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 Unpublished reports and gray studies were excluded.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.

Central and peripheral line-associated bloodstream infections in Victorian neonatal intensive care units: findings from a comprehensive Victorian surveillance network, 2008-2024

BACKGROUND

Neonates face a high risk of healthcare-associated bloodstream infections, leading to increased morbidity and mortality. Effective surveillance is crucial for safe neonatal care and infection prevention.

AIM

This study aimed to evaluate infection trends, pathogen distribution, and antimicrobial resistance patterns in central and peripheral line-associated bloodstream infections (CLABSIs and PLABSIs) in Victorian Level 6 neonatal intensive care units between July 1st, 2008, and June 30th, 2024.

METHODS

Data were collected by the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre using CDC National Healthcare Safety Network guidelines. A retrospective data analysis of prospectively collected data was conducted to examine infection epidemiology.

FINDINGS

Overall, 581 neonates developed CLABSIs or PLABSIs, corresponding to a mean CLABSI rate of 2.26 per 1,000 central line-days and a mean PLABSI rate of 0.60 per 1,000 peripheral line-days. The median age at diagnosis of all events was 16 days (IQR 9-35 days). No trends were observed in CLASBI or PLABSI rates over the study period. However, an increasing trend in CLABSI rates (IRR: 1.04, 95% CI: 1.00, 1.07, p = 0.043) and a decreasing trend in PLABSI rates (IRR: 0.95, 95% CI: 0.92, 0.99, p = 0.021) were noted among neonates with birth weight ≤750g. The most frequently reported organism was coagulase-negative Staphylococcus, responsible for 44.0% of CLABSIs and 39.5% of PLABSIs.

CONCLUSION

NICUs in Victoria have maintained low CLABSI and PLABSI rates over the study period. Higher infection rates in low-birth-weight neonates emphasize the need for targeted infection prevention strategies for this vulnerable population.

Influence of gastric residual assessment in preterm neonates on time to achieve enteral feeding (the GRASS trial)-Multi-centre, assessor-blinded randomised clinical trial

PURPOSE

Gastric residual measurement is routinely performed in premature infants prior to feeding despite a lack of evidence of benefit. We aimed to evaluate if the exclusion of routine gastric residual measurement and evaluation has an impact on the time taken to achieve full enteral feeding in preterm neonates.

METHODS

International multi-centre randomised controlled trial. Clinically stable, appropriate for gestational age infants between 26+0 and 30+6 weeks of gestation and less than 1.5 kg birth weight were eligible. Infants were randomised to the intervention arm (no monitoring of gastric aspirates) or control arm (routine care). Primary outcome was the achievement of enteral feeds of 100 ml/kg/day by day 5 of life.

RESULTS

Ninety-five infants were recruited with 88 included in an intention-to-treat analysis, 45 in the intervention arm and 43 in the control arm. There was no imbalance in baseline characteristics. Thirty-three (73.3%) infants in the intervention group and 32 infants (74.4%) in the control group reached full feeds by day 5 of life (p = 0.91) with no difference in median time to full feeds. There were no statistically significant differences in survival or the major morbidities of prematurity.

CONCLUSION

 There was no difference in time to attainment of enteral feeds of 100 ml/kg/day in premature infants when gastric residuals were not monitored. In the absence of a clinical benefit to routine monitoring, it may be appropriate to discontinue this practice and only monitor residuals when clinical concern of feeding intolerance or gastrointestinal pathology arises in this group of patients.

TRIAL REGISTRATION

 NCT03111329- https://clinicaltrials.gov/ . Registered 06/04/2017.

WHAT IS KNOWN

• Previous randomized trials have shown little benefit to the performance of routine assessment of gastric residuals in preterm infants. Despite this, they continue to be performed due to concerns from observational data regarding development of NEC. Meta-analysis to date has failed to answer the question regarding NEC.

