Risk factors for central vascular catheter-associated bloodstream infections among patients in a neonatal intensive care unit

Incidence and related factors of catheter-associated bloodstream infection in neonates: A systematic review and meta-analysis

OBJECTIVE

To identify the related factors of neonatal catheter-associated bloodstream infection (CABSI), and provide a basis for constructing a scientific and rational strategy for neonatal CABSI prevention.

METHODS

CNKI, Wanfang, PubMed, MEDLINE-Ovid, Web of Science, Embase, CINAHL, and Cochrane Library were searched for publications on neonatal CABSI from the time the database was established until September 30, 2023. The language of publications was not specified. Unpublished reports and gray studies were excluded. All cohort, case-control, and cross-sectional studies were included. A meta-analysis of the incidence and related factors of neonatal CABSI were made using Revman software. Heterogeneity was evaluated using the I2 statistic method, and the publication bias was analyzed with funnel plot tests.

RESULTS

A total of 35 studies involving 34,743 patients from 13 different countries were included. There were 15 case-control, 15 cohort, and 5 cross-sectional studies, with 14 related factors discussed. All the studies scored high (score ≥ 6) in their overall quality. According to the meta-analysis, the incidence of neonatal CABSI was 5.93/1000 catheter days (OR = 5.29). The risk factors were identified and ranked as follows according to the degree of influence: 5-minute Apgar score (OR = 4.69), the number of punctures during the stay of the line (OR = 3.49), male (OR = 3.17), mechanical ventilation (OR = 2.73), catheter repair (OR = 2.66), lower gestational age at birth (OR = 2.47), femoral vein catheter (OR = 1.92), dwell time of the catheter (OR = 1.34), and lower birth weight (OR = 1.05). Establishing sterile barrier throughout was a protective factor (OR = 0.41). Subgroup analysis suggested that the study design, catheter type and year of publication might be the primary sources of heterogeneity. The sensitivity analysis demonstrated the robustness of the results. However, the funnel plot indicated a potential publication bias.

CONCLUSION

Neonatal CABSI carries a significant morbidity rate and is influenced by numerous factors.

IMPLICATIONS FOR CLINICAL PRACTICE

It is crucial to underscore the necessity for additional longitudinal studies to explore evidence-based approaches to lowering the risk and ultimately reducing the incidence of CABSI. Registration The study protocol has been registered with the PROSPERO: CRD42023443697.

Long-term maintenance-related complications of brachiocephalic vein cannulations in neonates: A retrospective evaluation

BACKGROUND

Neonates are relatively prone to immediate, early, and late complications related to central venous cannulation (CVC). Ultrasound-guided brachiocephalic vein (BCV) cannulation has proven to be safe in neonates. Although studies addressed the immediate and early complications of CVC via BCV in neonates, few explored long-term maintenance-related complications.

AIMS

To evaluate the incidences of long-term maintenance-related complications including central line-associated blood stream infection (CLABSI), central line-associated thrombosis (CLAT), and mechanical complications (CLAMC) of nontunneled BCV cannulation in neonates and their relationship with patient and catheter-related factors.

METHODS

This study included BCV cannulations of neonates with postconceptional age of ≤44 weeks performed between January 2018 and January 2023. The incidences of complications were determined. Correlations between complications and postconceptional age, body weight, indication for catheter placement, the size and side of the catheter, as well as catheter dwell time were analyzed.

RESULTS

In total, 89 BCV cannulations performed in 71 neonates. The incidences were 19.3 [95%CI: 12.88-28.76] total complications, 5.9 [95%CI: 2.84-12.06] CLABSI, 3.4 [95%CI: 1.30-8.58] CLAT and 10.1 [95%CI: 5.76-17.49] CLAMC in 1000 catheter days. There were 23 (25.8%) total complications; 7 (7.9%) were CLABSI, 4 (4.5%) were CLAT, and 12 (13.5%) were CLAMC. The multivariate analysis revealed that prolonged dwell time was associated with high incidence of total complications [OR: 1.07, 95% CI: 1.00-1.14, p = .047] and the catheter of smaller size (3F in this study) was associated with higher incidence of CLABSI [OR: 8.91, 95% CI: 1.03-77.45, p = .047].

CONCLUSION

In this study, the prolonged dwell time and smaller sized catheter was found to be independent predictors of total complications and CLABSI, respectively. The independent predictive effects of postconceptional age and body weight should be addressed in larger studies as potential risk factors.

Cost-effectiveness of a new multi-lumen infusion device to reduce central-venous-line-associated bloodstream infections in neonates

BACKGROUND

A new medical device was developed for multi-infusion in neonatal intensive care units (NICUs) with the aim of addressing issues related to drug incompatibilities and central-line-associated bloodstream infections (CLABSIs).

AIM

To assess the cost-effectiveness of implementing this new perfusion system in an NICU setting.

METHODS

This single-centre, observational study was conducted in all infants admitted to the NICU within 3 days of birth, and who required a central venous line, to evaluate the cost and effectiveness before (2019) and after (2020) implementation of the new perfusion system. Costs were calculated from the hospital perspective, and the incidence of CLABSIs was examined over a time horizon from NICU admission to discharge. Resource utilization was measured (infusion device, infection-treating drugs and biological analyses), and corresponding costs were valued using tariffs for 2019. The incremental cost-effectiveness ratio (ICER) was calculated, expressed as Euros per CLABSI avoided, and one-way and multi-variate sensitivity analyses were conducted.

FINDINGS

Among 609 infants selected, clinical characteristics were similar across both periods. The CLABSI rate decreased significantly (rate ratio 0.22, 95% confidence interval 0.07-0.56), and total costs reduced from €65,666 to €63,932 per 1000 catheter-days (P<0.001) after implementation of the new perfusion system, giving an ICER of €251 saved per CLABSI avoided. The majority of sensitivity analyses showed that the new intervention remained economically dominant.

CONCLUSION

This single-centre study showed a significant decrease in the incidence of CLABSIs after implementation of the new perfusion system, without incurring additional costs. Further prospective multi-centre randomized studies are needed to confirm these results in other NICUs.

Is central line type an independent risk factor of central line-associated bloodstream infection in a neonatal intensive care unit population? Experiences at a pediatric hospital in South Texas

Background

Central line-associated bloodstream infection (CLABSI) causes significant harm in neonatal intensive care unit (NICU) patients. However, data regarding risk factors and prevention strategies for CLABSI in NICU patients is limited.

Objective

To examine risk factors for CLABSI in a NICU population, with particular interest in central line type and site placement.

Design

Retrospective case-control study.

Setting

NICU (Level IV, 67 bed) at a pediatric hospital in South Texas.

Participants

All central line insertions and subsequent CLABSI cases were extracted from the EHR for NICU admissions occurring from January 1, 2018, to November 3, 2022 (N = 1,356), along with potential CLABSI risk factors.

