Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit

Effect of ventilator care bundle for pediatric nurses on occurrence of ventilator-associated pneumonia among children

BACKGROUND

In pediatric intensive care units (PICUs), ventilator-associated pneumonia (VAP) is one of the most prevalent infections linked to healthcare. VAP affects 10% of children on mechanical ventilation (MV) and is associated with severe morbidity and mortality. The study aimed to evaluate the effect of the ventilator care bundle (VCB) on the occurrence of VAP among pediatric patients.

METHOD

A quasi-experimental design was conducted at Cairo University Specialized Pediatric Hospital (CUSPH), including all children who had mechanical ventilation within 24 h. VAP rates were evaluated before and after the implementation of a comprehensive VCB, which included head-of-bed elevation to 30-45°, hand hygiene reinforcement, sterile suctioning and handling of respiratory equipment, daily evaluation of extubation readiness, peptic ulcer prophylaxis, and deep venous thrombosis prophylaxis. A convenience sample of 30 nurses and a purposive sample of 60 ventilated children in the PICU participated in the study. Data collection was performed using (1) structured interview sheets, (2) the Nurses' Knowledge Assessment Questionnaire (pre/post-test), (3) the Ventilator Bundle Checklist, and (4) the Clinical Pulmonary Infection Scale (CPIS).

RESULTS

There was a significant increase in nurses' level of knowledge before and after the implementation of the VCB (X² = 21.46, p ≤ 0.01). There was a statistically significant difference between the total mean scores of nurses' practices in the first and second checklist readings (p < 0.01). Additionally, there were statistically significant differences between children in the study and control groups regarding the clinical pulmonary infection score (p < 0.01). The total mean score on the CPIS was significantly different between the study group and the control group (t = - 3.692, p = 0.001).

CONCLUSION

The study concluded that children who were cared for by nurses receiving VCB sessions were less likely to experience VAP compared to those in the control group.

RECOMMENDATION

Educational programs and in-service training courses for pediatric nurses to improve the quality of ventilator care for children and reduce the occurrence of VAP are essential.

Time to recovery of neonatal sepsis and its predictors in public hospitals of North Shoa Zone, Central Ethiopia

BACKGROUND

Neonatal sepsis remains one of the most common causes of morbidity and mortality among neonates in developing countries. It can cause severe morbidities and sequelae, even though patients survive. Prolonged recovery time of neonatal sepsis leads to hospitalization, increased cost of treatments, antimicrobial resistance, disseminated intravascular coagulation, respiratory failure, septic shock, brain lesions, renal failure, and cardiovascular dysfunction, and eventually death. Thus, this study aimed to identify the time-to-recovery of neonatal sepsis and its predictors among newborns admitted to public hospitals in the North Shoa Zone, Central Ethiopia.

METHODS

A retrospective cohort study was conducted among 508 septic neonates admitted to selected public hospitals in the North Shoa Zone between March 1, 2021, and March 1, 2023. A systematic random sampling method was used to select eligible medical records. The data were collected through the open data kit (ODK) Collect Android app and consequently exported to STATA version 17 for analysis. The data were analyzed using both univariable and multivariable Cox regression models. The adjusted hazard ratio (AHR) with its corresponding 95% confidence interval (CI) was employed.

RESULTS

Of all septic neonates, 441 were recovered. The predictors of time-to-recovery of neonatal sepsis were premature rupture of membrane (PROM) (AHR = 0.37; 95% CI: 0.21, 0.63), intrapartum fever (AHR = 0.49; 95% CI: 0.32, 0.75), chest-indrawing (AHR = 0.50; 95% CI: 0.36, 0.68), fifth-minute appearance, pulse, grimace, activity, and respiration (Apgar) score less than seven (AHR = 0.54; 95% CI: 0.38, 0.77), gestational age between 37 and 42 weeks (AHR = 1.35; 95% CI: 1.06, 1.70), septic shock (AHR = 0.52; 95% CI: 0.31, 0.85).

CONCLUSION

The median time to recovery from neonatal sepsis in this study was comparable to the previous studies. Premature rupture of membranes, intrapartum fever, term gestational age, low fifth minute Apgar score, chest indrawing, and septic shock were the predictors of time-to recovery of neonatal sepsis. Therefore, birth attendants are advised to closely adhere to the obstetrics management protocols when providing care for women who have intrapartum fever and premature rupture of membranes, as this will help to minimize neonatal sepsis and the subsequent delay in recovery.