WHAT IS NEW

• In very low birth weight infants who are fed using modern feeding practice of faster feed advancement, to minimize use of central access and parenteral nutrition, exclusion of routine checks of gastric residuals did not increase the proportion of infants reaching full enteral feeds by day 5. No harm was seen when residual checks were not performed. • In the absence of a clinical benefit to the routine performance of gastric residuals in very low birth weight infants, it may be appropriate to discontinue their use and instead check residuals when clinical concern of pathology arises.

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.

Risk of catheter-associated bloodstream infection by catheter type in a neonatal intensive care unit: a large cohort study of more than 1100 intravascular catheters

BACKGROUND

The aim of this study was to evaluate the risk of catheter-associated bloodstream infection (CABSI) among different catheter types using a large prospective database in the neonatal intensive care unit (NICU) of a tertiary care centre in Switzerland.

METHODS

We included all neonates admitted to the NICU with at least one central intravascular catheter inserted between January 2017 and December 2020. We used marginal Cox model to determine the risk of CABSI among different catheter types.

RESULTS

A total of 574 neonates and 1103 intravascular catheters were included in the study: 581 venous umbilical catheters, 198 arterial umbilical catheters and 324 peripherally inserted central catheters (PICCs). We identified 17, four and four CABSIs in neonates with venous umbilical catheters, arterial umbilical catheters and PICCs, respectively. The risk of CABSI increased after two days of umbilical catheter maintenance. Using univariable Cox models, and adjusting for sex and gestational age, we observed a similar CABSI risk between venous and arterial umbilical catheters (HR 0.57; 95% CI 0.16e2.08). Birth weight was associated with CABSI, with higher weight being protective (HR 0.37, 95% CI 0.16e0.81).

CONCLUSIONS

Strategies aimed at reducing umbilical catheter dwell time, particularly in low and very low birth weight neonates, may be effective in decreasing the incidence of CABSI in this population.

Risk factors of acute kidney injury in very low birth weight infants in a tertiary neonatal intensive care unit

OBJECTIVE

Acute kidney injury (AKI) in the neonatal period is associated with worst outcomes as increased mortality and increased length of hospital stay. Very low birth weight (VLBW) newborns are at higher risk for developing several other conditions that are associated with worst outcomes. Understanding the risk factors for AKI may help to prevent this condition and improve neonatal care for this population.

METHODS

This retrospective cohort study included 155 very low birth weight newborns admitted between 2015 and 2017. The authors compared the newborns who developed neonatal AKI with the non-AKI group and analyzed the main risk factors for developing AKI in the population. The authors also performed an analysis of the main outcomes defined as the duration of mechanical ventilation, length of stay, and death.

RESULTS

From the cohort, a total of 61 (39.4%) patients had AKI. The main risk factors associated with Neonatal AKI were necrotizing enterocolitis (aOR 7.61 [1.69 - 34.37]; p = 0.008), neonatal sepsis (aOR 2.91 [1.17 - 7.24], p = 0.021), and hemodynamic instability (aOR 2.99 [1.35 - 6.64]; p = 0.007). Neonatal AKI was also associated with an increase in the duration of mechanical ventilation in 9.4 days (p = 0.026) and in an increase in mortality 4 times (p = 0.009), after adjusting for the other variables.

CONCLUSION

The present results highlight the importance of minimizing sepsis and necrotizing enterocolitis, as well as the importance of identifying hemodynamic instability, to prevent AKI and diminish the burden of morbimortality in VLBW newborns.

Healthcare-associated Infections in Very Low Birth-weight Infants in a South African Neonatal Unit: Disease Burden, Associated Factors and Short-term Outcomes

BACKGROUND

Infection is a leading cause of death among very low birth-weight (VLBW) infants in resource-limited settings.

METHODS

We performed a retrospective review of healthcare-associated infection (HAI) episodes among VLBW infants from January 1, 2016, to December 31, 2017. The epidemiology, causative organisms and short-term outcomes were analyzed. Logistic regression was used to investigate for factors associated with development of HAI.