Methods

Central line insertions resulting in CLABSI (N = 35) were compared to instances without CLABSI (N = 1,321) using bivariate and multivariate analysis, with propensity score matching.

Results

Multivariate risk factors include implantable device (odds ratio [OR] = 14.5, P < .001), neck site placement (OR = 7.2, P < .001), and device dwell time (OR = 5.6, P = .001), as well as years 2021 (OR = 5.1, P = .017) and 2022 (OR = 5.9, P = .011). This indicates the odds of contracting CLABSI are 14.5 times higher when an implantable central line is used compared to the reference category (PICC devices). When cases are paired with matched controls, likelihood of CLABSI is 7.1% higher in patients with an implantable device than in similar patients with other central lines (p = 0.034).

Conclusions

Implantable central lines are an independent risk factor for CLABSI in NICU patients at this facility.

A new perfusion system to reduce the burden of central-venous-line-associated bloodstream infections in neonates

BACKGROUND

Central-venous-line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in preterm infants. As there is large variation in the reported effect of multi-modal preventive strategies, it could be relevant to propose new additional strategies.

AIM

To assess the impact of a new perfusion system on CLABSI rate.

METHODS

A before-and-after study was performed in infants born at <32 weeks of gestation or with birth weight <1500 g who required a multi-perfusion system connected to a central venous line. In the first 12-month period ('before'), the pre-existing perfusion system (multiple stopcocks) was used. An intervention period then occurred with implementation of a new perfusion closed system, without change in 'bundles' related to various aspects of central line care. During the second 12-month period ('after'), the CLABSI rate was assessed and compared with the pre-intervention period.

FINDINGS

In total, 313 infants were included in this study (before: N=163; after: N=150), and 46% had birth weight <1000 g. The change in perfusion system resulted in a significant decrease in CLABSI rate from 11.3 to 2.2 per 1000 catheter-days (P<0.001). The period was independently associated with an 88% reduction in the risk of CLABSI after implementation of the new perfusion system [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.03-0.39; P<0.001]. The duration of central line use was also associated with CLABSIs (for each additional day: OR 1.05, 95% CI 1.02-1.07; P<0.001).

CONCLUSIONS

Implementation of the new perfusion system was feasible in a large neonatal unit, and reduced the CLABSI rate soon after implementation.

Infectious Risks Related to Umbilical Venous Catheter Dwell Time and Its Replacement in Newborns: A Narrative Review of Current Evidence

The use of umbilical venous catheters (UVCs) has become the standard of care in the neonatal intensive care unit (NICU) to administer fluids, medications and parenteral nutrition. However, it is well known that UVCs can lead to some serious complications, both mechanical and infective, including CLABSI (Central Line-Associated Bloodstream Infections). Most authors recommend removing UVC within a maximum of 14 days from its placement. However, the last Infusion Therapy Standards of Practice (INS) guidelines recommends limiting the UVC dwell time to 7 to 10 days, to reduce risks of infectious and thrombotic complications. These guidelines also suggest as an infection prevention strategy to remove UVC after 4 days, followed by the insertion of a PICC if a central line is still needed. Nevertheless, the maximum UVC dwell time to reduce the risk of CLABSI is still controversial, as well as the time of its replacement with a PICC. In this study we reviewed a total of 177 articles, found by using the PubMed database with the following search strings: "UVC AND neonates", "(neonate* OR newborn*) AND (UVC OR central catheter*) AND (infection*)". We also analyze the INS guidelines to provide the reader an updated overview on this topic. The purpose of this review is to give updated information on CVCs infectious risks by examining the literature in this field. These data could help clinicians in deciding the best time to remove or to replace the UVC with a PICC, to reduce CLABSIs risk. Despite the lack of strong evidence, the risk of CLABSI seems to be minimized when UVC is removed/replaced within 7 days from insertion and this indication is emerging from more recent and larger studies.

Nutritional Considerations for the Neonate With Congenital Heart Disease

The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.

Central Venous Catheter-Related Infectious Complications in Pediatric Surgical Patients: A Single-Center Experience

The purpose of this study was to estimate the rate of central venous catheter (CVC) colonization and catheter-related bloodstream infections (CRBSIs) in pediatric surgical patients at our institute and to determine the various risk factors for their occurrence. The electronic medical records of 260 children undergoing surgery with simultaneous CVC insertion were retrospectively reviewed. Data on demographics, primary organ system involved, site of CVC, CVC dwell time, CVC colonization, CRBSI, and organisms isolated on culture were collated, categorized, and analyzed. The rate of CVC colonization and CRBSI was 32.8 per 1,000 catheter days (19.6%) and 17.4 per 1,000 catheter days (10.4%), respectively. Patients with CVC colonization and CRBSI had a significantly higher proportion of patients younger than 1 year of age (p = 0.014). The CVC dwell time was significantly higher in both CVC colonization (7 [5–8] days) and CRBSI (6 [5–9] days) patients (p = 0.005). The frequency of femoral catheterization was significantly higher in patients with CRBSI and CVC colonization (p < 0.001). Coagulase negative staphylococcus was the commonest isolate in CVC infections. Age (adjusted odds ratio [OR] = 0.87; p = 0.009), CVC dwell time (adjusted OR = 1.28; p = 0.003), and femoral CVC (adjusted OR = 9.61; p < 0.001) were independent risk factors for CRBSI. Conclusion: This study reveals important observations regarding the infectious complications of CVC in pediatric surgical patients. The rates of CVC colonization and CRBSI in this study were found to be higher as compared with previously reported rates in Western literature. However, these findings are significant in view of paucity of existing literature in pediatric surgical patients. In our study, higher risk of CRBSI was associated with younger age, increasing CVC dwell time, and femoral venous catheterization. We recommend strict compliance with CVC insertion and maintenance practices and adherence to CVC care bundles to minimize these serious complications.

Evaluating methods for the use and decontamination of needleless connectors: A qualitative inquiry

BACKGROUND

Needleless connectors (NCs) are essential devices designed to provide safe, needle-free connection between venous access devices, syringes and infusions. There is a variety of designs, and associated decontamination products and practices; the resulting confusion can cause detrimental patient outcomes. This study aimed to explore nurses' attitudes, techniques, and practices around the use and decontamination of NCs in clinical practice.

METHODS

Qualitative inquiry was conducted with seven focus groups of 4-6 participants each in the cancer and surgical units of a large tertiary hospital in Australia between January and March 2019. Participants comprised nurses who had taken part in a recent clinical trial of NC decontamination. Focus group sessions were recorded, transcribed and synthesised using content analysis.

RESULTS

Seven focus groups were conducted (total, N = 30 participants), lasting 16-20 min. Six major themes were identified surrounding needleless connector use and decontamination: 'safety and utility'; 'terminology and technological understanding'; 'clinical practice determinants'; 'decontamination procedures and influencers'; 'education and culture'; and 'research and innovation'.

