Antimicrobial resistance in NICUs: The rise of ESKAPE pathogens and their impact on neonatal health.

BACKGROUND

Antimicrobial resistance (AMR) in Neonatal Intensive Care Units (NICUs) is a growing public health concern, particularly due to ESKAPE pathogens, which are major causes of severe healthcare-associated infections.

METHODS

This retrospective cohort study analyzed the incidence, resistance patterns, and risk factors of invasive ESKAPE infections in a Brazilian NICU from 2015 to 2024, using National Healthcare Safety Network surveillance data.

RESULTS

Among 2035 admitted neonates, 6.7% developed invasive ESKAPE infections, with incidence increasing from 3.5% in 2015 to 9.2% in 2024. A total of 173 infection episodes were identified, predominantly bloodstream (59.5%) and urinary tract infections (34.7%). Klebsiella pneumoniae (52%) was the most frequent pathogen, followed by Staphylococcus aureus (26.6%) and Enterobacter cloacae (16.8%). As the study included only ESKAPE isolates exhibiting resistance to at least one antimicrobial agent, all isolates had an AMR phenotype; among them, 54.9% classified as multidrug-resistant (MDR) and 3.5% as extensively drug-resistant (XDR). ESBL production was detected in 28.3% of isolates. Prior exposure to broad-spectrum antimicrobials-especially carbapenems (OR = 25.71), glycopeptides (OR = 8.69), and fourth-generation cephalosporins (OR = 8.23)-was significantly associated with infection. Infections prolonged hospital stay and were associated with a 23.5% case-fatality rate, which was more than twice the mortality rate observed among neonates without invasive healthcare-associated infections. Mortality was particularly high in Acinetobacter baumannii infections.

CONCLUSIONS

These findings underscore the urgent need for strengthened surveillance, infection prevention, and antimicrobial stewardship strategies in NICUs.