RESULTS

During the study period, 715 VLBW infants with suspected HAI were investigated, including 162/715 (22.7%) proven and 158/715 (22.1%) presumed HAI. Of the proven infections, 99/162 (61.1%) contained at least one Gram-negative organism per blood culture; 84/162 (51.9%) single Gram-negative organisms and 15/162 (9.3%) polymicrobial growth. Independent factors associated with development of any HAI included low gestational age, small for gestational age, indwelling central venous catheter and invasive ventilation. Compared with infants in whom HAI had been excluded, infants with HAI were more likely to be diagnosed with necrotizing enterocolitis (5.6% vs. 23.1%; P &lt; 0.001) and bronchopulmonary dysplasia (1.0% vs. 4.4%; P = 0.007). Infants with any HAI also had a longer hospital stay [44 (25-65) vs. 38 (26-53) days; P &lt; 0.001] and increased mortality [90/320 (28.1%) vs. 21/395 (5.3%); P &lt; 0.001] compared with infants who did not develop HAI episodes.

CONCLUSIONS

Proven and presumed HAI are a major contributor to neonatal morbidity and mortality; further research is urgently needed to better understand potential targets for prevention and treatment of HAI in resource-limited neonatal units.

Preventable contributors to the neonatal healthcare-associated infections: a uni-center analytical study from South India

BACKGROUND

Globally, neonatal healthcare-associated infections (HAIs) are known to cause high mortality. HAIs is a preventable condition related to the healthcare environment. The current study explored the contributors to neonatal HAIs in one of the largest tertiary care referral hospitals in South India.

METHODS

Neonates from December 2016 to June 2018 were observed for the occurrence of healthcare-associated infections and compared with the matched control group. Various observations on neonatal demography, maternal contributors, and medical procedures were made and recorded to explore and analyse the contributors to neonatal HAIs. Univariate and multivariate analysis was carried out to find the contributors. The Odds ratio with 95% CI was also computed and reported.

RESULTS

Bloodstream infection (83%) was prevalent among neonates; the maternal contributor was only preterm labor (Odds ratio of 11.93; 95% CI; 6.47-21.98; p<.05) to acquire HAIs. On univariate analysis, mechanical ventilation for > 3days duration, NIV for > five days, and PICC line insertion procedure were significant (p<0.05) contributors to neonatal HAIs. IV cannulation for more than three times in four consecutive days was found in 100(85%) neonates considered being associated with neonatal HAIs. On multivariate analysis, NIV, PICC line, preterm labor, and low birth weight were significant (p<0.05) contributors to neonatal HAIs.

CONCLUSION

The increased duration of invasive and non-invasive therapeutic devices and catheters contributes to neonatal HAIs. Neonates are acquiring bloodstream infections; low birth weight (LBW) neonates are more susceptible to acquiring HAIs.

The road to zero nosocomial infections in neonates-a narrative review

Aim

Nosocomial infections (NI) in neonates are associated with prolonged hospitalisation, adverse neurodevelopmental outcome and high mortality. Over the past decade, numerous prevention strategies have resulted in significant reductions in NI rates. In this review, we aim to provide an overview of current NI rates from large, geographically defined cohorts.

Methods

PubMed, Web of Science, EMBASE and Cochrane Library were searched for evidence regarding epidemiology and prevention of NI in neonates. Extracted studies were synthesised in a narrative form with experiential reflection.

Results

Despite the abundance of geographically defined incidence proportions, an epidemiological overview of NI is difficult to provide, given the lack of consensus definition for neonatal NI and different baseline populations being compared. Successful prevention efforts have focused on implementing evidence‐based practices while eliminating outdated strategies. The most promising model for reduction in infection rates is based on quality improvement (QI) collaboratives and benchmarking, involving identification and implementation of best practices, selection of measurable outcomes and fostering a sense of community and transparency.

Conclusion

The preventative rather than curative approach forms the new paradigm for reducing the burden of neonatal infections. Despite progress achieved, continued work towards improved prevention practices is required in the strive towards zero NIs.