CONCLUSION

The participants articulated positive attitudes towards needleless connector use for needle-stick and infection prevention, however rationales for care and maintenance practices demonstrated limited understanding of guidelines (e.g., disinfection time) and specific NC function (e.g., positive, negative pressure). The findings indicated the need for targeted, standardised needleless connector education, to enhance staff confidence, improve consistency of care and ensure patient safety.

Risk factors for umbilical vascular catheter-related adverse events: A scoping review

INTRODUCTION

Adverse events associated with umbilical catheters include malposition, bloodstream infections, thrombosis, tip migration, and extravasation, resulting in loss of vascular access and increased risk of morbidity and mortality. There is a need for greater understanding of risk factors associated with adverse events to inform safe practice.

OBJECTIVES

The aim of the study was to summarise the existing evidence regarding risk factors for umbilical catheter-related adverse events to inform the undertaking of future research.

REVIEW METHOD USED

A scoping review of peer-reviewed original research and theses was performed.

DATA SOURCES

The US National Library of Medicine National Institutes of Health, Embase, EMcare, and ProQuest Dissertations and Theses were the data sources.

REVIEW METHODS

Informed by the Joanna Briggs Institute Reviewer's Manual, all types of original research studies reporting adverse events published in English from 2009 to 2020 were eligible for inclusion. Studies where umbilical artery catheter and umbilical venous catheter data could not be extracted separately were excluded.

RESULTS

Searching identified 1954 publications and theses, 1533 were excluded at screening, and 418 were assessed for eligibility at full text. A total of 89 studies met the inclusion criteria. A range of potential risk factors for umbilical arterial and venous catheters were identified. Longer dwell time and prematurity were associated with increased risk of bloodstream infection and thrombosis in cohort studies. Case studies detailed analogous factors such as insertion techniques and lack of catheter surveillance during dwell warrant further investigation.

CONCLUSIONS

We identified a vast range of patient, device, and provider risk factors that warrant further investigation. There was a lack of large cohort studies and randomised controlled trials to demonstrate the significance of these risk factors. Improvement in methods to ensure correct catheter tip location and to detect adverse events early is essential. In addition, policy needs to be developed to guide clinicians in catheter surveillance measures to reduce the risk of adverse events.

Origin of Catheter-Related Bloodstream Infections Caused by Staphylococcus epidermidis in Critical Neonates

Bloodstream infection (BSI) remains the most frequent adverse event among premature infants worldwide, associated with increased hospital stay length and costs, poor outcomes, and even death. The aim of this study was to investigate the origin of catheter-related bloodstream infections (CR-BSIs) by Staphylococcus epidermidis in critical neonates, using molecular biology techniques. This was an observational study comprising neonates presenting BSI using central venous catheters (CVCs) for over 24 hours. Skin cultures obtained from the catheter insertion site, CVC hub, and neonate nasal and intestinal mucosa, were performed weekly from 48 hours from the beginning of the invasive procedure, as well as from the tip of the CVC after its withdrawal. Quantitative cultures were also performed of the tip with modifications and the “roll-plate” technique. Isolates identification were obtained using a VITEK II automated system. Molecular subtyping by pulsed-field gel electrophoresis (PFGE) was used to determine the origin of all BSIs. Among 19 primary BSI caused by S. epidermidis, BSI origin was defined in only 21.1% of the cases, where one was characterized as definite intraluminal, two as definite extraluminal, and one as translocation. Origin was indeterminate in 78.9% of the cases analyzed by PFGE. A total of 27 different genotype profiles were obtained. The spread of a prevalent clone in the unit (clone A) was detected in 28.6% of the samples. Most BSIs related to catheter caused by S. epidermidis were not able to prove the origin of most microorganisms present in neonate blood, demonstrating the difficulty in determining it in this population of patients. The lack of a better explanation of the origin of CR-BSI in neonates limits the direction of specific intervention measures.

Routine scrubbing reduced central line associated bloodstream infection in NICU

BACKGROUND

The main aim of this study was to estimate the effectiveness of routine scrubbing by change of the incidence of central line-associated bloodstream infections (CLABSI).

METHODS

We surveyed cultures from the NICU environment in December 2017. We found that areas close to infants harbored more bacteria. We implemented routine scrubbing to control sites with the most bacteria starting from January 2018. We retrospectively reviewed and compared the data between the pre (2017) and post (2018) intervention periods.

RESULTS

A total of 916 infants were included; 10 CLABSI episodes were identified, 9 and 1 episodes in the pre- and postintervention periods, respectively. We found that the incidence of CLABSI decreased significantly among all admitted infants (P = .006) and also among very low birth weight infants (P = .085). The number of CLABSI cases per 1,000 central line days decreased from 1.89 in 2017 to 0.23 in 2018 (P = .018). The most common bacterial species found in the cultures established from the NICU environment were identical to the CLABSI-causing coagulase-negative Staphylococcus.

CONCLUSIONS

Routine scrubbing significantly reduced CLABSI in the NICU.

Risk factors for central line-associated bloodstream infections in children with tunneled central venous catheters

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are among the most common complications of central venous catheters (CVCs). The aim of this study was to examine the epidemiology of CLABSIs in tunneled CVCs and analyze their risk factors in a general pediatric population.

METHODS

Children with a tunneled CVC inserted at the University Children's Hospital Zürich between January 2009 and December 2015 were eligible for the study. The influence of CVC dwell time on the risk of CLABSI was examined using life tables. Hazard ratios (HRs) for CLABSIs were analyzed using Cox regression for age and diagnosis with cluster robust standard errors.

RESULTS

Fifty-five CLABSIs were observed in 193 patients with 284 tunneled CVCs. Overall, CVCs in children with gastrointestinal disorders and in children 2 to 5 years of age showed the highest incidence rates of 6.06 and 5.85 CLABSIs per 1,000 catheter days, respectively, during the first 90 days after placement. Gastrointestinal disease (HR, 3.89; 95% CI, 2.19-6.90; P < .001) and age 2 to 5 years (HR, 2.48; 95% CI, 1.45-4.22; P = .001) were identified as independent risk factors for CLABSI. In children without gastrointestinal disease, tunneled CVCs showed an increasing risk of CLABSI after a dwell time of 90 days.

CONCLUSIONS

The need for tunneled CVCs requires the evaluation of targeted CLABSI prevention measures, especially in young children with underlying gastrointestinal disease.

Epidemiology and healthcare factors associated with neonatal enterococcal infections

OBJECTIVE

To investigate the epidemiology and healthcare factors associated with late-onset neonatal enterococcal infections.

DESIGN

Multicentre, multinational retrospective cohort study using prospectively collected infection data from a neonatal infection surveillance network between 2004 and 2016; this was supplemented with healthcare data from a questionnaire distributed to participating neonatal units.

SETTING

Sixty neonatal units across Europe (UK, Greece, Estonia) and Australia.

PATIENTS

Infants admitted to participating neonatal units who had a positive culture of blood, cerebrospinal fluid or urine after 48 hours of life.

