Nosocomial infections in paediatric and neonatal intensive care units

Antibiotic Susceptibility of Microorganisms Grown in Tracheal Aspirate Cultures of Pediatric Intensive Care Patients

Background

Microorganisms proliferating in the hospital setting cause infections with high morbidity and mortality rates. In intensive care units (ICUs), the rates of antibiotic resistance and microorganisms grown in cultures may vary by time period. Antibiotic sensitivity must be known for a correct empirical treatment approach. This study aimed to investigate the distribution and antibiotic resistance profiles of pathogenic microorganisms isolated from tracheal aspirate samples in the ICU.

Methodology

This study enrolled 100 tracheostomized patients aged one month to 18 years, regardless of gender, who were followed in the ICU of Dicle University for more than 72 hours. Medical data were retrospectively evaluated from the medical records. Care was taken to collect samples before changing antibiotics. Antibiotherapy was continued until after culture antibiogram results were obtained, or empirical antibiotic therapy was started by giving consideration to the potential source in patients with a suspected infection.

Results

An analysis of the tracheal aspirate culture samples of the patients showed that Pseudomonas aeruginosa (54%), Acinetobacter baumannii (16%), and Staphylococcus aureus (8%) were the most common pathogens. An analysis of the culture antibiogram results of the tracheal aspirate samples obtained from the entire study population showed that P. aeruginosa was 100% resistant against vancomycin, clindamycin, and teicoplanin, but highly sensitive to colistin and amikacin. A. baumannii was highly resistant to almost all antibiotics but showed no resistance against colistin. Carbapenems being frequently preferred for cases where empirical therapy should be initiated for ICU infections can be one of the reasons for a high carbapenem resistance rate in our hospital.

Conclusions

We believe that starting empirical therapy with colistin when infections caused by Pseudomonas and Acinetobacter are suspected may be an appropriate initial therapy until culture antibiogram results become available. Microbiological data are crucial for a correct empirical treatment approach. In this way, intensive antibiotic usage and subsequent high antibiotic resistance can be adequately controlled.

The Impact of the Implementation of Culture-based Antibiotic Policy on the Incidence of Nosocomial Infections in Neonates Hospitalized in Neonatal Intensive Care Unit in a General Egyptian Hospital in Upper Egypt, 2016-2018

Nosocomial infections mainly are due to inefficient cleaning in association with the uncontrollable prescription of antimicrobials resulting in the emergence of multi-drug resistant pathogens in the hospital environment. Objectives:The study aims to evaluate the impact of the implementation of culture-guided antibiotic policy with strict infection control strategies on the occurrence of nosocomial infections and the resistance pattern ofthe isolated clinical and environmental pathogens. The study was done in 2 periods. Firstly, (August 2016 – April 2017), routine disinfection procedures and the applied antibiotic policy were evaluated. Secondly, according to the results a new antibiotic policy depending on the culture sensitivity results were implemented starting from June 2017 to February 2018 in association with strict infection control practices. As a result of this intervention, A change in the type of the isolated microorganisms was observed.Antibiotic resistance was decreased. Mortality rate was reduced from 14.1% to 9.5% of neonates with nosocomial infections, the number of the prescribed antibiotics didn’t exceed 4 antibiotics decreasing the overall cost for neonates’ therapy during their hospital stay. Each hospital should have its own antibiotic policy with the application of strict infection control strategies for the control of nosocomial infection.

Effect of Lentivirus-Mediated miR-499a-3p on Human Umbilical Vein Endothelial Cells

Objective

To explore the possible role of miR-499a-3p in the function of primary human umbilical vein endothelial cells (HUVECs) and the expression of ADAM10 in primary HUVEC.

Method

miR-499a-3p was first transfected into primary HUVECs via lentivirus vector. The viability, proliferation, and migration of stable transfected primary HUVEC were then determined by flow cytometry, CCK8 assays, scratch tests, and Transwell tests. The transcription of miR-499a-3p and ADAM10 was examined by reverse transcription-polymerase chain reaction (RT-PCR), and the expression of ADAM10 was examined by Western blot (WB).

Results

After transfection, miR-499a-3p transcription was significantly increased (P < 0.01), compared to the blank and nonspecific control (NC) groups, while both ADAM10 transcription and expression were significantly decreased (P < 0.05). In contrast, in the inhibitors group, miR-499a-3p transcription was significantly reduced (P < 0.05) whereas both ADAM10 transcription and expression were significantly increased (P < 0.05). The viability, proliferation, and migration of primary HUVECs were significantly impaired (P < 0.05) by the transfection of miR-499a-3p but enhanced by miR-499a-3p inhibitors (P < 0.05).

Conclusions

Upregulation of miR-499a-3p transcription will inhibit the expression of ADAM10 in HUVECs; cell migration and proliferation, however, promote apoptosis. And reverse effects were established by downregulation of miR-499a-3p transcription. All these effects may be achieved by regulating the transcription and expression of ADAM10. These results combined suggested that miR-499a-3p may affect the proliferation, migration, and apoptosis of endothelial cells and regulate AS by regulating ADAM10. miR-499a-3p may become a candidate biomarker for the diagnosis of unstable angina pectoris (UA).