The appropriate frequency of dressing for percutaneous central venous catheters in preventing catheter-related blood stream infection in NICU - A randomized controlled trial

BACKGROUND

Complications of percutaneous central venous catheters (PCVCs) include catheter-related blood stream infection (CRBSI), occlusion, leakage, and phlebitis, which may lead to sepsis or prolonged hospitalization. The primary objective of this randomized controlled trial was to determine the appropriate frequency of dressing for percutaneous central venous catheters in preventing CRBSI, every week regularly vs. non-regularly, in premature neonates in NICU.

METHODS

Patients in NICU requiring PCVCs from March 2019-May 2020 were enrolled. Enrolled patients were randomly assigned into 2 groups: regular dressing group (RD), for which dressings were changed every week regularly, or additionally when oozing was noticed; and non-regular dressing group (ND), for which dressings were changed only when oozing was visible. The incidence of CRBSI, occlusion, leakage, and phlebitis were compared between the two groups using the Chi-squared test. The incidence of catheter-related complications was defined as numbers of episodes per 1000 catheter-days.

RESULTS

A total of 197 PCVCs were enrolled. The ND and RD groups had 99 and 98 PCVCs, respectively. The average CD interval was 9.3 days in ND group and 5.8 days in RD group. The incidence of CRBSI in RD group was 0‰, which was significantly lower than that of ND group, which was 2.0‰ (p = 0.048), but no significant differences were found between groups in the incidence of occlusion, leakage, and phlebitis of PCVCs.

CONCLUSION

Regular dressing changes every week and when oozing occurs while maintaining the protocol of maximum sterile barrier precautions is the best method and frequency of dressings of PCVCs.

Influence of Parenteral Nutrition Delivery Techniques on Growth and Neurodevelopment of Very Low Birth Weight Newborns: A Randomized Trial

Background and Objectives: In very low birth weight (VLBW) newborns, parenteral nutrition (PN) is delivered via a peripheral venous catheter (PVC), a central venous catheter (CVC), or a peripherally inserted central venous catheter (PICC). Up to 45% of PICCs are accompanied by complications, the most common being sepsis. A PVC is an unstable PN delivery technique requiring frequent change. The growth and neurodevelopment of VLBW newborns may be disturbed because of catheters used for early PN delivery and complications thereof. The aim of the conducted study was to evaluate the effect of two PN delivery techniques (PICC and PVC) on anthropometric parameters and neurodevelopment of VLBW newborns. Materials and Methods: A prospective randomized clinical trial was conducted in VLBW (≥750–<1500 g) newborns that met the inclusion criteria and were randomized into two groups: PICC and PVC. We assessed short-term outcomes (i.e., anthropometric parameters from birth until corrected age (CA) 36 weeks) and long-term outcomes (i.e., anthropometric parameters from CA 3 months to 12 months as well as neurodevelopment at CA 12 months according to the Bayley II scale). Results: In total, 108 newborns (57 in the PICC group and 51 in the PVC group) were randomized. Short-term outcomes were assessed in 47 and 38 subjects, and long-term outcomes and neurodevelopment were assessed in 38 and 33 subjects of PICC and PVC groups, respectively. There were no differences observed in anthropometric parameters between the subjects of the two groups in the short- and long-term. Mental development index (MDI) < 85 was observed in 26.3% and 21.2% (p = 0.781), and psychomotor development index (PDI) < 85 was observed in 39.5% and 54.5% (p = 0.239) of PICC and PVC subjects, respectively. Conclusions: In the short- and long-term, no differences were observed in the anthropometric parameters of newborns in both groups. At CA 12 months, there was no difference in neurodevelopment in both groups.

Preventive bundles to reduce catheter-associated bloodstream infections in neonatal intensive care

This systematic survey includes a total of 27 studies published between 2002 and 2016 on the benefit of preventive bundles for the prevention of central-line associated bloodstream infections (CLABSI) in neonatal intensive care. These studies are mainly cohort studies or studies analyzing an interrupted time series before and after intervention. The studies showed heterogeneity in terms of endpoint definitions (CLABSI), details of the implemented measures, and evidence of a publication bias favoring the use of of preventive bundles. The cumulative analysis showed a statistically and clinically significant benefit of preventive bundles to avoid CLABSI in neonatal intensive care.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review

OBJECTIVE

This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population.