RESULTS

In total, 414 episodes of invasive Enterococcus spp infection were reported in 388 infants (10.1% of a total 4083 episodes in 3602 infants). Enterococcus spp were the second most common cause of late-onset infection after coagulase-negative Staphylococcus spp and were strongly associated with necrotising enterocolitis (NEC) (adjusted OR 1.44, 95% CI 1.02 to 2.03, p=0.038), total parenteral nutrition (TPN) (adjusted OR 1.34, 95% CI 1.06 to 1.70, p=0.016), increasing postnatal age (per 1-week increase: adjusted OR 1.04, 95% CI 1.02 to 1.06, p<0.001) and decreasing birth weight (per 1 kg increase: adjusted OR 0.85, 95% CI 0.74 to 0.97, p=0.017). There was no evidence that inadequate nurse to patient staffing ratios in high-dependency units were associated with a higher risk of enterococcal infections.

CONCLUSIONS

Enterococcus spp were the second most frequent cause of late-onset infections. The association between enterococcal infections, NEC and TPN may inform empiric antimicrobial regimens in these contexts and provide insights into reducing these infections.

Risk Factors for Central Line-Associated Bloodstream Infection in Critically Ill Neonates

OBJECTIVE

To identify independent risk factors to develop a central line- associated bloodstream infection (CLABSI) in critically ill neonates with major underlying diseases.

METHODS

A nested case-control study was conducted in a neonatal intensive care unit (NICU). Patients with a central venous catheter (CVC) were included. Cases were neonates who developed a CLABSI and controls were patients without CLABSI. Variables included: perinatal history, characteristics of the catheter, installation and catheter use, surgical interventions, and hospital stay. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. X², Fisher exact, and Mann-Whitney U tests were used when appropriate. Variables with a p value ≤0.10 in the univariate analysis were introduced in a non-conditional logistic regression model.

RESULTS

Seventy four cases and 105 controls were analyzed. Univariate risk factors were: any surgery, abdominal surgery, length of hospitalization (≥14 d), double-lumen CVC, surgical cut-down technique, complications, CVC placement in internal jugular vein, dressing type, blood transfusions, parenteral nutrition, and number of CVC manipulations (>200). In the logistic regression analysis, independent risk factors with a p value <0.05 were: double-lumen catheter (OR 5.8, 95% CI 1.2-30), length of hospitalization ≥14 d (OR 4.6, 95% CI 1.8-11.4), abdominal surgery (OR 2.7, 95% CI 1.2-6.2) and blood transfusions (OR 2.5, 95% CI 1.2-5.3).

CONCLUSIONS

One risk factor was related to the catheter itself. Management of underlying diseases in specialized NICU contributes to a greater extent to the development of a central line-associated bloodstream infection.

Incidence of and associated factors for bacterial colonization of intravenous catheters removed from dogs in response to clinical complications

BACKGROUND

Infection rate associated with intravenous (IV) catheter placement is emerging as an important issue in small animal veterinary medicine, mostly because of the economic costs associated with these infections. Identification of possible associated factors may provide useful information for the surveillance and prevention of such infections.

OBJECTIVES

To determine the incidence of positive bacterial cultures obtained from IV catheters used in dogs hospitalized for at least 48 hours and removed because of clinical complication. To identify the bacteria involved and factors associated with bacterial colonization.

ANIMALS

One-hundred eighty-two dogs that underwent IV catheterization from January 2015 to July 2015 at the Veterinary Teaching Hospital of Alfonso X el Sabio University of Madrid were enrolled in the study.

RESULTS

The bacterial colonization rate of all IV catheters removed in response to clinical complications was 39.6%, the cumulative proportion of catheters that remained in place at 24, 48, and 72 hours after placement was 89.5, 78, and 59.4%, respectively. Multivariable Cox proportional hazards regression indicated significant associations for staff who performed catheterization (junior, P = .002; student, P = .034) and use of steroidal anti-inflammatory drugs (P = .036). The most frequently isolated bacterium was Acinetobacter spp. (21.7%).

CONCLUSIONS AND CLINICAL IMPORTANCE

The bacterial colonization incidence related to IV catheter placement was slightly higher than the incidence described in other veterinary studies. Associated factors not previously described in veterinary medicine were found. The most frequently isolated organism was Acinetobacter spp., indicating its importance as an emerging pathogen in catheter colonization.

Incidence of Fever and Positive Bacterial Cultures in Neonates Receiving Prostaglandin

Prostaglandin E (PGE₁) is necessary to maintain ductus arteriosus patency in many newborns with congenital heart disease. Because PGE₁ therapy commonly leads to fever, and given this population's fragile state, a complete sepsis workup is often performed in febrile, but otherwise asymptomatic, patients. This practice of liberal evaluation with bacterial cultures, empiric antibiotic treatment, and delays in essential surgical intervention may result in poor resource utilization and lead to increased iatrogenic morbidity. This study sought to determine the incidence of fever and culture-positive infection in patients receiving PGE₁, and identify diagnostic variables that predict culture-positive infection. The study included a single-center retrospective review of all neonates receiving PGE₁ between 2011 and 2014. Logistic regression and receiver operator characteristic analysis were used to identify significant predictors of positive bacterial cultures. Among 435 neonates, 175 (40%) had fevers (≥ 38.3 °C) while concurrently receiving PGE₁, but only 9 (2%) had culture-positive infection and 1 (< 1%) had culture-positive bacteremia. Among 558 cultures collected, only 16 (3%) had bacterial growth. Multivariable analysis revealed age (p = 0.049, AUC 0.604), hospital length of stay (p = 0.002, AUC 0.764) and hypoxemia (p = 0.044, AUC 0.727) as the only significant predictors of positive cultures. Fever (p = 0.998, AUC 0.424) was not a significant predictor. In conclusion, given that fever occurs frequently in neonates receiving PGE₁ and it is a very non-specific marker and not a predictor of positive cultures, the common practice of complete sepsis workup should be re-examined in febrile patients at low risk of bacterial illness.

Dwell time and risk of central-line-associated bloodstream infection in neonates

BACKGROUND

Umbilical venous catheters (UVCs) or peripherally inserted central catheters (PICCs), widely used in high-risk neonates, may have a threshold dwell time for subsequent increased risk of central-line-associated bloodstream infection (CLABSI).

AIM

To evaluate the CLABSI risks in neonates having either UVC, PICC, or those having both sequentially.

METHODS

The study included 3985 infants who had UVC or PICC inserted between 2007 and 2009 cared for in 10 regional neonatal intensive care units: 1392 having UVC only (group 1), 1317 PICC only (group 2), and 1276 both UVC and PICC (group 3).