Similar Strains of Coagulase-Negative Staphylococci Found in the Gastrointestinal Tract and Bloodstream of Bacteremic Neonates

Objectives

Premature neonates are susceptible to opportunistic and nosocomial infections. Efforts have been made to determine whether the neonatal gut microbiome possesses potential for causing bloodstream infections in newborns via microbial translocation from the gastrointestinal tract. We aimed to examine similarities in coagulase-negative staphylococci (CoNS) strains found in the gastrointestinal tract and bloodstream in bacteremic neonates.

Methods

CoNS strains isolated from blood cultures and perianal and pharyngeal swab samples of neonates from two neonatal intensive care units were investigated using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and pulsed-field gel electrophoresis. Molecular mass and genetic similarities of CoNS strains were compared.

Results

Marked similarity was found in the molecular mass and genetic profile of examined CoNS isolates from blood cultures and perianal/pharyngeal samples. The percentage of neonates developing bacteremia following perianal and pharyngeal colonization by CoNS was significantly higher when compared to those colonized by Enterobacteriales species (p < 0.0002).

Conclusions

CoNS colonizing the gut may be a source of bacteremia in neonates. Enterobacteriales species do not contribute as significantly to bacteremia when compared to CoNS, and may be protective against gut mucosa-originated systemic infection.

Prevalence and Anti-Microbial Susceptibility of Hospital Acquired Infections in Two Pediatric Intensive Care Units in Egypt

BACKGROUND:

Hospital-acquired (nosocomial) infection is a common serious health problem worldwide, especially in pediatric intensive care units and is associated with high mortality and morbidity, prolonged hospital stays and high cost.

AIM:

To determine the types of organisms involved in hospital-acquired an infection in two pediatric intensive care units during the one-year study and its anti-microbial susceptibility.

MATERIAL AND METHODS:

This study was carried out in the pediatric intensive care units (PICU) of Ain Shams & Cairo Universities, where 86 pediatric patients were recruited. Their age ranged from 1 month to 156 months with mean 20.7 ± 25.8 months. Male to female ratio was 37:29. Four samples were collected from each child for culture and sensitivity: blood, endotracheal aspirate, urine and skin swab.

RESULTS:

The most common microorganism was staphylococcus while Gram-negative bacteria were the commonest group. Amikacin and imipenem are the most sensitive antibiotics. Risk estimate for different risk factors among studied patients revealed no significance.

CONCLUSION:

Staphylococcus was the commonest micro-organism while Gram-negative infections were the commonest group among PICU with a predominance of Acinetobacter and Klebsiella. Respiratory infections were the most common, followed by blood-borne infection. Risk factors for mortality were not significant.

Impact of International Quality Improvement Collaborative on Congenital Heart Surgery in Pakistan

BACKGROUND

The International Quality Improvement Collaborative (IQIC) was formed to reduce mortality and morbidity from congenital heart disease (CHD) surgeries in low/middle-income countries.

OBJECTIVES

We conducted this study to compare the postoperative outcomes of CHD surgeries at a centre in Pakistan before and after joining IQIC.

METHODS

The IQIC provides guidelines targeting key drivers responsible for morbidity and mortality in postoperativepatients with CHD. We focused primarily on nurse empowerment and improving the infection control strategies at our centre. Patients with CHD who underwent surgery at this site during the period 2011-2012 (pre-IQIC) were comparedwith those getting surgery in 2013-2014 (post-IQIC). Morbidity (major infections), mortality and factors associated with them were assessed.

RESULTS

There was a significant decrease in surgical site infections and bacterial sepsis in the post-IQIC versus pre-IQIC period (1% vs 30%, p=0.0001, respectively). A statistically insignificant decrease in the mortality rate was also noted in post-IQIC versus pre-IQIC period (6% vs 9%, p=0.17, respectively). Durations of ventilation and intensive care unit (ICU) and hospital stay were significantly reduced in the post-IQIC period. Age <1 year, malnutrition, low preoperative oxygen perfusion, Risk Adjustment for Congenital Heart Surgery score >3, major chromosomal anomalies, perfusion-related event, longer ventilation and ICU/hospital stay durations were associated with greater odds of morbidity and mortality.

CONCLUSION

Enrolling in the IQIC programme was associated with an improvement in the postsurgical outcomes of the CHD surgeries at our centre.

Mortality and Morbidity of Extremely Low Birth Weight Infants in the Mainland of China: A Multi-center Study

BACKGROUND

With the progress of perinatal medicine and neonatal technology, more and more extremely low birth weight (ELBW) survived all over the world. This study was designed to investigate the short-term outcomes of ELBW infants during their Neonatal Intensive Care Unit (NICU) stay in the mainland of China.