DATA SOURCE

The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified.

DATA SYNTHESIS

A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs.

CONCLUSION

Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

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.

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.

The Implementation of an Evidence-Based Bundle for Bloodstream Infections in Neonatal Intensive Care Units in Germany: A Controlled Intervention Study to Improve Patient Safety

OBJECTIVE

To improve the patient safety of very-low-birthweight infants in neonatal departments in Germany.

DESIGN

Multicenter cohort study with a baseline (24 months), an intervention (12 months), and a postinterventional follow-up period (12 months) and time series analysis.

STUDY POPULATION

Very-low-birthweight patients from 32 neonatal departments in Germany.

METHODS

Neonatal departments showing a standardized infection ratio of bloodstream infection 10% higher than the expected number (standardized infection ratio ≥1.1) were invited to participate in the study. To reduce the occurrence of primary bloodstream infections, evidence-based bundles to improve catheter maintenance routines, insertion practice, and hand-hygiene compliance were implemented in the participating infirmaries.

RESULTS

Thirty-four departments participated in the study and 32 reported data. In total, 6,222 very-low-birthweight infants with 231,868 patient-days and 1,405 cases of bloodstream infections were analyzed. In the baseline period the pooled mean bloodstream infection rate was 6.63 (95% CI, 6.17–7.12) per 1,000 patient-days. The bloodstream infection rate decreased in the intervention period to 5.68 (relative risk, 0.86 [95% CI, 0.76–0.97]) and in the 1-year follow-up period to 5.31 per 1,000 patient-days (relative risk, 0.80 [95% CI, 0.70–0.92]). The multivariable time series analysis of monthly aggregated data showed a significant change in the slope for the frequency of bloodstream infections from the start to the end of the intervention (change in slope incidence rate ratio, 0.97; P=.001).

CONCLUSION

The implementation of an intervention bundle is feasible and can reduce bloodstream infections in neonatal departments.

Infect Control Hosp Epidemiol 2016;37:798–804

Surface modification of a polyethylene film for anticoagulant and anti-microbial catheter

A functional anticoagulant and anti-bacterial coating for polyethylene (PE) films is described. The stepwise preparation of this nanocomposite surface coating involves O2 plasma etching of PE film, carbodiimide coupling of cysteamine to the etched PE film, binding of Ag to sulfhydryl groups of cysteamine, and assembly of heparin capped AgNPs on the PE film. The nanocomposite film and its components were characterized by 1H-nuclear magnetic resonance spectroscopy, attenuated total reflectance-Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, and field emission-scanning electron microscopy. The resulting PE films demonstrate anticoagulant activity using a hemoglobin whole blood clotting assay, and anti-bacterial activity against Bacillus cereus 3551 (Gram-positive) and Escherichia coli BL21 (Gram-negative) bacteria. The hydrophilicity of the heparin coated PE was determined by contact angle measurements; and the stability of the nanocomposite film, with respect to Ag leaching, was assessed by atomic absorption spectroscopy.

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.

Update on infection control challenges in special pediatric populations

PURPOSE OF REVIEW

Compared with adults, neonatal and pediatric populations are especially vulnerable patients who have specific diagnostic and therapeutic differences; therefore, the standard infection control practices designed for adults are sometimes not effective or need modifications to work. This review focuses on the recent literature addressing the challenges and successes in preventing healthcare-associated infections (HAIs) in children.

RECENT FINDINGS

Improving the implementation of pediatric versions of preventive bundles focusing on proper catheter insertion and maintenance, mainly as a part of a larger multimodal strategy, is effective in reducing the central-line-associated bloodstream infections in neonatal and pediatric populations including oncology patients. Appropriate feeding, antimicrobial stewardship, and infection control measures should be combined in reducing necrotizing enterocolitis in preterm neonates. Implementing a multimodal bundle strategy adapted for pediatric population is successful in preventing ventilator-associated pneumonia. Appropriate use of antimicrobial prophylaxis remains the cornerstone for preventing surgical-site infections irrespective of age, with few additional effective adjuvant preventive practices in specific pediatric patients.