FINDINGS

There were 403 CLABSIs among 6000 venous catheters inserted, totalling 43,302 catheter-days. CLABSI rates were higher in group 3 infants who were of lowest gestation (16.9 per 1000 UVC-days and 12.5 per 1000 PICC-days; median: 28 weeks) when compared with group 1 (3.3 per 1000 UVC-days; 37 weeks) and group 2 (4.8 per 1000 PICC-days; 30 weeks). Life table and Kaplan-Meier hazard analysis showed that UVC CLABSI rate increased stepwise to 42 per 1000 UVC-days by day 10, with the highest rate in group 3 (85 per 1000 UVC-days). PICC CLABSI rates remained relatively stable at 12-20 per 1000 PICC-days. Compared to PICC, UVC had a higher adjusted CLABSI risk controlled for dwell time. Among group 3, replacing UVC electively before day 4 may have a trend of lower CLABSI risk than late replacement.

CONCLUSION

There was no cut-off duration beyond which PICC should be removed electively. Early UVC removal and replacement by PICC before day 4 might be considered.

Bloodstream Infection Incidence of Different Central Venous Catheters in Neonates: A Descriptive Cohort Study

Central venous catheters (CVCs) in neonates are associated with a risk of central line-associated bloodstream infections (CLABSI). Most reports on the incidence of CLABSI in neonates focus on umbilical venous catheters (UVCs) and peripherally inserted central catheters (PICCs). We evaluated the incidence and risk factors for CLABSI in a cohort of neonates with femoral venous catheters (FVCs), UVCs, and PICCs, with a gestational age ≥34 weeks born between January 1, 2006 and June 30, 2013. We included 2,986 neonates with a total of 656 catheters. The CLABSI incidence rate varied from 12.3 per 1,000 catheter-days in FVCs to 10.6 per 1,000 catheter-days in UVCs and 5.3 per 1,000 catheter-days in PICCs. In a Kaplan-Meier survival analysis, we did not find a difference in CLABSI risk between the catheter types (p = 0.29). The following factors were independently associated with an increased risk of CLABSI: parenteral nutrition [hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.25-5.41], male gender (HR 2.63, 95% CI 1.17-5.90), and higher birth weight (HR 1.04, 95% CI 1.002-1.09), whereas antibiotic treatment at birth (HR 0.25, 95% CI 0.12-0.52) was associated with a decreased risk.

CONCLUSION

In our cohort, we did not find a difference between the CLABSI incidence in FVCs, PICCs, and UVCs. Occurrence of CLABSI is associated with parenteral nutrition, male gender, and higher birth weight. Antibiotic treatment at birth was associated with a decreased risk of CLABSI.

CLABSI Risk Factors in the NICU: Potential for Prevention: A PICNIC Study

OBJECTIVE Central-line-associated bloodstream infections (CLABSI) are an important cause of morbidity and mortality in neonates. We aimed to determine whether intra-abdominal pathologies are an independent risk factor for CLABSI. METHODS We performed a retrospective matched case-control study of infants admitted to the neonatal intensive care units (NICUs) of the Montreal Children's Hospital (Montreal) and the Royal Alexandra Hospital, Edmonton, Canada. CLABSI cases that occurred between April 2009 and March 2014 were identified through local infection control databases. For each case, up to 3 controls were matched (National Healthcare Safety Network [NHSN] birth weight category, chronological age, and central venous catheter (CVC) dwell time at the time of CLABSI onset). Data were analyzed using conditional logistic regression. RESULTS We identified 120 cases and 293 controls. According to a matched univariate analysis, the following variables were significant risk factors for CLABSI: active intra-abdominal pathology (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.8-6.4), abdominal surgery in the prior 7 days (OR, 3.5; 95% CI, 1.0-10.9); male sex (OR, 1.7; 95% CI, 1.1-2.6) and ≥3 heel punctures (OR, 4.0; 95% CI, 1.9-8.3). According to a multivariate matched analysis, intra-abdominal pathology (OR, 5.9; 95% CI, 2.5-14.1), and ≥3 heel punctures (OR, 5.4; 95% CI, 2.4-12.2) remained independent risk factors for CLABSI. CONCLUSION The presence of an active intra-abdominal pathology increased the risk of CLABSI by almost 6-fold. Similar to CLABSI in oncology patients, a subgroup of CLABSI with mucosal barrier injury should be considered for infants in the NICU with active intra-abdominal pathology. Infect Control Hosp Epidemiol 2016;1446-1452.

Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?

OBJECTIVE

Infants in neonatal intensive care units (NICUs) are vulnerable to a variety of infections, and occupancy in the unit may correlate with risk of infection.

STUDY DESIGN

A retrospective cohort of infants admitted to the NICUs between 1997 and 2014. Survival analysis was used to model the relative hazard of sepsis infection in relation to two measures of occupancy: 1) the average census and 2) proportion of infants <32 weeks gestation in the unit.

RESULT

There were 446 (2.3%) lab-confirmed cases of bacterial or fungal sepsis, which steadily declined over time. For each additional percentage of infants <32 weeks gestation, there was an increased hazard of 2% (hazard ratio 1.02, 95% confidence interval: 1.00, 1.03) over their NICU hospitalization. Census was not associated with risk for infection.

CONCLUSION

During times of a greater proportion of infants <32 weeks gestation in the NICU, enhanced infection-control interventions may be beneficial to further reduce the incidence of infections.

Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants

BACKGROUND AND OBJECTIVE

Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI.

METHODS

Retrospective cohort study of 13,327 infants with 15,567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256,088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type.

RESULTS

Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1.

CONCLUSIONS

Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates

BACKGROUND

Neonatal parenteral nutrition may be delivered via peripheral cannulas or central venous catheters (umbilical or percutaneous). As the result of complications associated with umbilical catheters, many neonatal units prefer to use percutaneous catheters after initial stabilisation. Although they can be difficult to place, these catheters may be more stable than peripheral cannulae and require less frequent replacement. These delivery methods may be associated with different risks of adverse events, including acquired invasive infection and extravasation injury.

OBJECTIVES

To determine the effects of infusion of parenteral nutrition via percutaneous central venous catheters versus peripheral cannulae on nutrient input, growth and development and complications among hospitalised neonates receiving parenteral nutrition in terms of adverse consequences such as bacteraemia or invasive fungal infection, cardiac tamponade or other extravasation injuries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1966 to June 2015) and EMBASE (1980 to June 2015), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised controlled trials that compared delivery of intravenous fluids (primarily parenteral nutrition) via percutaneous central venous catheters versus peripheral cannulae in hospitalised neonates.

DATA COLLECTION AND ANALYSIS

We extracted data using standard methods of the Cochrane Neonatal Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We found six trials recruiting a total of 549 infants. One trial showed that use of a percutaneous central venous catheter was associated with a smaller deficit between prescribed and actual nutrient intake during the trial period (mean difference (MD) -7.1%, 95% confidence interval (CI) -11.02 to -3.2). Infants in the percutaneous central venous catheter group needed significantly fewer catheters/cannulae (MD -4.3, 95% CI -5.24, -3.43). Meta-analysis of data from all trials revealed no evidence of an effect on the incidence of invasive infection (typical risk ratio (RR) 0.95, 95% CI 0.72 to 1.25; typical risk difference (RD) -0.01, 95% CI -0.08 to 0.06).

