Preventing nosocomial bloodstream infection in very low birth weight infants

Cost Analysis of Fluconazole Prophylaxis for Prevention of Neonatal Invasive Candidiasis

BACKGROUND

Fluconazole prophylaxis (FP) in premature infants is well studied and has been shown to decrease invasive candidiasis (ICs). IC in neonates has significant financial costs; determining the cost-benefit of FP may provide additional justification for targeting high-risk neonates. We aimed to determine the IC rate in premature infants at which FP is cost-beneficial.

METHODS

A decision tree cost-analysis model using cost of FP related to costs associated with IC was used. We searched PubMed for all papers that used intravenous FP and reported rates of IC in very low birth weight neonates. Average IC rates in those who received FP (2.0%; range, 0-6.1%) and in those who did not receive FP (9.2%; range, 0-20.5%) were used. Incremental hospital costs because of IC and for FP were retrieved from the literature. Sensitivity analysis was performed to determine the incremental cost of FP across the range of published IC rates.

RESULTS

The average cost per patient attributed to IC in patients receiving FP was $785 versus $2617 in those not receiving FP. Sensitivity analysis demonstrates the rate of IC would need to be <2.8% for FP to lose its cost-benefit. In Monte Carlo simulation, targeting infants <1000 g would lead to $50,304,333 in cost savings per year in the United States.

CONCLUSIONS

FP provides a cost-advantage across most IC rates seen in the youngest premature infants. Using a rate of 2.8% for their individual high-risk neonatal intensive care unit patients, providers can determine if FP is cost-beneficial in determining for whom to provide IC prophylaxis.

A multicentred clinical improvement project among preterm population evaluation of current practices

Sepsis, a potentially life-threatening infection, is a common complication related to the use of central venous catheters (CVCs) in the preterm infant population. Best practice guidelines include successful strategies to prevent infections. Central venous catheter use is a fairly recent intervention in Finnish neonatal intensive care units (NICUs). As part of a quality improvement project to evaluate catheter-related care practices, 4 NICUs collaborated in a multicenter, multiprofessional study aimed at decreasing the incidence of catheter-related sepsis among a population of preterm infants. This article describes the initial phase that evaluated current protocols and practices. The findings were that current protocols need revision to include more detailed and accurately focused instructions on infection prevention associated with CVC. Many challenges in performing certain procedures with catheters were found. Precis CVC protocols and practices in 4 Finnish NICUs were reviewed for infection control measures.

A silver-alginate-coated dressing to reduce peripherally inserted central catheter (PICC) infections in NICU patients: a pilot randomized controlled trial

OBJECTIVE

Our aim was to evaluate the safety of a silver-alginate-containing dressing to reduce peripherally inserted central catheter (PICC) infections in neonatal intensive care unit (NICU) patients.

STUDY DESIGN

Patients were randomized 3:1 to receive a patch containing silver, alginate and maltodextrin or standard of care. Patches were placed under the regular transparent retention dressing at the PICC exit site at insertion and were replaced with every dressing change at least every 2 weeks until PICC discontinuation. All study infants were monitored for adverse skin reactions.

RESULT

A total of 100 infants were followed up for 1922 person-days, including 75 subjects with 89 PICCs who received the patch. The median birth weight (1330 g) and median gestational age (30 weeks) was lower in the patch group when compared with the controls (P=0.001 and 0.005, respectively). Study patients received the patch with their PICC at a median age of 5 days; the patch stayed in place for a median of 13 days. We noted no adverse skin reactions and found no evidence that the patch alters the microbiology of PICC-associated infections.

CONCLUSION

This pilot trial suggests that silver-alginate-coated dressings are skin safe and their inclusion in future trials aimed at reduction of PICC-associated bloodstream infections in the NICU should be considered.

Population pharmacokinetics of cefepime in the neonate

Newborn infants cared for in neonatal intensive care units may develop nosocomial infections. Cefepime, a "fourth-generation" cephalosporin (i.e., with activity against virtually all of the chromosomal-beta-lactamase-producing and many extended-spectrum-beta-lactamase-producing organisms), provides excellent activity against many gram-negative pathogens resistant to expanded-spectrum cephalosporins currently used to treat neonatal infections. The purpose of this study was to determine the pharmacokinetics of cefepime in this population to optimize dosing and minimize potential adverse events. Premature and term infants <4 months of age hospitalized in two neonatal intensive care units were studied. Limited pharmacokinetic (PK) sampling occurred following a dose of cefepime at 50 mg/kg of body weight infused over 30 min. Population pharmacokinetic parameters were determined using the program NONMEM. Fifty-five infants were enrolled. Their average (+/- standard deviation) gestational age at birth was 30.5 +/- 5.3 weeks, and their average postnatal age at PK evaluation was 14.5 +/- 14.7 days. In the final PK model, cefepime clearance (CL) was strongly associated with serum creatinine (SCr) (CL [ml/min/kg] = 0.26 + 0.59/SCr). The volume of distribution for infants with a postconceptional age of <30 weeks was larger than that for infants with a postconceptional age of >30 weeks (0.51 versus 0.39 liter/kg, respectively). The Bayesian analysis-predicted cefepime trough concentration at a dose of 50 mg/kg every 12 h for infants < or = 14 days of age was 29.9 +/- 16.6 microg/ml. Cefepime, dosed at 30 mg/kg/dose every 12 h for infants less than 14 days of age, regardless of gestational age, should provide antibiotic exposure equivalent to or greater than 50 mg/kg every 8 h in older infants and children.

Antimicrobial-resistance and enterotoxin-encoding genes among staphylococci isolated from expressed human breast milk

Resistance traits and the presence of enterotoxin-encoding genes were investigated in staphylococcus isolates obtained from expressed human breast milk. A total of 54 staphylococcal isolates identified as Staphylococcus epidermidis (53.6 %), Staphylococcus warneri (20.4 %), Staphylococcus haemolyticus (13 %) and Staphylococcus aureus (13 %) were investigated. By using a disc-diffusion method, higher rates of resistance, including intermediate resistance, were observed for penicillin (87 %) and erythromycin (59.3 %). All strains were susceptible to clindamycin and vancomycin. Minimal inhibitory concentration (MIC) was determined by a macrodilution method for four clinically relevant antimicrobial drugs. High rates of resistance or intermediate resistance were observed for erythromycin, gentamicin and oxacillin. Additionally, three isolates showed reduced susceptibility to vancomycin (MIC, 8 microg ml(-1)). Genetic determinants of resistance were detected by using PCR and the results showed good correlation with the macrodilution tests. Moreover, in four staphylococcus isolates, the presence of enterotoxin-encoding genes (seg, seh and sea) was identified. The results demonstrated that expressed human breast milk can be a reservoir of multiresistant staphylococci that may also harbour important virulent determinants.

Antibiotic resistance: is the end of an era near?

Any attempt to shape the world and modify human personality in order to create a self-chosen pattern of life involves many unknown consequences. Human destiny is bound to remain a gamble, because at some unpredictable time and in some unforeseen manner, nature will strike back.