SUMMARY

Several evidence-based practices are effective in reducing the incidence and the impact of HAIs in children; however, proper implementation remains a challenge. Additionally, several adult preventive practices are still unestablished in children and need further thorough examination.

Incidence, clinical characteristics and risk factors for adverse outcome in neonates with late-onset sepsis

BACKGROUND

Late-onset sepsis (LOS) is a common complication in the neonatal intensive care unit. We aimed to describe the epidemiology, clinical characteristics and risk factors for adverse outcome in neonates with LOS.

METHODS

We conducted a cohort study of all neonates with LOS at the neonatal intensive care unit of a Tertiary Taiwan Medical Center from January 2004 through December 2011 and used multivariate logistic regression to identify risk factors for final adverse outcome.

RESULTS

Among 5010 neonates over 253,644 neonate-days, 713 (14.2%) experienced a total of 942 episodes of LOS (incidence rate, 3.71 episodes per 1000 neonate-days). Although the rates of LOS were inversely proportional to birth weight and gestational age, the incidence rates were comparable among extremely preterm, late preterm and full term neonates. Fungemia was found to have significantly higher rate of infectious complication (30.8%), persistent bloodstream infection (19.2%) and sepsis attributable mortality (23.1%). The overall mortality rate was 12.6% (90/713), and sepsis attributable mortality rate was 7.2% (68/942 episodes). Independent predictors of in-hospital mortality were Pseudomonas LOS (adjusted odds ratio [OR], 14.31; 95% confidence interval [CI]: 3.87-53.0), fungemia (OR, 5.69; 95% CI: 2.48-13.01), presence of congenital anomalies (OR, 4.12; 95% CI: 1.60-10.60), neuromuscular comorbidities (OR, 3.34; 95% CI: 1.66-6.73) and secondary pulmonary hypertension with/without cor pulmonale (OR, 23.48; 95% CI: 5.96-92.49).

CONCLUSIONS

LOS predisposes hospitalized neonates to increased risk of mortality or morbidity, especially caused by Pseudomonas aeruginosa or Candida spp. More aggressive treatment strategy is worth consideration in neonates with presumed LOS, particularly those with certain underlying chronic conditions.

Improving patient safety during insertion of peripheral venous catheters: an observational intervention study

BACKGROUND

Peripheral venous catheters are frequently used in hospitalized patients but increase the risk of nosocomial bloodstream infection. Evidence-based guidelines describe specific steps that are known to reduce infection risk. However, the degree of guideline implementation in clinical practice is not known. The aim of this study was to determine the use of specific steps for insertion of peripheral venous catheters in clinical practice and to implement a multimodal intervention aimed at improving both compliance and the optimum order of the steps.

METHODS

The study was conducted at University Hospital Hamburg. An optimum procedure for inserting a peripheral venous catheter was defined based on three evidence-based guidelines (WHO, CDC, RKI) including five steps with 1A or 1B level of evidence: hand disinfection before patient contact, skin antisepsis of the puncture site, no palpation of treated puncture site, hand disinfection before aseptic procedure, and sterile dressing on the puncture site. A research nurse observed and recorded procedures for peripheral venous catheter insertion for healthcare workers in four different departments (endoscopy, central emergency admissions, pediatrics, and dermatology). A multimodal intervention with 5 elements was established (teaching session, dummy training, e-learning tool, tablet and poster, and direct feedback), followed by a second observation period. During the last observation week, participants evaluated the intervention.