AUTHORS' CONCLUSIONS

Data from one small trial suggest that use of percutaneous central venous catheters to deliver parenteral nutrition increases nutrient input. The significance of this in relation to long-term growth and developmental outcomes is unclear. Three trials suggest that use of percutaneous central venous catheters decreases the number of catheters/cannulae needed to deliver nutrition. No evidence suggests that percutaneous central venous catheter use increases risks of adverse events, particularly invasive infection, although none of the included trials was large enough to rule out an effect on uncommon severe adverse events such as pericardial effusion.

Antimicrobial-impregnated central venous catheters for prevention of catheter-related bloodstream infection in newborn infants

BACKGROUND

Central venous catheter-related bloodstream infection is an important cause of mortality and morbidity in newborn infants cared for in neonatal units. Potential strategies to prevent these infections include the use of central venous catheters impregnated with antimicrobial agents.

OBJECTIVES

To determine the effect of antimicrobial-impregnated central venous catheters in preventing catheter-related bloodstream infection in newborn infants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 8), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing central venous catheters impregnated or coated with any antibiotic or antiseptic versus central venous catheters without antibiotic or antiseptic coating or impregnation in newborn infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Group, with independent evaluation of risk of bias and data extraction by two review authors.

MAIN RESULTS

We found only one small trial (N = 98). This trial found that silver zeolite-impregnated umbilical venous catheters reduced the incidence of bloodstream infection in very preterm infants (risk ratio 0.11, 95% confidence interval 0.01 to 0.87; risk difference -0.17, 95% CI -0.30 to -0.04; number needed to treat for benefit 6, 95% CI 3 to 25].

AUTHORS' CONCLUSIONS

Although the data from one small trial indicates that antimicrobial-impregnated central venous catheters might prevent catheter-related bloodstream infection in newborn infants, the available evidence is insufficient to guide clinical practice. A large, simple and pragmatic randomised controlled trial is needed to resolve on-going uncertainty.

Bloodstream infections: epidemiology and resistance

Bloodstream infections in the neonatal intensive care unit (NICU) are associated with many adverse outcomes in infants, including increased length of stay and cost, poor neurodevelopmental outcomes, and death. Attention to the insertion and maintenance of central lines, along with careful review of when the catheters can be safely discontinued, can minimize central-line-associated bloodstream infections rates. Good antibiotic stewardship can further decrease the incidence of bloodstream infections, minimize the emergence of drug-resistant organisms or Candida as pathogens in the NICU, and safeguard the use of currently available antibiotics for future infants.

Prevention of healthcare-associated infections in neonates: room for improvement

Infants in neonatal intensive care units (NICUs) are highly susceptible to infection due to the immaturity of their immune systems. Healthcare-associated infections (HCAIs) are associated with prolonged hospital stay, and represent a significant risk factor for neurological development problems and death. Improving HCAI control is a priority for NICUs. Many factors contribute to the occurrence of HCAIs in neonates such as poor hand hygiene, low nurse–infant ratios, environmental contamination and unnecessary use of antibiotics. Prevention is based on improving neonatal management, avoiding unnecessary use of central venous catheters, restricting use of antibiotics and H2 blockers, and introducing antifungal prophylaxis if necessary. Quality improvement interventions to reduce HCAIs in neonates seem to be the cornerstone of infection control.

Cohort Study of the Pathogenesis and Molecular Epidemiology of Catheter-Related Bloodstream Infection in Neonates With Peripherally Inserted Central Venous Catheters

Objective.

To better define the pathogenesis of catheter-related bloodstream infection (BSI) in neonates with peripherally inserted central venous catheters (PICCs) to guide the development of more effective strategies for prevention.

Design.

Prospective nested cohort study.

Setting.

Level III neonatal intensive care unit in a community hospital.

Methods.

During a randomized trial to assess the safety and efficacy of a prophylactic vancomycin-heparin catheter-lock solution for the prevention of catheter-related BSI in neonates with PICCs, we performed cultures of peripheral and catheter-drawn blood samples, and quantitative cultures of catheter hub samples if BSI was suspected clinically. We performed semiquantitative cultures of the catheter tip and the catheter hub and the skin at the insertion site when the catheter was removed. Molecular subtyping by pulsed-field electrophoresis was used to determine the probable pathogenesis of all BSIs due to coagulase-negative staphylococci (CoNS); for BSIs caused by other microorganisms, epidemiologic concordance was based on speciation and antibiograms. Catheter-related BSI was considered extraluminally acquired if concordance was demonstrable solely between isolates recovered from the catheter tip and the blood, independent of concordance with isolates recovered from the insertion site. Catheter-related BSI was considered intraluminally acquired if concordance was demonstrated only between isolates recovered from the catheter hub and the blood. The source of the infection was considered indeterminate if both concordance patterns were present.

Results.

Nosocomial BSI was identified in 23 of the 82 neonates in the cohort. Fifteen of these infections, 14 of which were caused by CoNS, were considered definite or probable catheter-related BSIs. Catheter-related BSI was intraluminally acquired in 10 (67%) of 15 patients, extraluminally acquired in 3 (20%), and indeterminate in 2 (13%).

Conclusions.

Most catheter-related BSIs in neonates with PICCs are caused by CoNS and derive from intraluminal contamination. Strategies for prevention of catheter-related BSI directed at this predominant mechanism of infection are most likely to be effective.

Use of Central Venous Catheter and Peripheral Venous Catheter as Risk Factors for Nosocomial Bloodstream Infection in Very-Low-Birth-Weight Infants

Objective.

To describe the relationship between the use of central and peripheral venous catheters and the risk of nosocomial, primary, laboratory-confirmed bloodstream infection (BSI) for neonates with a birth weight less than 1,500 g (very-low-birth-weight [VLBW] infants).

Methods.

Cox proportional hazard regression analysis with time-dependent variable was used to determine the risk factors for the occurrence of BSI in a cohort of VLBW infants. We analyzed previously collected surveillance data from the German national nosocomial surveillance system for VLBW infants. All VLBW infants in 22 participating neonatal departments who had a complete daily record of patient information were included.

Results.

Of 2,126 VLBW infants, 261 (12.3%) developed a BSI. The incidence density for BSI was 3.3 per 1,000 patient-days. The multivariate analysis identified the following significant independent risk factors for BSI: lower birth weight (hazard ratio [HR], 1.1–2.2), vaginal delivery (HR, 1.5), central venous catheter use (HR, 6.2) or peripheral venous catheter use (HR, 6.0) within 2 days before developing BSI, and the individual departments (HR, 0.0–4.6).

Conclusions.

After adjusting for other risk factors, use of peripheral venous catheter and use of central venous catheter were significantly related to occurrence of BSI in VLBW infants.

Validation of nosocomial infection in neonatology: a new method for standardized surveillance

BACKGROUND

Nosocomial infections (NIs) are a leading cause of mortality and morbidity in premature infants. We present a new method for detecting and confirming NIs in a neonatal intensive care unit.