METHODS

All infants admitted to 26 NICUs with a birth weight (BW) < l000 g were included between January l, 2011 and December 31, 2011. All the data were collected retrospectively from clinical records by a prospectively designed questionnaire. The data collected from each NICU transmitted to the main institution where the results were aggregated and analyzed. Categorical variables were performed with Pearson Chi-square test. Binary Logistic regression analysis was used to detect risk factors.

RESULTS

A total of 258 ELBW infants were admitted to 26 NICUs, of whom the mean gestational age (GA) was 28.1 ± 2.2 weeks, and the mean BW was 868 ± 97 g. The overall survival rate at discharge was 50.0%. Despite aggressive treatment 60 infants (23.3%) died and another 69 infants (26.7%) died after medical care withdrawal. Furthermore, the survival rate was significantly higher in coastal areas than inland areas (53.6% vs. 35.3%, P = 0.019). BW < 750 g and GA < 28 weeks were the largest risk factors, and being small for gestational age was a protective factor related to mortality. Respiratory distress syndrome was the most common complication. The incidence of patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, retinopathy of prematurity was 26.2%, 33.7%, 6.7%, 48.1%, and 41.4%, respectively. Ventilator associated pneumonia was the most common hospital acquired infection during hospitalization.

CONCLUSIONS

Our study was the first survey that revealed the present status of ELBW infants in the mainland of China. The mortality and morbidity of ELBW infants remained high as compared to other developed countries.

Hospital-Acquired Pneumonia in Newborns with Birth Weight Less Than 1500 Grams: Risk Factors and Causes

Low birth weight newborns (≤1500 grams) are at a high risk of acquiring hospital infections due to the immaturity of the immune system, lack of efficient structural barriers, and an incomplete development of endogenous microbial flora.

The aim of this study was to reveal the potential risk factors for hospital-acquired pneumonia in low birth weight newborns.

This study was a prospective cohort design with a nested case-control study and was conducted between January 1st, 2012 and June 30th, 2015 at the Neonatology Department, Clinical Centre Kragujevac, Serbia. There were 1140 newborns hospitalized at the Neonatology Department for longer than 48 hours during the study period, and 169 of them (14.82%) weighed less than 1500 grams at birth. In total, 73 (43.19%) newborns with low birth weights developed HIs. The most prevalent HI was hospital pneumonia (n=64, 87.67%).

Although univariate analyses identified many risk factors with a significant influence on the occurrence of hospital pneumonia, multivariate analysis identified only the following two independent risk factors for hospital pneumonia in newborns with birth weights below 1500 grams: mechanical ventilation (p=0.003, OR=68.893, 95% CI=4.285-1107.699) and longer hospitalization (p=0.003, OR=1.052, 95% CI=1.017-1.088). Almost all of the pathogens isolated from the patients with pneumonia were gram-negative bacteria (98.50%). More than half of all of the isolates were Acinetobacter spp (37.50%) and Enterobacter spp (18.75%).

Our study showed that mechanical ventilation and prolonged hospitalization were significant risk factors for the development of hospital pneumonia in newborns with birth weights below 1500 grams.

Incidence, Etiology and Risk Factors Associated with Neonatal Healthcare-Associated Conjunctivitis: A Prospective Study from a Tertiary Care Hospital in India

INTRODUCTION

Healthcare-associated conjunctivitis (HAC) can lead to serious sequelae including blindness. We conducted a one-year prospective study to determine the epidemiology of neonatal HAC at a tertiary-care hospital in India.

METHODS

From the neonates fulfilling a set of predefined inclusion criteria, cases of HAC were diagnosed based on CDC guidelines. Conjunctival swabs, obtained from neonates with suggestive clinical signs, were processed using standard protocols. Twenty-eight potential risk factors were analyzed.

RESULTS

We detected 24 cases of HAC among 591 enrolled neonates, with Escherichia coli being the most frequently isolated microorganism. On multivariate analysis, intubation at birth (p = 0.046) and orogastric feeding (p = 0.029) had a statistically significant association with neonatal HAC. Average hospitalization increased from 9.6 to 20.8 days for neonates diagnosed with HAC.

CONCLUSION

A standardized case-definition and physician awareness of potential serious sequelae would help improve detection rates and timely institution of therapy. Hand hygiene could help control the menace of neonatal HAC.

Influence of supplemental parenteral nutrition approach on nosocomial infection in pediatric intensive care unit of Emergency Department: a retrospective study

BACKGROUND & AIMS

Nutritional support for patients in the intensive-care unit (ICU) is a part of standard care which promotes medical quality and decreases nosocomial infection. Supplemental parenteral nutrition (SPN) approach (enteral nutrition (EN) combined with parenteral nutrition (PN) when EN alone is insufficient) has become one major concern in nutrition research field. This research aims to explore the following relationships: (i) the relationship between SPN and nosocomial infection, (ii) the relationship between early and late SPN initiation and the development of nosocomial infection.