RESULTS

In the control period, 207 insertions were observed, and 202 in the intervention period. Compliance improved significantly for four of five steps (e.g., from 11.6% to 57.9% for hand disinfection before patient contact; p<0.001, chi-square test). Compliance with skin antisepsis of the puncture site was high before and after intervention (99.5% before and 99.0% after). Performance of specific steps in the correct order also improved (e.g., from 7.7% to 68.6% when three of five steps were done; p<0.001). The intervention was described as helpful by 46.8% of the participants, as neutral by 46.8%, and as disruptive by 6.4%.

CONCLUSIONS

A multimodal strategy to improve both compliance with safety steps for peripheral venous catheter insertion and performance of an optimum procedure was effective and was regarded helpful by healthcare workers.

Central line-associated bloodstream infection in neonatal intensive care units

OBJECTIVE

Describe the epidemiology of central line-associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) participating in a standardized and mandatory CLABSI surveillance program.

DESIGN

Retrospective cohort. Setting. We included patients admitted (April 2007-March 2011) to 7 level II/III NICUs who developed a CLABSI (as defined by the National Healthcare Safety Network).

METHODS

CLABSIs/1,000 central line-days and device utilization ratio were calculated; χ(2) test, Student t test, Kruskal-Wallis, and Poisson regression were used.

RESULTS

Overall, 191 patients had 202 CLABSI episodes for a pooled mean rate of 4.0 CLABSIs/1,000 central line-days and a device utilization ratio of 0.20. Annual pooled mean CLABSI rates increased from 3.6 in 2007-2008 to 5.1 CLABSIs/1,000 central line-days in 2010-2011 (P - .01). The all-cause 30-day case fatality proportion was 8.9% (n = 17) and occurred a median of 8 days after CLABSI. Coagulase-negative Staphylococcus was identified in 112 (50.5%) cases. Staphylococcus aureus was identified in 22 cases, and 3 (13.6%) were resistant to methicillin. An underlying intra-abdominal pathology was found in 20% (40/202) of CLABSI cases, 50% of which were reported in the last year of study. When adjusted for mean birth weight, annual CLABSI incidence rates were independently associated with the proportion of intra-abdominal pathology (P = .007) and the proportion of pulmonary pathology (P = .016) reported.

CONCLUSION

The increase in CLABSI rates in Quebec NICUs seems to be associated with an increased proportion of cases with underlying intra-abdominal and pulmonary pathologies, which needs further investigation.

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.

Assessment of orally dosed commercial silver nanoparticles on human ex vivo platelet aggregation

Enhanced in vitro human and ex vivo rat platelet aggregation from direct exposure to silver nanoparticles is previously reported. Given the increasing human use of engineered silver nanoscale products, platelet aggregation prompted by silver nanoparticles may contribute to human cardiovascular events. To understand how direct washed platelet exposure to silver nanoparticles translates to ex vivo platelet aggregation, the authors conducted a placebo-controlled, single-blind, dose-monitored, cross-over study design in 18 healthy human volunteers. After 2 weeks of daily oral silver nanoparticle ingestion, platelet aggregation was evaluated by light transmission aggregometry in response to collagen and ADP agonists, both at baseline and after silver nanoparticle or placebo diluent oral dosing. Final percent aggregation (PA) and the changes in PA were determined using a paired design (i.e., active and placebo solutions). Enhanced ex vivo platelet activation was not detectable at peak serum silver concentrations <10 µg/L. Further studies of colloidal silver nanoparticles on human platelet activities are warranted.

The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates - results of nation-wide cohort study in Germany

Background

Very low birthweight (VLBW) newborns on neonatal intensive care units (NICU) are at increased risk for developing central venous catheter-associated bloodstream infections (CVC BSI). In addition to the established intrinsic risk factors of VLBW newborns, it is still not clear which process and structure parameters within NICUs influence the prevalence of CVC BSI.

Methods

The study population consisted of VLBW newborns from NICUs that participated in the German nosocomial infection surveillance system for preterm infants (NEO-KISS) from January 2008 to June 2009. Structure and process parameters of NICUs were obtained by a questionnaire-based enquiry. Patient based date and the occurrence of BSI derived from the NEO-KISS database. The association between the requested parameters and the occurrance of CVC BSI and laboratory-confirmed BSI was analyzed by generalized estimating equations.