METHODS

Newborns with birth weight < 1,500 g or gestational age (GA) < 33 weeks were included prospectively over 2 years in a single-center tertiary neonatal intensive care unit. The computerized physician order entry system (CPOE) generated alerts when antibiotics were prescribed for at least 5 consecutive days and these cases were reviewed by an expert group following international recommendations.

RESULTS

Four hundred sixty-one neonates were included, with a mean GA of 30 weeks (range, 26-32 weeks) and mean birth weight 1,270 g (range, 950-1600 g). The CPOE flagged 158 cases of potential NI, 85.1% of which were classified as true NI and 14.9% of which were false positive. Incidence and device-associated nosocomial bloodstream infection rates were 21.9% and 10.8 per 1,000 central venous catheter days, respectively. GA ≤ 28 weeks (odds ratio, 2.18; 95% confidence interval, 1.2-4) and > 7 central venous catheter days (odds ratio, 1.47; 95% confidence interval, 1.3-1.7) were independently associated with the risk of nosocomial bloodstream infection.

CONCLUSION

Combining CPOE and interdisciplinary review may improve the accuracy of NI recording in a neonatal intensive care unit.

Complications associated with parenteral nutrition in the neonate

Although parenteral nutrition (PN) is life-sustaining, it is associated with many complications including parenteral nutrition-associated liver disease (PNALD) and central line-associated bloodstream infections (CLASBIs), which carry a high morbidity and mortality and impose a burden on the health care system. Evidence has emerged that the dose and composition of intravenous lipid products may alter the incidence of PNALD. However, other patient and PN-related factors, such as prematurity, birth weight, and gastrointestinal anatomy and function, are important. To improve neonatal care, future research on optimizing the content of PN and decreasing the incidence IFALD and CLASBIs is required.

Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study

OBJECTIVE

To determine whether the daily risk of central line-associated bloodstream infections (CLABSIs) increases over the dwell time of peripherally inserted central catheters (PICCs) in high-risk neonates.

METHODS

Multicenter retrospective cohort including NICU patients with a PICC inserted between January 2005 and June 2010. We calculated incidence rates and used Poisson regression models to assess the risk of developing CLABSI as a function of PICC dwell time.

RESULTS

A total of 4797 PICCs placed in 3967 neonates were included; 149 CLABSIs occurred over 89,946 catheter-days (incidence rate 1.66 per 1000 catheter-days). In unadjusted analysis, PICCs with a dwell time of 8 to 13 days, 14 to 22 days, and ≥23 days each had an increased risk of infection compared with PICCs in place for ≤7 days (P < .05). In adjusted analysis, the average predicted daily risk of CLABSIs after PICC insertion increased during the first 2 weeks after PICC insertion and remained elevated for the dwell time of the catheter. There was an increased risk of CLABSIs in neonates with concurrent PICCs (adjusted incidence rate ratio 2.04, 1.12-3.71). The incidence of Gram-negative CLABSIs was greater in PICCs with dwell times >50 days (incidence rate ratio 5.26, 2.40-10.66).

CONCLUSIONS

The risk of CLABSIs increased during the 2 weeks after PICC insertion and then remained elevated until PICC removal. Clinicians should review PICC necessity daily, optimize catheter maintenance practices, and investigate novel CLABSI prevention strategies in PICCs with prolonged dwell times.

Incidence and risk factors for catheter-associated bloodstream infections in neonatal intensive care

AIM

To determine the incidence and potential novel risk factors for catheter-associated bloodstream infections (CABSI) in neonates.

METHODS

A retrospective study was conducted for infants admitted to the VU University Medical Center neonatal intensive care unit in 2007.

RESULTS

One hundred and ninety six infants with a total of 369 central catheters were included. The CABSI rate was 18.1 infections/1000 catheter-days (95% CI 13.7-23.8) according to adjusted criteria used by the Centers for Disease Control and Prevention prior to 2008. Umbilical catheters had a higher infection rate than nonumbilical central catheters: rate ratio (rate ratio 2.4, 95% CI 1.2-4.9). Longer umbilical catheter dwell-time also increased infection rate (p < 0.05). Gestational age, birth weight, duration of parenteral nutrition and the administration of all-in-one feeding mixture versus parenteral nutrition administered in separate components were not related to infection rate in multivariate analysis.

CONCLUSION

Of all catheter types, umbilical catheters carried the highest infection rate. Longer umbilical catheter dwell-time also increased infection rate. The present data suggest that the impact of gestational age and birth weight on infection rate is mainly due to a prolonged hospital stay. The composition, way of preparation and duration of parenteral nutrition did not seem to influence infection rate.

Peripherally inserted central venous catheters in critically ill premature neonates

PURPOSE

To evaluate the safety of peripherally inserted central venous catheters (PICCs) and their complications in critically ill premature neonates.

METHODS

A retrospective collection of data of infants with very low birth weight (VLBW) who underwent PICC placement over a 2-year period. Gestational age, birth weight (BW), sex, site of catheter placement, reason for catheter removal, duration of the catheter use, proven sepsis, type of the reported organism and the rate of complications were collected. The infants were classified into two groups according to BWs: Group 1-VLBW infants (BW between 1,000 and 1,500 g) and Group 2-BW <1,000 g (extremely low birth weight, ELBW group).

RESULTS

During the study period, 90 VLBW infants were admitted to the neonatal intensive care unit. PICCs were attempted in 71 patients. A PICC was successfully inserted into 62 patients (87.3%). Totally, 68 PICCs were inserted into 62 infants. PICCs placed in either the upper or the lower extremity have no differences in complication rates. The median time of catheter insertion was 10 (1-22) days for Group 1 and 16 (1-47) days for Group 2 (p=0.001). The median duration of PICCs was 9 (2-18) and 12.0 (3-30) days, respectively (p=0.012). There were no significant differences between groups for the reasons for removal (p=0.859).

CONCLUSIONS

PICCs are convenient for the administration of long course antibiotics and parenteral nutrition for both VLBW and ELBW infants. The risk of catheter complications did not increase in ELBW infants. Although the technique of insertion is easy and using PICCs has many benefits, serious and fatal complications may occur in premature neonates in critical states.

Complications of peripherally inserted central venous catheter in Japanese neonatal intensive care units

BACKGROUND

The aim of this study was to investigate the incidence and risk factors of peripherally inserted central venous catheter (PICC)-related complications using a multicenter case survey.

METHOD

A prospective cohort study was carried out by 19 neonatal intensive care units (NICUs) in Japan from February 2005 to March 2007. A total of 975 case records were collected. PICC-related complications including pericardial effusion/cardiac tamponade pleural effusion/ascites, catheter removal difficulties, catheter-related bloodstream infection (CR-BSI), and symptomatic catheter-related thrombosis were collected from case record forms. As for precautions during insertion, institutions were classified into three groups: those with maximum barrier precautions; standard precautions; and no specific precautions.