Use of mucolytics and inhaled antibiotics in the NICU

Clearance of airway secretions and treatment of respiratory tract infections (RTIs) are two common problems caregivers face in the neonatal intensive care unit (NICU). Mucolytics degrade crosslinks in mucus gel, reducing mucus viscosity and facilitating their removal by cough or endotracheal suctioning. While such medications have been studied in older children and adults, their use is not as well described in the NICU. For RTIs, systemic antibiotics are usually prescribed, although their use is often associated with adverse effects. Inhaled antibiotics may provide increased drug concentrations to the infected airways while minimizing systemic toxicity. The use of inhaled antibiotics in the NICU has been described in small case series. As underlying physiologic differences will lend to inaccuracies when extrapolating data obtained from older children, there is an urgent need to determine the safety, efficacy, and optimal dosing of inhaled mucolytics and antibiotics in infants of varying gestational and post-natal ages.

Understanding how methyltransferase-like 3 functions in lung diseases: From pathogenesis to clinical application

Lung diseases have complex pathogenesis and treatment challenges, showing an obvious increase in the rate of diagnosis and death every year. Therefore, elucidating the mechanism for their pathogenesis and treatment ineffective from novel views is essential and urgent. Methyltransferase-like 3 (METTL3) is a novel post-transcriptional regulator for gene expression that has been implicated in regulating lung diseases, including that observed in chronic conditions such as pulmonary fibrosis (PF), pulmonary arterial hypertension (PAH), and chronic obstructive pulmonary disease (COPD), as well as acute conditions such as pneumonia, severe acute respiratory syndrome coronavirus 2 infection, and sepsis-induced acute respiratory distress syndrome. Notably, a comprehensive summary and analysis of findings from these studies might help understand lung diseases from the novel view of METTL3-regulated mechanism, however, such a review is still lacking. Therefore, this review aims to bridge such shortage by summarising the roles of METTL3 in lung diseases, establishing their interrelationships, and elucidating the potential applications of METTL3 regarding diagnosis, treatment, and prognosis. The analysis collectively suggests METTL3 is contributable to the onset and progression of these lung diseases, thereby prospecting METTL3 as a valuable biomarker for their diagnosis, treatment, and prognosis. In conclusion, this review offers elucidation into the correlation between METTL3 and lung diseases in both research and clinical settings and highlights potential avenues for exploring the roles of METTL3 in the respiratory system.

The spectrum of pneumonia among intubated neonates in the neonatal intensive care unit

We review the pathophysiology, epidemiology, diagnosis, treatment, and prevention of ventilator-associated pneumonia (VAP) in neonates. VAP has been studied primarily in adult ICU patients, although there has been more focus on pediatric and neonatal VAP (neo-VAP) in the last decade. The definition as well as diagnosis of VAP in neonates remains a challenge to date. The neonatal intensivist needs to be familiar with the current diagnostic tools and prevention strategies available to treat and reduce VAP to reduce neonatal morbidity and the emergence of antibiotic resistance. This review also highlights preventive strategies and old and emerging treatments available.

Preventive strategies in paediatric cardiovascular surgery: impact on surgical site infections and beyond

BACKGROUND

Surgical management of congenital heart disease (CHD) has increased worldwide, but healthcare-associated infections (HAIs) can threaten these efforts.

AIM

To analyse the incidence of HAI, the impact of preventive interventions, and microbiological profiles in a paediatric cardiovascular surgery programme.

METHODS

Cohort study including children aged <12 years with CHD who underwent cardiovascular surgery between 2010 and 2021 in Medellín, Colombia (a middle-income setting). Data were collected from medical and laboratory records and infection control programme databases. Impact of various preventive interventions was assessed using a Poisson model. P < 0.05 was considered statistically significant.

FINDINGS

A total of 2512 surgeries were analysed. Incidence of surgical site infection (SSI) was 5.9%, followed by central line-associated bloodstream infection (CLABSI; 4.7%), catheter-associated urinary tract infection (CAUTI; 2.2%), and ventilator-associated pneumonia (VAP; 1.4%). Most of the strategies focused on preventing SSI, resulting in a reduction from 9.5% in 2010 to 3.0% in 2021 (P = 0.030). Antibiotic prophylaxis based on patient weight and continuous infusion had an impact on reducing SSI (RR: 0.56; 95% CI: 0.32-0.99). Vacuum-assisted closure (VAC) in clean wounds reduced 100% of infections. No significant risk reduction was observed for other HAI with the implemented interventions.

CONCLUSION

Preventive strategies effectively reduced SSI but no other infections, emphasizing the need for targeted approaches to address a broader spectrum of HAI successfully.

