Costs and Extra Length of Stay because of Neonatal Bloodstream Infection at a Teaching Hospital in Ghana

Predictive Value of Inflammatory Markers NLR, PLR, APRI, SII, and Liver Function Tests in Systemic Inflammatory Response Syndrome Detection in Full-Term Newborns

Systemic Inflammatory Response Syndrome (SIRS) is associated with significant morbidity and mortality in full-term newborns. This study aimed to evaluate the predictive value of the Neutrophil-to-Lymphocyte Ratio (NLR), Derived Neutrophil-to-Lymphocyte Ratio (dNLR), Platelet-to-Lymphocyte Ratio (PLR), Neutrophil, Lymphocyte, and Platelet Ratio (NLPR), AST-to-Platelet Ratio Index (APRI), and Systemic Immune-Inflammation Index (SII) in identifying the risk for SIRS development in full-term newborns. Conducted between January 2023 and January 2024, this observational cohort study compared full-term newborns diagnosed with SIRS with newborns without SIRS, measuring the inflammatory markers within the first day of life and three days post-birth. The study included 229 newborns, 81 with SIRS and 148 controls without SIRS. Statistically significant differences were observed in NLR (3.81 vs. 2.20, p < 0.0001), PLR (68.12 vs. 52.30, p < 0.0001), and liver enzymes (AST 40.96 U/L vs. 31.58 U/L, ALT 34.66 U/L vs. 22.46 U/L, both p < 0.0001) between the groups. The NLPR demonstrated substantial diagnostic value, with a sensitivity of 78.36% and specificity of 83.52% at 72 h (p < 0.0001). Regression analysis highlighted that the NLPR and SII were strongly predictive of SIRS, with the NLPR showing over three-times higher SIRS risk (HR 3.29, p < 0.0001) and SII indicating nearly 3.5 times the risk (HR 3.47, p < 0.0001). The NLPR, APRI, and SII showed similar prediction values to CRP levels measured on the first and third days of life (HR 3.16). Inflammatory markers like NLR, PLR, and systemic indices such as NLPR and SII, alongside liver function tests, are significant predictors of SIRS in full-term newborns. These findings support the integration of these markers into routine neonatal care, allowing for early identification and potentially improved management of newborns at risk for SIRS, thereby enhancing clinical outcomes.

Epidemiology, risk factors, clinical presentation and complications of late-onset neonatal sepsis among preterm neonates in Cyprus: a prospective case-control study

BACKGROUND

Late-onset neonatal sepsis (LOS) is common in preterm neonates, with increasing incidence in recent years. In the present study, we examined the epidemiology, clinical presentation, and complications of LOS in Cyprus and quantified possible risk factors for the development of this condition.

METHODS

The study subjects were preterm neonates admitted in the Neonatal Intensive Care Unit (NICU) of Archbishop Makarios III Hospital, the only neonatal tertiary centre in Cyprus. A prospective, case-control study was designed, and carried out between April 2017-October 2018. Depending on blood culture results, preterm neonates were classified as "Confirmed LOS": positive blood culture - microorganism isolated and LOS symptoms, "Unconfirmed LOS": negative blood culture and LOS symptoms, and "Controls" group: negative blood culture and absence of LOS symptoms. Comparisons between the 3 groups were performed and the associations between demographic, clinical and treatment characteristics with the likelihood of LOS were assessed using univariate and multivariate logistic regression.

RESULTS

A total of 350 preterm neonates were included in the study and the incidence of LOS was 41.1%. 79 (22.6%) and 65 (18.6%) neonates were classified as "Confirmed LOS", and "unconfirmed LOS" cases respectively while 206 (58.9%) served as controls. The rate of confirmed LOS ranged from 12.2% in moderate to late preterm neonates to 78.6% in extremely preterm neonates. In the multivariate model, we demonstrated an independent association between LOS and duration of hospitalization (OR: 1.06, 95%CI: 1.01-1.10), duration of ventilation (OR: 1.23, 95%CI: 1.07-1.43) and necrotising enterocolitis (OR: 3.41, 95%CI: 1.13-10.25).