METHODS

A retrospective study was conducted in patients who met the inclusion criteria from February 2012 to February 2015 in Pediatric ICU (PICU). Patients were classified into two groups according to nutrition delivery approach-SPN group and EN alone group. Then SPN group were further divided into two subgroups by initiation timing, which were defined as early-initiation SPN and late-initiation SPN group respectively. Age, gender, serum albumin at admission, severity of disease, length of stay in PICU, nutrition delivery approach, amounts of delivered caloric intake and occurence of nosocomial infection were recorded. Univariate analysis and binary logistic regression analysis were performed to identify the risk factors and assess the independent effect of SPN approach on nosocomial infection in PICU of Emergency Department.

RESULTS

204 patients were included in our study. Compared with EN alone group, patients delivered by SPN approach had a higher nosocomial infection rate (34.0 vs.10.9%, p < 0.001). The late-initiation subgroup of SPN approach was found to be an independent predictor of nosocomial infection in the logistic regression analysis model (OR = 3.40; 95% CI, 1.13 ~ 10.19; p = 0.029). Serum albumin at admission (OR = 0.91; 95% CI, 0.84 ~ 0.97; p = 0.008), mechanical ventilation (OR = 3.85; 95% CI, 1.43 ~ 10.39; p = 0.008), severity of disease (OR = 3.79; 95% CI, 1.03 ~ 13.99; p = 0.045) and PICU length of stay (OR = 1.23; 95% CI, 1.11 ~ 1.35; p < 0.001) were also identified as significant risk factors for nosocomial infection.

CONCLUSIONS

Our study shows late-initiation SPN approach increases the incidence of nosocomial infection compared with early-initiation approach in critically ill children in PICU of Emergency Department. Compared with EN alone group, patients delivered by SPN approach had a higher nosocomial infection rate.

Pattern of Blood Stream Infections within Neonatal Intensive Care Unit, Suez Canal University Hospital, Ismailia, Egypt

Introduction. Blood stream infection (BSI) is a common problem of newborn in neonatal intensive care units (NICUs). Monitoring neonatal infections is increasingly regarded as an important contributor to safe and high-quality healthcare. It results in high mortality rate and serious complications. So, our aim was to determine the incidence and the pattern of BSIs in the NICU of Suez Canal University Hospital, Egypt, and to determine its impact on hospitalization, mortality, and morbidity. Methods. This study was a prospective one in which all neonates admitted to the NICUs in Suez Canal University hospital between January, 2013 and June 2013 were enrolled. Blood stream infections were monitored prospectively. The health care associated infection rate, mortality rate, causative organism, and risk factors were studied. Results. A total of 317 neonates were admitted to the NICU with a mortality rate of 36.0%. During this study period, 115/317 (36.3%) developed clinical signs of sepsis and were confirmed as BSIs by blood culture in only 90 neonates with 97 isolates. The total mean length of stay was significantly longer among infected than noninfected neonates (34.5 ± 18.3 and 10.8 ± 9.9 days, resp., P value < 0.001). The overall mortality rates among infected and noninfected neonates were 38.9% and 34.8%, respectively, with a significant difference. Klebsiella spp. were the most common pathogen (27.8%) followed by Pseudomonas (21.6%) and Staphylococcus aureus (15.4%). Conclusion. The rate of BSIs in NICU at Suez Canal University Hospital was relatively high with high mortality rate (36.0%).

[Epidemiology of nosocomial bacterial infection in a neonatal intensive care unit in Morocco]

In neonatal intensive care units, the incidence of nosocomial infection is high. This study aimed to determine the epidemiology of a nosocomial bacterial infection in the neonatal intensive care unit of Mohamed VI university hospital. A total of 702 newborns were included in this study. Of the 702 neonates studied, 91 had developed a nosocomial infection. The incidence rate was 13% and incidence density was 21.2 per 1000 patient-days. The types of infection were: bloodstream infections (89%), pneumonia (6.6%), meningitis (3.3%), and urinary tract infections (1.1%). Nosocomial infection was particularly frequent in cases of low birth weight, prematurity, young age at admission, umbilical venous catheter, and mechanical ventilation. Multiresistant bacteria included enterobacteria producing betalactamase (76.9%), especially enterobacteria that were dominated by Klebsiella pneumoniae (39.7%). The mortality rate was 52.7% in nosocomial infections, 19 (20.87%) of whom had septic shock. The results of this study show that nosocomial infection is an intrahospital health problem that could be remedied by a prevention strategy.

A 4-year surveillance of device-associated nosocomial infections in a neonatal intensive care unit

BACKGROUND

The aim of this study was to determine the rate of health care-associated infection (HC-AI) and device-associated health care-associated infections (DA-HAIs), and distribution of causative microorganisms and etiologic factors responsible for these infections in a neonatal intensive care unit (NICU) of a state hospital in southeastern Turkey.