Results

We analyzed data on 5,586 VLBW infants from 108 NICUs and found 954 BSI cases in 847 infants. Of all BSI cases, 414 (43%) were CVC-associated. The pooled incidence density of CVC BSI was 8.3 per 1,000 CVC days. The pooled CVC utilization ratio was 24.3 CVC-days per 100 patient days. A low realized staffing rate lead to an increased risk of CVC BSI (OR 1.47; p=0.008) and also of laboratory-confirmed CVC BSI (OR 1.78; p=0.028).

Conclusions

Our findings show that low levels of realized staffing are associated with increased rates of CVC BSI on NICUs. Further studies are necessary to determine a threshold that should not be undercut.

Intake of own mother's milk during the first days of life is associated with decreased morbidity and mortality in very low birth weight infants during the first 60 days of life

BACKGROUND

The incidence of necrotizing enterocolitis (NEC) and possibly also of sepsis is lower in preterm infants fed their own mother's milk (hereafter 'mother's milk') compared with formula-fed infants. It is unclear whether this is caused by the protective properties of breast milk or by the absence of cow's milk. Especially in early life, mother's milk is often unavailable to preterm infants, while minimal enteral nutrition is initiated immediately.

OBJECTIVES

To determine whether there is an association between intake of mother's milk during the first days of life and the combined outcome of sepsis, NEC and death over a prolonged period.

METHODS

Retrospective study in infants with a birth weight <1,500 g. Intake of mother's milk and formula during the first 10 days of life was recorded. The occurrence of sepsis, NEC and death was registered during the first 60 days. Data were analysed using Cox regression analysis, taking confounders into account.

RESULTS

In total, 349 infants were included. Intake of mother's milk during the first 5 days of life was associated with a lower incidence of NEC, sepsis and/or death during the first 60 days of life (hazard ratio (HR) in the category 0.01-50% intake of mother's milk: 0.49, 95% confidence interval (CI) 0.28, 0.87; HR in the category 50.01-100% intake of mother's milk: 0.50, 95% CI 0.31, 0.83, both compared to no mother's milk). During days 6-10, the protective effect was only present if >50% of the total intake was mother's milk (HR = 0.37, 95% CI 0.22, 0.65).

CONCLUSION

The type of enteral nutrition during the first 10 days of life is associated with the risk of NEC, sepsis and/or death during the first 60 days of life.

Knowledge and practices regarding prevention of infections associated with central venous catheters: a survey of intensive care unit medical and nursing staff

BACKGROUND

Infections associated with central venous catheters (CVCs) are associated with considerable morbidity and mortality.

METHODS

We conducted a survey to evaluate the theoretical knowledge and practices of intensive care unit doctors and nursing staff regarding CVC-related infections.

RESULTS

A questionnaire was distributed to 345 doctors and nurses. The response rate was 71.6%. Of the responders, 84.9% worked in public hospitals, 40% had been trained in CVC-related infection issues, and 27% were familiar with the relevant Centers of Disease Control and Prevention guidelines. The mean percentage of correct answers (± standard deviation) on the 3 parts of the questionnaire were 42.9% ± 16.2%, 86.9% ± 9.5%, and 85.4% ± 7.2%. In the subset of questions referring to procedures that were doctors' exclusive responsibility, 13.6% of the doctors answered all questions correctly. Age >37 years, awareness of relevant official guidelines, working in a private hospital, and being a doctor were identified as independent variables associated with high scores in knowledge regarding the prevention of CVC-related infections. Female sex and training in infection prevention were associated with higher scores on the part evaluating adherence to specific practices regarding CVC insertion, whereas being a nurse was associated with higher scores on the part evaluating CVC maintenance.

CONCLUSION

Our findings suggest that there is a need for increased theoretical knowledge and improvement in practices regarding CVC care. Educational programs directed at doctors and nurses working in intensive care units may aid this effort.