CONCLUSIONS

The present study highlights the epidemiology of LOS in preterm neonates in Cyprus and its association with the duration of ventilation and hospitalization as well as with necrotizing enterocolitis. Establishment of protocols for the prevention of nosocomial infections during hospitalization in the NICUs and mechanical ventilation of preterm neonates is recommended.

Implementation of infection prevention and control for hospitalized neonates: A narrative review

BACKGROUND

The most prevalent infections encountered in neonatal care are healthcare-associated infections. The majority of healthcare-associated infections are considered preventable with evidence-based infection prevention and control (IPC) practices. However, substantial knowledge gaps exist in IPC implementation in neonatal care. Furthermore, the knowledge of factors which facilitate or challenge the uptake and sustainment of IPC programmes in neonatal units is limited. The integration of implementation science approaches in IPC programmes in neonatal care aims to address these problems.

OBJECTIVES

The aim of this narrative review was to identify determinants which have been reported to influence the implementation of IPC programmes and best practices in inpatient neonatal care settings.

SOURCES

A literature search was conducted in PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) in May 2022. Primary study reports published in English, French, German, Spanish, Portuguese, Italian, Danish, Swedish or Norwegian since 2000 were eligible for inclusion. Included studies focused on IPC practices in inpatient neonatal care settings and reported determinants which influenced implementation processes.

CONTENT

The Consolidated Framework for Implementation Research was used to identify and cluster reported determinants to the implementation of IPC practices and programmes in neonatal care. Most studies reported challenges and facilitators at the organizational level as particularly relevant to implementation processes. The commonly reported determinants included staffing levels, work- and caseloads, as well as aspects of organizational culture such as communication and leadership.

IMPLICATIONS

The presented knowledge about factors influencing neonatal IPC can support the design, implementation, and evaluation of IPC practices.

Attributable Patient Cost of Antimicrobial Resistance: A Prospective Parallel Cohort Study in Two Public Teaching Hospitals in Ghana

OBJECTIVE

The aim of this study was to evaluate the attributable patient cost of antimicrobial resistance (AMR) in Ghana to provide empirical evidence to make a case for improved AMR preventive strategies in hospitals and the general population.

METHODS

A prospective parallel cohort design in which participants were enrolled at the time of hospital admission and remained until 30 days after the diagnosis of bacteraemia or discharge from the hospital/death. Patients were matched on age group (± 5 years the age of AMR patients), treatment ward, sex, and bacteraemia type. The AMR cohort included all inpatients with a positive blood culture of Escherichia coli or Klebsiella spp., resistant to third-generation cephalosporins (3GC), or methicillin-resistant Staphylococcus aureus (MRSA). We matched the AMR cohort (n = 404) with two control arms, i.e., patients with the same bacterial infections susceptible to 3GC or S. aureus that was methicillin-susceptible (susceptible cohort; n = 152), and uninfected patients (uninfected cohort; n = 404). Settings were Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana. The outcome measures were the length of hospital stay (LOS) and the associated patient costs. Outcomes were evaluated from the patient perspective.

RESULTS

From a total of 5752 blood cultures screened, 1836 participants had growth in blood culture, of which, based on our inclusion criteria, 426 were enrolled into the AMR cohort; however, only 404 completed the follow-up and were matched with participants in the two control cohorts. Patients in the AMR cohort stayed approximately 5 more days (95% confidence interval [CI] 4.0-6.0) and 8 more days (95% CI 7.2-8.6) compared with the susceptible and uninfected cohorts, respectively. The mean extra patient cost due to AMR relative to the susceptible cohort was US$1300 (95% CI 1018-1370), of which about 30% resulted from productivity loss due to presenteeism and absenteeism from work. Overall, the estimated annual patient cost due to AMR translates to about US$1 million and US$1.4 million when compared with the susceptible and uninfected cohorts, respectively.

CONCLUSION

We have shown that AMR is associated with a significant excess LOS and patient costs in Ghana using prospective data from two public tertiary hospitals. This calls for infection prevention and control strategies aimed at mitigating the prevalence of AMR.