METHODS

A laboratory-based, active, prospective nosocomial infection surveillance study was performed in NICUs from January 2008 to December 2011. The rates of HC-AIs were determined on a daily basis. The findings were evaluated by applying the definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network.

RESULTS

In a 4-year period, 580 HC-AIs, 81 of which were DA-HAIs, were detected among 6932 patients. The rate of hospital acquired infection was 8.3% and 7.69/1000 patient days. Ventilator-associated pneumonia (VAP) was the second most frequent (13.1%) HC-AI and the most frequent was DA-HAI. The VAP rate was 6.4 per 1000 ventilator days. Mechanical ventilation was the most frequently used invasive device. Median time to diagnosis of VAP was 32.11 ± 29.3 days from the time of admission. Acinetobacter baumannii (48%) and Pseudomonas aeruginosa (32%) were the most frequent microorganisms. Colistin was the most effective antibiotic by in vitro test. The antibiotic resistance ratios of A. baumannii were ≥54% for carbapenems, aminoglycosides, and cefoperazone-sulbactam; ≥88% for quinolones; and ≥92% for ceftazidime, ceftriaxone, and piperacillin-tazobactam.

CONCLUSIONS

Device-associated nosocomial infections was a particularly important problem in NICU. Close monitoring will decrease the rates of device-related nosocomial infections.

Prevalence of viruses in stool of premature neonates at a neonatal intensive care unit

AIM

Premature neonates represent a population highly vulnerable to infection. This study aims to profile viral colonisation of gut and the associated clinical manifestations among premature neonates admitted to a neonatal intensive care unit (NICU) in Australia.

METHODS

In a cohort of 75 premature neonates born at less than 32 weeks gestation, who were followed for 4 weeks following admission to a NICU in Sydney, Australia, multiplex polymerase chain reaction assays were used to determine viral presence in stool, and clinical data were examined.

RESULTS

Overall, viral RNA or DNA was detected in 24/419 (5.7%) of specimens, including norovirus genogroup 2 (1.9%), enterovirus (1.2%), herpes simplex virus-2 (1.2%), cytomegalovirus (0.7%), Epstein-Barr virus (0.5%) and rotavirus (0.2%). Viral infection was detected in 13/75 (17%) of premature neonates at some time point, including five (7%) neonates shedding more than one type of virus in stool. A higher rate of infection was observed among premature neonates with intrauterine growth restriction (56%) compared with those infants born appropriate for gestational age (12%. P = 0.006).

CONCLUSION

The overall viral detection rate in stool of 5.7% (affecting 17% of neonates) indicates viral infections are an important health risk for premature infants in NICU.

Risk of parenteral nutrition in neonates--an overview

Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.

Prophylactic antibiotics to reduce morbidity and mortality in newborn infants with intercostal catheters

BACKGROUND

Intercostal catheters are commonly used for the drainage of intrathoracic collections in newborn infants, including pneumothorax and pleural effusions. Placement of an intercostal drain is a potential risk factor for nosocomial infection due to breach of the cutaneous barrier. Therefore, neonates who require intercostal drainage, especially those in high risk groups for nosocomial infection, may benefit from antibiotic prophylaxis. However, injudicious antibiotic use carries the risk of promoting the emergence of resistant strains of micro-organisms or of altering the pattern of pathogens causing infection.

OBJECTIVES

To determine the effect of prophylactic antibiotics compared to selective use of antibiotics on mortality and morbidity (especially septicaemia) in neonates undergoing placement of an intercostal catheter.

SEARCH METHODS

The standard search strategy of the Cochrane Neonatal Review Group was used to search the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 5), MEDLINE (1948 to June 2011) and CINAHL (1982 to June 2011).

SELECTION CRITERIA

Randomised controlled trials or some types of non-randomised (that is, quasi-randomised) controlled trials of adequate quality in which either individual newborn infants or clusters of infants were randomised to receive prophylactic antibiotics versus placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We did not find any randomised controlled trials that met the eligibility criteria.

AUTHORS' CONCLUSIONS

There are no data from randomised trials to either support or refute the use of antibiotic prophylaxis for intercostal catheter insertion in neonates. Any randomised controlled trials of antibiotic prophylaxis would need to account for the fact that neonates who require insertion of an intercostal catheter may already be receiving antibiotics for other indications.

Reduction in coagulase-negative staphylococcus infection rates in the NICU using evidence-based research

Coagulase-negative Staphylococcus (CoNS) bloodstream infection is the most common cause of sepsis in the NICU and can lead to significant morbidity and mortality. There is evidence that hand hygiene using an alcohol-based gel and wearing gloves during patient care, management of central and peripheral intravenous lines using the Centers for Disease Control and Prevention (CDC) guidelines, and a closed medication administration system can reduce the incidence to CoNS sepsis in the (NICU). To successfully apply the evidence and decrease the CoNS infection rate, a systematic process is necessary. One approach to process change that significantly reduced the CoNS infection rate in a health care system with two Level III NICUs included using system thinking; working within a multidisciplinary team; using evidence to revise, develop, and implement policies and procedures; developing staff education programs; and monitoring and providing feedback to all staff members.