Variations and National Perspectives on Evaluation and Management of Ventilator-Associated Pneumonia in Neonatal Intensive Care Units: An In-Depth Survey Analysis

Introduction Infants in the neonatal intensive care unit (NICU) are vulnerable to ventilator-associated pneumonia (VAP), which increases their morbidity and mortality. There is a significant overlap of clinical features of neonatal VAP with other pulmonary pathologies, particularly in preterm infants, which can make the definitive diagnosis and management of VAP challenging. Objective Our study surveyed NICU providers across the United States to understand the perspectives and variations in neonatal VAP diagnostic and management practices. Methods The REDCap survey was distributed to the actively practicing members of the Section on Neonatal-Perinatal Medicine (SoNPM) of the American Academy of Pediatrics (AAP). We used descriptive statistics to analyze the data from the respondents. Results Of 254 respondents, the majority (86.6%, 220) were neonatologists and had a relatively even geographical distribution. Most (75.9%, 193) stated that they would perform a gram stain and respiratory culture as part of a sepsis workup irrespective of the patient's duration on invasive mechanical ventilation (IMV); 224 (88.2%) of providers preferred the endotracheal aspiration (ETA) technique to collect specimens. In cases where a positive respiratory culture was present, VAP (52.4%, 133) was the predominantly assigned diagnosis, followed by pneumonia (27.2%, 69) and ventilator-associated tracheitis (VAT) (9.8%, 25). Respondents reported a prescription of intravenous gentamicin (70%, 178) and vancomycin (41%, 105) as the initial empiric antibiotic drugs, pending final respiratory culture results. Most respondents (55.5%, 141) opted for seven days of antibiotics duration to treat VAP. The reported intra-departmental variation among colleagues in acquiring respiratory cultures and prescribing antibiotics for VAP was 48.8% (124) and 37.4% (95), respectively, with slightly more than half (53.5%, 136) of providers reporting having VAP prevention guidelines in their units. Conclusion The survey study revealed inconsistencies in the investigation, diagnostic nomenclature, choice of antibiotic, and treatment duration for neonatal VAP. Consequently, there is a pressing need for further research to establish a clear definition and evidence-based criteria for VAP.

Diet influences community dynamics following vaginal group B streptococcus colonization

The vaginal microbiota plays a pivotal role in reproductive, sexual, and perinatal health and disease. Unlike the well-established connections between diet, metabolism, and the intestinal microbiota, parallel mechanisms influencing the vaginal microbiota and pathogen colonization remain overlooked. In this study, we combine a mouse model of Streptococcus agalactiae strain COH1 [group B Streptococcus (GBS)] vaginal colonization with a mouse model of pubertal-onset obesity to assess diet as a determinant of vaginal microbiota composition and its role in colonization resistance. We leveraged culture-dependent assessment of GBS clearance and culture-independent, sequencing-based reconstruction of the vaginal microbiota in relation to diet, obesity, glucose tolerance, and microbial dynamics across time scales. Our findings demonstrate that excessive body weight gain and glucose intolerance are not associated with vaginal GBS density or timing of clearance. Diets high in fat and low in soluble fiber are associated with vaginal GBS persistence, and changes in vaginal microbiota structure and composition due to diet contribute to GBS clearance patterns in nonpregnant mice. These findings underscore a critical need for studies on diet as a key determinant of vaginal microbiota composition and its relevance to reproductive and perinatal outcomes.IMPORTANCEThis work sheds light on diet as a key determinant influencing the composition of vaginal microbiota and its involvement in group B Streptococcus (GBS) colonization in a mouse model. This study shows that mice fed diets with different nutritional composition display differences in GBS density and timing of clearance in the female reproductive tract. These findings are particularly significant given clear links between GBS and adverse reproductive and neonatal outcomes, advancing our understanding by identifying critical connections between dietary components, factors originating from the intestinal tract, vaginal microbiota, and reproductive outcomes.

A comprehensive study on machine learning models combining with oversampling for bronchopulmonary dysplasia-associated pulmonary hypertension in very preterm infants

BACKGROUND

Bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) remains a devastating clinical complication seriously affecting the therapeutic outcome of preterm infants. Hence, early prevention and timely diagnosis prior to pathological change is the key to reducing morbidity and improving prognosis. Our primary objective is to utilize machine learning techniques to build predictive models that could accurately identify BPD infants at risk of developing PH.

METHODS

The data utilized in this study were collected from neonatology departments of four tertiary-level hospitals in China. To address the issue of imbalanced data, oversampling algorithms synthetic minority over-sampling technique (SMOTE) was applied to improve the model.