Cost-effectiveness analysis of alcohol handrub for the prevention of neonatal bloodstream infections: Evidence from HAI-Ghana study

Published evidence of the cost-effectiveness of alcohol-based handrub (ABH) for the prevention of neonatal bloodstream infections (BSI) is limited in sub-Saharan Africa. Therefore, this study evaluates the cost-effectiveness of a multimodal hand hygiene involving alcohol-based hand rub (ABH) for the prevention of neonatal BSI in a neonatal intensive care unit (NICU) setting in Ghana using data from HAI-Ghana study. Design was a before and after intervention study using economic evaluation model to assess the cost-effectiveness of a multimodal hand hygiene strategy involving alcohol-based hand rub plus soap and water compared to existing practice of using only soap and water. We measured effect and cost by subtracting outcomes without the intervention from outcomes with the intervention. The primary outcome measure is the number of neonatal BSI episode averted with the intervention and the consequent cost savings from patient and provider perspectives. The before and after intervention studies lasted four months each, spanning October 2017 to January 2018 and December 2018 to March 2019, respectively. The analysis shows that the ABH program was effective in reducing patient cost of neonatal BSI by 41.7% and BSI-attributable hospital cost by 48.5%. Further, neonatal BSI-attributable deaths and extra length of hospital stay (LOS) decreased by 73% and 50% respectively. Also, the post-intervention assessment revealed the ABH program contributed to 16% decline in the incidence of neonatal BSI at the NICU. The intervention is a simple and adaptable strategy with cost-saving potential when carefully scaled up across the country. Though the cost of the intervention may be more relative to using just soap and water for hand hygiene, the outcome is a good reason for investment into the intervention to reduce the incidence of neonatal BSI and the associated costs from patient and providers' perspectives.

Risk Factors and Clinical Outcomes of Neonatal Sepsis in Manado Tertiary Referral Hospital: A Single-center Study

BACKGROUND: Neonatal sepsis remains a major cause of morbidity and mortality among newborn infants, both term and preterm. Even with effective treatment, the outcome is still uncertain, with inflated health-care cost due to prolonged length of stay in the Neonatal Intensive Care Unit. AIM: This study aimed to evaluate risk factors and their association with clinical outcomes of neonatal sepsis in a tertiary referral hospital in Manado, Indonesia. METHODS: This is a single-center retrospective cohort study of 365 neonatal sepsis subjects, conducted between January 2016 and December 2018. Risk factors were divided into two groups: Neonatal-related and maternal-related risk factors. Clinical outcomes analyzed were survival outcome (discharged or death) and hospital length of stay. Logistic regression, Mann–Whitney, and Kruskal–Wallis test were used in statistical analysis. RESULTS: From all risk factors, the highest mortality rate was found in neonates with sclerema (83.1%), and the lowest mortality rate in neonates without tachypnea (11.6%). Further multivariate statistical analysis revealed two risk factors associated with mortality, such as tachypnea (OR 4.94, 95% CI 2.257–10.841; p < 0.001) and sclerema (OR 34.47, 95% CI 15.135‒78.509; p < 0.001). Further analysis also reported several risk factors associated with prolonged length of stay, such as very low birth weight (p < 0.001), premature rupture of the membrane (p = 0.009), preterm gestational age (p < 0.001), and non-hospital delivery location (p = 0.013). CONCLUSION: In neonatal sepsis, the presence of tachypnea and sclerema was significant risk factors for mortality. Meanwhile, premature rupture of the membrane, very low birth weight, preterm gestational age, and non-hospital delivery location were risk factors associated with prolonged length of stay.

Recurrent late-onset neonatal sepsis traced to breast milk: A case report

Breast milk feeding is an important late-onset sepsis reduction strategy in the Neonatal Intensive Care Unit (NICU). However, multiple studies have reported transfer of bacteria-contaminated breast milk to infants. We describe a case of culture-positive breast milk resulting in persistent Enterococcus bacteremia in an infant. Beyond the development of an infant's innate and specific immunity as well as colonization of the gastrointestinal (GI) tract with commensal organisms, the risk of bacterial translocation from the GI tract into the bloodstream is shaped and modified by maternal health, birth history, and an infant's NICU course. While freezing and/or pasteurizing breast milk reduces or eliminates its bacterial load, it also diminishes its immunologic and nutritional benefits.