducted between October 2013 and December 2015 in two large Bavarian clinics (gynaecological hospital Rotkreuzklinikum Munich and gynaecological hospital Klinikum Augsburg). Pregnant women were recruited before birth, at the time of inpatient admission. After the study was described and a written consent form was signed, data collection was carried out through a questionnaire-based interview of the mother as well as by data extraction from the expectant mother's record of prenatal care and the patient’s file. In addition, skin swabs were collected in the delivery room from the mother and the child (also from the newborn three days after the birth in the U2). The prevalence of MRSA, methicillin-susceptible Staphylococcus aureus (MSSA) and ESBL as well as the costs of the hospital stay of the mother and the child were determined with G-DRG (German-Diagnosis Related Groups) and stratified into two groups (group 1: birth without complicating diagnoses, group 2: birth with complicating diagnoses). For one clinic, the actual costs of the hospital stay could be determined by means of resource consumption and compared with the revenues on a case-by-case basis. The nose, mamilla, perianal region and vagina of the pregnant mother were screened. Samples from the newborn were collected from the nose and navel, as well as at U2 from the nose, navel and perianal region. Screening of the samples was done using culture based (blood agar, ChromID, CHROMAgar plates and MRSA Broth) and molecular methods (pulse field gel electrophoresis (PFGE), spa typing) as well as phenotypic antibiotic resistance analysis (BD Phoenix TM system). The results were analyzed using SAS 9.4. Results The data from 763 women had shown that the prevalence of MRSA/MSSA (0.4%/14.5%) as well as ESBL (2.6%) in pregnant women just before giving birth corresponded to the prevalence found in the general population, or was slightly lower. Of the 658 newborns, 0.9% were colonized with MSSA at birth and 13.1% at U2. Similarly, 0.5% of the newborns were colonized with MRSA and 2.6% with ESBL. For the economic evaluation, 635 mothers and 566 newborns were included in the evaluation. The average hospital income for the pregnant women was €2,174.38 (group 1 at €1,742.63 and group 2 at €2,493.61; p < 0.0001). For the newborns, the hospital's income had an average of €1,295.01(€782.05 for group 1 and €3,713.29 for group 2) (p < 0.0001). The difference in average hospital income between MRSA/ESBL and MSSA colonization was not statistically significant in both DRG groups. Furthermore, colonization with MRE/MSSA did not have a statistically significant influence on the costs and health status of the mother or neonate. Mothers with an age over 35 years, with first-term infants, with pre-existing diseases or diseases during pregnancy were significantly more frequent in group 2 with complicating diagnoses. This resulted in significantly higher reimbursements than for mothers without complicated births. In the case of first-term infants and mothers with diseases during pregnancy, the average hospital income was higher than the relative cost. However, this was not statistically significant. All ESBL-producing gram-negative bacteria identified in this study were E. coli. With nasal sampling, 91.0% of pregnant women colonized with MRSA/MSSA and 60.0% of newborns were identified. In newborns, 84.0% of the colonized cases were detected by a combination of nasal and navel sampling three days after birth. ESBL-E. coli sampling in the perianal region was positive in all colonized pregnant women and in 88.2% of colonized newborns. The colonization of newborns with MRSA, MSSA and ESBL-producing E. coli was significantly higher three days after birth at U2 than immediately after. Conclusion In this study it could be shown that the prevalences of MRSA/MSSA and ESBL in pregnant women shortly before delivery were equal to or less than in the general population. Furthermore, similar prevalence of MRE and MSSA among pregnant women and neonates in the two DRG groups (birth without complicating diagnoses and birth with complicating diagnoses) were found. A colonization with MRE/MSSA did not have a statistically significant effect on the revenues and on the real hospitalization costs. Therefore, further health-economics studies on cost evaluation are necessary in order to improve the efficiency of resource allocation within the DRG system. In order to optimize resource consumption and to further improve data-based studies, a central cost calculation using an invoice method and the possibility to code the colonization of MRE separately would be desirable. For the screening of MRE, nasal sampling for MRSA and perianal sampling for ESBL were suitable for the screening of pregnant women. In newborns, most cases were detected by birth at U2 (third day after birth). Therefore, in the case of the newborns, the nasal, perianal and umbilical samples (MRSA and ESBL) should be taken on the third day after birth in order to further increase the sensitivity. In addition, a combination of sheep blood agar and contrast MRSA broth for MRSA screening, as well as CHROMagar for ESBL E. coli is recommended. Lastly, the study "Risk assessment of the occurrence of antibiotic-resistant pathogens in pregnant women and newborns for the determination of the need for prevention concepts: quality assurance of antibiotic resistance in children and pregnant women” (QARKS) has shown that a MRE/MSSA colonization of the mother or child at the time of birth did not lead to increased costs during the hospital stay. The combination of nasal and perianal sampling is optimal for screening for potential antibiotic-resistant bacteria.

• Dokumententyp: Dissertationen (Dissertation, LMU München)
• Keywords: MRSA, ESBL, Obstetrics, Hospitalization cost, Sampling location
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften ; 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• Fakultäten: Medizinische Fakultät
• Sprache der Hochschulschrift: Deutsch
• Datum der mündlichen Prüfung: 21. Juni 2018
• 1. Bericht­erstatter:in: Herr, Caroline