Transfusion of leukocyte-depleted red blood cells is not a risk factor for nosocomial infections in critically ill children

OBJECTIVES

Transfusion of red blood cells is increasingly linked with adverse outcomes in critically ill children. We tested the hypothesis that leukocyte-depleted red blood cell transfusions were independently associated with increased development of bloodstream infections, ventilator-associated pneumonias, or urinary tract infections.

DESIGN

Historical, descriptive cohort study.

SETTING

Single-center, mixed medical-surgical, closed nine-bed pediatric intensive care unit of a tertiary university hospital.

PATIENTS

All children <18 yrs of age consecutively admitted to the pediatric intensive care unit during a 3-yr period (January 1, 2005, to December 31, 2007).

INTERVENTIONS

None.

RESULTS

One thousand one hundred twenty-three patients were admitted, of whom 503 (44.8%) were admitted for >48 hrs. Sixty-five (12.9%) had a nosocomial infection (incidence 19.3 per 1,000 pediatric intensive care unit admissions per year). Patients with a nosocomial infection were significantly more often male (72.3% vs. 27.7%, p = .033), had a higher Pediatric Risk of Mortality II score (median 19.1 [range, 6-44] vs. 18.0 [range, 2-39], p = .023), were more often ventilated (95.4% vs. 80.1%, p = .003), and received more often red blood cell transfusions (55.4% vs. 40.2%, p = .021). Multivariate logistic regression analysis showed that male gender (odds ratio, 2.07; 95% confidence interval, 1.14-3.76), presence of an indwelling central venous catheter (odds ratio, 2.41; 95% confidence interval, 1.29-4.48), and simultaneous use of more than one type of antimicrobial drug were independently associated with the development of nosocomial infections. Red blood cell transfusion was discarded as a predictor.

CONCLUSIONS

Transfusion of leukocyte-depleted red blood cells was not independently associated with the development of nosocomial infections in a heterogeneous group of critically ill children.

Healthcare-associated infections in a neonatal intensive care unit in Turkey in 2008: incidence and risk factors, a prospective study

In this study, we have prospectively recorded healthcare-associated infections (HAIs) in NICU and found incidence density as 18 infections per 1000 patient days. Of the infections, 51.3% was bacteriemia (BSI), and 45.1% was ventilator-associated pneumonia (VAP). Gram-negative microorganisms were predominant in VAP and Staphylococcus epidermidis was the leading microorganism (53.0% of BSIs) in BSIs. Multivariate logistic regression analysis showed the importance of hood O(2) use in days (RR: 1.3) and total parenteral nutrition use in days (RR: 1.09) for BSIs. Umbilical arterial catheterization in days (RR: 1.94), ventilator use in days (RR: 1.05), chest tube (RR: 12.55), orogastric feeding (RR: 3.32) and total parenteral nutrition in days (RR: 1.05) were found to be significantly associated with VAP. In conclusion, incidence density in our unit is high and Gram-negative rods are predominant similar to developing countries. These results strongly suggest improving measures of prevention and control of HAIs in the unit.

[Prolonged stay in pediatric intensive care units: mortality and healthcare resource consumption]

OBJECTIVE

To analyze mortality and resource consumption in patients with long stays in pediatric intensive care units (PICUs).

DESIGN

A retrospective, descriptive case series study.

SCOPE

Medical-surgical PICU in a third level hospital.

PATIENTS

Data were collected from patients with a stay of 28 days or more in PICU between 2006 and 2010. Of the 2118 patients assisted in this period, 83 (3.9%) required prolonged stay.

STUDY VARIABLES

Morbidity-mortality and resource consumption among patients with prolonged stay in the PICU.

RESULTS

Mortality was higher in patients with a long stay (22.9%) than in the rest of patients (2%) (p<0.001). In 52.6% of these patients, death occurred after withdrawal of treatment or after not starting resuscitation measures. Patients with prolonged stay showed a high incidence of nosocomial infection (96.3%) and an important consumption of healthcare resources (97.6% required conventional mechanical ventilation, 90.2% required transfusion of blood products, 86.7% required intravenous vasoactive drugs and 22.9% required extracorporeal membrane oxygenation [ECMO]).

CONCLUSIONS

Critical children with prolonged stay in the PICU show important morbidity and mortality, and an important consumption of healthcare resources. The adoption of specific measures permitting early identification of patients at risk of prolonged stay is needed in order to adapt therapeutic measures and available resources, and to improve treatment efficiency.

Individualized catheter surveillance among neonates: a prospective, 8-year, single-center experience

OBJECTIVE

To monitor trends in central line-associated bloodstream infections and clinical sepsis (CLABICS) among neonates and to determine risk factors for infection, especially dwell time.

DESIGN

Prospective, single-center cohort study conducted from 2001 through 2008.

SETTING

University-affiliated tertiary care center.