RESULTS

PICC complications occurred in 27 cases (2.9%) among 946 PICC. The incidence was 1.6% for CR-BSI, and 0.1% for cardiac tamponade. CR-BSI rate per 1000 catheter-days was 1.1 with maximum barrier precautions at catheter insertion, 1.2 with standard precautions, and 1.8 with no specific precautions. Multiple logistic regression analysis showed that proximal placement (odds ratio [OR], 3.88; 95% confidence interval [CI]: 1.42-10.60, P = 0.008) and longer placement duration (OR, 1.35; 95%CI: 1.14-1.60, for each week, P = 0.0005) independently contributed to overall complications.

CONCLUSION

The incidence of cardiac tamponade was rare in this multicenter prospective study. Longer duration and proximal placement may be risk factors for PICC complications. In this cohort, the CR-BSI rate was low irrespective of the degree of barrier precautions at insertion.

[Neonatal liver abscess after umbilical venous catheter]

INTRODUCTION

The use of an umbilical venous catheter (UVC) is common practice in neonatal units and is subjected to strict rules of insertion and monitoring to detect potential complications. Hepatic abscess is one of these rare complications.

OBSERVATION

We report the observation of a 15-day-old female newborn admitted for a hepatic abscess. The patient had been hospitalized at birth in a neonatal intensive care unit. With the appearance of hemodynamic instability on the 4th day of life, a nosocomial infection was suspected and was treated with ceftazidime, vancomycin and amikacin. Later, as the need for O(2) increased and plasma C-reactive protein (CRP) was 190 mg/L, the patient received imipenem and vancomycin, while an abdominal ultrasound examination showed a hepatic abscess. A triple antibiotic treatment was initiated with imipenem, vancomycin, and metronidazole, while the initial examination showed a clinically stable patient with a CRP at 208 mg/L. Abdominal ultrasounds showed a hepatic abscess measuring 53.4×24.9 mm on day 21 and 51.4 mg/L CRP. Then the abscess dimensions decreased to 35.7×14 mm. The antibiotic therapy was maintained for 4 weeks.

CONCLUSION

Hepatic abscess should be suspected in neonates with UVC with sepsis and persistent signs of inflammation in spite of adequate antibiotic treatment.

Healthcare - associated infections: A public health problem

Disinfection and sterilization in hospitals, is of increasing concern. Nosocomial infections can be defined as those occurring within 48 hours of hospital admission, 3 days of discharge or 30 days of an operation. They affect 1 in 10 patients admitted to hospital. Nosocomial infections are associated with a great deal of morbidity, mortality, and increased financial burden

Evidence-based approach to preventing central line-associated bloodstream infection in the NICU

AIM

To review care practices and methods of implementation that reduce the risk of central line-associated bloodstream infection (CLABSI).

METHODS

Medical and quality improvement-oriented literature was reviewed.

RESULTS

Although effective catheter practices, equipment and staff training methods are available to reduce CLABSI, their implementation is often difficult.

CONCLUSION

A successful CLABSI reduction programme requires not only identification of best practices but also understanding of the specific context or unit culture into which they will be introduced.

Strategies for prevention of health care-associated infections in the NICU

Health care-associated infections in the NICU result in increased morbidity and mortality, prolonged lengths of stay, and increased medical costs. Neonates are at high risk of acquiring health care-associated infections because of impaired host-defense mechanisms, limited amounts of protective endogenous flora on skin and mucosal surfaces at time of birth, reduced barrier function of their skin, use of invasive procedures and devices, and frequent exposure to broad-spectrum antibiotic agents. This clinical report reviews management and prevention of health care-associated infections in newborn infants.

Catheter management in neonates with bloodstream infection and a percutaneously inserted central venous catheter in situ: removal or not?

BACKGROUND

This study investigated whether removal of a percutaneously inserted central venous catheter (PICC) is compulsory in neonates with bloodstream infection (BSI), and also examined the risk factors for infectious complications when a PICC is retained in these patients.

METHODS

This was a cohort study of neonates with a PICC who developed a BSI between 2001 and 2007. BSI was defined according to Centers for Disease Control and Prevention criteria.

RESULTS

Of the 234 neonates in the cohort, 99 had early removal of PICC (ER-PICC, defined as removal within 3 days after the onset of clinical sepsis), and 135 had late removal of PICC (LR-PICC, defined as retention for more than 3 days after the onset of clinical sepsis). Resolution of clinical sepsis within 2 days was more frequent in the ER-PICC group compared with the LR-PICC group (80.8% vs 57.8%; P < .001). There was no significant difference between the 2 groups in terms of infectious complications and case fatalities, but the LR-PICC group had a significantly higher incidence of recurrence within 1 month after BSI (P = .002). Inappropriate initial antibiotic treatment was the only variable independently associated with infectious complications (odds ratio, 11.4; 95% confidence interval, 3.34∼39.2; P < .001).

CONCLUSIONS

PICCs should be removed in neonates with BSI, because retention of PICCs for more than 3 days is associated with delayed resolution of clinical sepsis and a higher incidence of recurrence within 1 month.

Complications associated with 2 different types of percutaneously inserted central venous catheters in very low birth weight infants

OBJECTIVE

To identify the prevalence and risk factors for complications associated with percutaneously inserted central venous catheters (PICCs) and evaluate the effect of different catheter types and their indwelling time on catheter-related complications.

DESIGN

Retrospective cohort study.

SETTING

A 49-bed neonatal intensive-care teaching hospital in Taiwan.

PATIENTS

Between 2004 and 2007, 518 single-lumen PICCs (defined as "old type") and 290 PICCs with a stiffening stylet and a thicker introducer ("new type") were inserted in a total of 534 neonates with a birth body weight of 1,500 g or less.

RESULTS

Independent risk factors of catheter-related sepsis (CRS) were longer duration for PICC placement and PICC inserted at femoral site (compared with nonfemoral sites) (odds ratio [OR], 1.53 [95% confidence interval {CI}, 1.07-2.25]; P = .044). An independent predictor of catheter-related noninfectious complications was time spent for PICC insertion of more than 60 minutes (compared with less than 30 minutes) (OR, 1.96 [95% CI, 1.08-3.53]; P = .026). New-type PICCs were significantly associated with a higher rate of femoral site insertion, catheter-related noninfectious complications, and longer time for successful insertion than old-type PICCs. The hazard rates of CRS according to indwelling time, determined over 5-day periods by survival analysis, showed 0.05% for catheters in place for 4 days or less; 0.27% for 5-9 days; 0.40% for 10-14 days; 0.68% for 15-19 days; 1.18% for 20-24 days; 3.96% for 25-29 days; and 10.45% for 30 or more days.

CONCLUSIONS

Different catheters do influence the complication rates. Spending more than 60 minutes for successful PICC insertion and PICCs indwelling for more than 30 days are associated with higher rates of catheter-related complications.