RESULTS

Seven hundred sixty one clinical records were collected in our study. Following data pre-processing and feature selection, 5 of the 46 features were used to build models, including duration of invasive respiratory support (day), the severity of BPD, ventilator-associated pneumonia, pulmonary hemorrhage, and early-onset PH. Four machine learning models were applied to predictive learning, and after comprehensive selection a model was ultimately selected. The model achieved 93.8% sensitivity, 85.0% accuracy, and 0.933 AUC. A score of the logistic regression formula greater than 0 was identified as a warning sign of BPD-PH.

CONCLUSIONS

We comprehensively compared different machine learning models and ultimately obtained a good prognosis model which was sufficient to support pediatric clinicians to make early diagnosis and formulate a better treatment plan for pediatric patients with BPD-PH.

Nosocomial Infections in the Neonatal Intensive Care Unit

Nosocomial infections are relatively common in the NICU. These infections increase morbidity and mortality, particularly in the smallest and most fragile infants. The impact of these infections on long-term outcomes and health-care costs is devastating. Worldwide efforts to decrease the incidence of nosocomial infections have focused on implementing specific prevention protocols such as handwashing, central line teams, care bundles, and antimicrobial stewardship. This review summarizes common nosocomial infections in patients in the NICU.

Health care-associated infections in neonatology

Health care-associated infections are common in neonatology, but there is no consensus on their definitions. This makes it difficult to compare their incidence or assess the effectiveness of prevention bundles. This is why we think it is very important to achieve a consensus on the definitions and diagnostic criteria for one of the most frequent causes of morbidity in hospitalised neonates. This document aims to standardise the definitions for the most frequent health care-associated infections, such as catheter-associated bloodstream infection, ventilator-associated pneumonia and surgical wound infection, as well as the approach to their diagnosis and treatment.

Risk factors for neonatal VAP: A retrospective cohort study

Ventilator-associated pneumonia (VAP) is a serious complication in neonates requiring mechanical ventilation. This study aimed to determine the risk factors associated with the development of VAP in neonates admitted to the neonatal intensive care unit (NICU) of the Affiliated Hospital of Southwest Medical University. In a retrospective observational study, neonates admitted to the NICU from 1 January 2019, to 31 December 2021, requiring ventilation for more than 48 h were included. Neonates who died within 48 h of NICU admission, those without obtainable consent, or identified with a genetic syndrome were excluded. Various neonatal and clinical variables were evaluated. Univariate and multivariate analyses were performed to determine risk factors associated with VAP. Of the total neonates included, several risk factors were identified for VAP, such as being a premature infant and use of dexamethasone and sedatives. Moreover, reintubation was found to decrease the risk of VAP. Some factors like gestational age, birth weight, Apgar scores at 5 min, and other parameters were found not significantly associated with the development of VAP. The study identified several risk factors associated with the development of VAP in neonates. Recognizing these risk factors could help in the prevention and early management of VAP, thus improving the prognosis for these patients. Further studies are needed to validate these findings and explore the mechanistic links between these factors and VAP.

Risk factors for postoperative pulmonary complications in neonates: a retrospective cohort study

Objective

Postoperative pulmonary complications (PPCs) are an important quality indicator and are associated with significantly increased mortality in infants. The objective of this study was to identify risk factors for PPCs in neonates undergoing non-cardiothoracic surgery.

Methods

In this retrospective study, all neonates who underwent non-cardiothoracic surgery in a children's hospital from October 2020 to September 2022 were included for analysis. Demographic data and perioperative variables were obtained. The primary outcome was the occurrence of PPCs. Univariate analysis and multivariable logistic regression analysis were used to investigate the effect of patient-related factors on the occurrence of PPCs.

Results

Totally, 867 neonatal surgery patients met the inclusion criteria in this study, among which 35.3% (306/867) patients experienced pulmonary complications within 1 week postoperatively. The PPCs observed in this study were 51 exacerbations of pre-existing pneumonia, 198 new patchy shadows, 123 new pulmonary atelectasis, 10 new pneumothorax, and 6 new pleural effusion. Patients were divided into two groups: PPCs (n=306) and non-PPCs (n=561). The multivariate stepwise logistic regression analysis revealed five independent risk factors for PPCs: corrected gestational age (OR=0.938; 95% CI 0.890 to 0.988), preoperative pneumonia (OR=2.139; 95% CI 1.033 to 4.426), length of surgery (> 60 min) (OR=1.699; 95% CI 1.134 to 2.548), preoperative mechanical ventilation (OR=1.857; 95% CI 1.169 to 2.951), and intraoperative albumin infusion (OR=1.456; 95% CI 1.041 to 2.036) in neonates undergoing non-cardiothoracic surgery.

Conclusion

Identifying risk factors for neonatal PPCs will allow for the identification of patients who are at higher risk and intervention for any modifiable risk factors identified.