METHODS

Individualized surveillance of catheter use and CLABICS episodes was conducted. Data were obtained via regular on-site visits made 3 times a week. Trends over time were estimated by Poisson regression, and risk factor analysis was conducted using a Cox proportional hazards model and logistic regression.

RESULTS

In all, 1,124 neonates were exposed to 2,210 central lines for a total of 12,746 catheter-days and 11,467 catheter-days at risk. The median duration of catheter use was 8 (interquartile range, 5-11) days for peripherally inserted central catheters (PICCs) and 4 (interquartile range, 2-6) days for umbilical catheters; 102 CLABICS episodes were detected. The median time to infection was 7 days. Incidence densities were 8.5 CLABICS episodes per 1,000 catheter-days at risk and 8.0 CLABICS episodes per 1,000 catheter-days. The highest rates were identified among neonates weighing 750 g or lower (14.9 CLABICS episodes per 1,000 catheter days at risk) and for PICCs (13.2 CLABICS episodes per 1,000 catheter days at risk). Catheter dwell time was associated with CLABICS for all umbilical catheters (odds ratio [OR], 1.2 per day of use [95% confidence interval {CI}, 1.1-1.3]; P < .001) and for PICCs for up to 7 days (OR, 1.2 [95% CI, 1.1-1.4]; P = .041), but not thereafter (OR, 1.0 [95% CI, 0.9-1.1]; P = .90).

CONCLUSION

Catheter dwell time is a risk factor for CLABICS during the first 7 days, irrespective of catheter type. After 7 days, PICCs are less likely to become infected.

Management and outcome of positive urine cultures in a neonatal intensive care unit

OBJECTIVES

The aim of this study was to describe the management and outcome of positive urine cultures in a neonatal intensive care unit (NICU).

STUDY DESIGN

A chart review was completed of infants born October 1, 2004 to December 31, 2006 and admitted to the NICU at the Royal Alexandra Hospital, Edmonton, Alberta with any growth of bacteria or fungi in urine.

RESULTS

Positive urine cultures were obtained in 64 of 2936 admissions (2%) and were classified as contaminated urines (n=34), possible urinary tract infection (UTI) (n=14), definite UTI (n=10), and candidal UTI (n=6). Management was inconsistent. Two children required new assisted ventilation but no other complications occurred.

CONCLUSIONS

The diagnosis of UTI in NICU is hampered by use of urine collection methods that are subject to contamination. Outcome is generally excellent, but there is a great need for guidelines on management of positive urine cultures in the NICU.

Clinical characteristics of nosocomial infections in neonatal intensive care unit in eastern China

A retrospective cohort study on nosocomial infections (NI) in the neonatal intensive care unit (NICU) was performed in the Children's Hospital of Zhejiang University, Hangzhou district, China. The most common infection site was pneumonia and bloodstream infection. Low admission age, long NICU stay, and mechanical ventilation were significant risk factors for NI. Klebsiella pneumoniae was the most common pathogen, followed by Acinetobacter baumannii, Staphylococcus epidermidi, Pseudomonas aeruginosa, Enterobacter cloacae, and Stenotrophomonas maltophilia. Antibiotic resistance of the isolated bacterium was high. In conclusion, this study described the clinical characteristics of NI in a Chinese NICU, which might contribute to implementation of more effective therapeutic and preventive strategies.

A 6-year prospective surveillance of healthcare-associated infections in a neonatal intensive care unit from southern part of Turkey

AIM

To report the incidence of healthcare-associated infections (HAIs), site of infection and bacterial epidemiology in the Neonatal Intensive Care Unit in a university hospital in Adana, Turkey, between 2001 and 2006.

METHODS

During these years, HAIs were collected by an active surveillance system.

RESULTS

Five hundred one of 2832 infants hospitalised more than 72 h had 1124 HAI. The HAI incidence and incidence density ranged between 14.1 and 29.7 infections/100 patients, and 10.9-17.3 infections/1000 patient days within the study period; 61.5% of HAIs were ventilator-associated infections; 26.2% were bloodstream infections; 3.5% were urinary tract infections; 3.5% were necrotising enterocolitis (Stages II and III) and 1.4% was meningitis. The most frequent pathogens were gram-negative pathogens (75.6% of all infections) followed by gram-positive micro-organisms (21.4%) and Candida species (3.0%). Birthweight, gestational age and Apgar scores were lower and overall mortality rate (32.9% vs. 19.7%) and number of inpatient days were higher in patients with HAIs (for all P<0.001) when compared with those who did not have HAIs. Furthermore, HAI rate was inversely related to birthweight (P<0.001).

CONCLUSION

In this study, the overall infection rate is high compared with developed countries and predominant micro-organisms are gram-negative enteric rods. These results strongly suggest the need for improving measures for prevention and control of HAIs in this hospital.

Clinical microbiology of early-onset and late-onset neonatal sepsis, particularly among preterm babies

Prematurity has got special challenge for clinicians and also other medical staff, such as microbiologists. Immature host defense mechanisms support early-onset sepsis, which can be very serious with very high mortality. While the past decade has been marked by a significant decline in early-onset group B streptococcal (GBS) sepsis in both term and preterm neonates, the overall incidence of early-onset sepsis has not decreased in many centers, and several studies have found an increase in sepsis due to gram-negative organisms. With increasing survival of these more fastidious preterm infants, late-onset sepsis or specially nosocomial bloodstream infection (BSI) will continue to be a challenging complication that affects other morbidities, length of hospitalization, cost of care, and mortality rates. Especially the very low birthweight (VLBW) infants sensitive to serious systemic infection during their initial hospital stay. Sepsis caused by multiresistant organisms and Candida spp. are also increasing in incidence, has become the most common cause of death among preterm infants. This review focuses on the clinical microbiology of neonatal sepsis, particularly among preterm babies, summarizing the most frequent bacterial and fungal organisms causing perinatally acquired and also nosocomial sepsis.

Which factors predict hospital-acquired late-onset neonatal sepsis?

Neonates are one of the highest risk groups of hospitalized patients for sepsis. There is a wide variation in the incidence and microbial causes of late-onset neonatal sepsis, owing to differences in both patient populations and standards of care in the individual neonatal units. Stratification according to risk factors is required to allow the meaningful comparison of infection rates between units. Knowledge of risk factors is also important in order to target interventions on high-risk aspects of neonatal care. Few independent risk factors for late-onset sepsis have been identified, the most common being birth gestational age and parenteral nutrition. Further work is required to validate that these observations can be generalized, and that they could, therefore, be used to stratify infection rates in multicenter surveillance schemes.

Acinetobacter septicus sp. nov. association with a nosocomial outbreak of bacteremia in a neonatal intensive care unit

Acinetobacter species other than Acinetobacter baumannii have rarely been reported to be associated with nosocomial outbreaks of bloodstream infections. Within a period of 1 week, seven Acinetobacter-like isolates were recovered from peripheral blood and catheter specimens of five patients at a neonatal intensive care unit (NICU) in a tertiary hospital in Turkey. All five patients had placement of central venous catheters and had received total parenteral nutrition before the onset of bacteremia. Two of the five patients died. Medical devices, tap water, aerators, water samples, various surfaces, intravenous fluids, and the hands of health care workers in the NICU were sampled and were culture negative for the bacterium. All seven of the isolates had identical biochemical reactions, antimicrobial susceptibility results, and pulsed-field gel electrophoresis patterns, indicating a clonal nosocomial outbreak. A panel of standard biochemical reaction profiles and three phenotypic commercial identification systems failed to identify these isolates. Phenotypically, the isolate differed from Acinetobacter ursingii by its hemolysis on sheep blood agar and its negative citrate utilization. Sequences of the full 16S rRNA gene, which contained at least three different gene copies with polymorphic sequences between nucleotide positions 70 and 206, were determined from the first recovered isolate. The complete 1,529- to 1,531-bp 16S rRNA gene sequences and partial 801-bp rpoB gene sequences had similarities of 99.5% and 97.2%, respectively, to an A. ursingii isolate. The DNA-DNA similarities of the strain against the type strain of A. ursingii were 64.7 and 68.7%, which were lower than the recommended threshold value of 70% for the definition of bacterial species. These data indicate that a novel Acinetobacter organism caused the nosocomial outbreak of bacteremia in the NICU unit. We propose the designation of Acinetobacter septicus sp. nov. for these isolates, with isolate AK001 as the type strain.

Nosocomial infection in a newborn intensive care unit (NICU), South Korea

Background

This study aimed to determine the occurrence of nosocomial infections (NIs), including infection rates, main infection sites, and common microorganisms. Patients included in the study were taken from a newborn intensive care unit (NICU), in a hospital in South Korea.

Methods

A retrospective cohort study was performed by reviewing chart. The subjects were 489 neonates who were admitted to the NICU, survived longer than 72 hours, and not transferred to another unit, between Jan. 1. 1995 to Sep. 30, 1999. NIs were identified according to the NNIS definition. Data were analyzed with descriptive statistics.

Results

Cumulative incidence rate for NIs was 30.3 neonates out of 100 admissions, with a total of 44.6 infections. The incidence density was average 10.2 neonates and 15.1 infections per 1000 patient days. The most common infections were pneumonia (28%), bloodstream infection (26%), and conjunctivitis (22%). Major pathogens were Gram-positives such as Staphylococcus aureus and coagulase-negative staphylococci. The factors associated with NI was less than 1500 g of birth weight, less than 32 weeks of gestational age, and less than 8 of apgar score. There's no statistical difference in discharge status between two groups, but hospital stay was longer in subjects with nosocomial infection than those without infection.

Conclusion

Although the distribution of pathogens was similar to previous reports, a high rate of nosocomial infection and in particular conjunctivitis was observed in this study that merits further evaluation.