Risk factors for nosocomial infections in a neonatal intensive-care unit

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.

Neonatal Vascular Access Practice and Complications: An Observational Study of 1,375 Catheter Days

Vascular access devices play vital roles within neonatal care. We aimed to identify neonatal vascular access device insertion and management practices, and describe the incidence and risk factors for complication development. This is a prospective cohort study of neonates requiring vascular access devices over 3 months in an Australian quaternary-referral neonatal intensive care unit. In addition to describing current practices, primary outcomes were device failure, complications, and skin complications. Results are reported using descriptive statistics and with risk factors calculated via Cox proportional hazards regression. A total of 104 neonates required 302 vascular access devices, over 1375 catheter days. Peripheral intravenous catheters (PIVCs) were most used (n = 186; 62%), followed by umbilical venous catheters (n = 52; 17%). Insertion attempts were often undocumented; but for those recorded, 5% of devices (n = 15) required 4 attempts or more. Device failure occurred in 28% (n = 82), at an incidence rate of 62.5 per 1000 catheter days (95% confidence interval [CI] 49.7-75.9). Failure was most frequent in PIVCs (37%; n = 68), peripheral arterial catheters (33%; n = 2), and peripherally inserted central catheters (20%; n = 6). Infiltration and extravasation were the most frequent cause of PIVC failure (12%; n = 35). A birth weight less than 1500 g was associated with a significant decrease in PIVC failure (hazard ratio 0.58; 95% CI 0.34-0.99).

Determinants of morbidity and mortality related to health care-associated primary bloodstream infections in neonatal intensive care units: a prospective cohort study from the SEPREVEN trial

Background

Health care-associated primary bloodstream infections (BSIs), defined as not secondary to an infection at another body site, including central line-associated BSI, are a leading cause of morbidity and mortality in patients in neonatal intensive care units (NICUs). Our objective was to identify factors associated with severe morbidity and mortality after these infections in neonates in NICUs.

Methods

This ancillary study of the SEPREVEN trial included neonates hospitalized ≥2 days in one of 12 French NICUs and with ≥ 1 BSI during the 20-month study period. BSIs (all primary and health care-associated) were diagnosed in infants with symptoms suggestive of infection and classified prospectively as possible (one coagulase-negative staphylococci (CoNS)-growing blood culture) or proven (two same CoNS, or ≥1 recognized pathogen-growing blood culture). BSI consequences were collected prospectively as moderate morbidity (antibiotic treatment alone) or severe morbidity/mortality (life-saving procedure, permanent damage, prolonged hospitalization, and/or death).

Results

Of 557 BSIs identified in 494 patients, CoNS accounted for 378/557 (67.8%) and recognized bacterial or fungal pathogens for 179/557 (32.1%). Severe morbidity/mortality was reported in 148/557 (26.6%) BSIs. Independent factors associated with severe morbidity/mortality were corrected gestational age <28 weeks (CGA) at infection (P < .01), fetal growth restriction (FGR) (P = .04), and proven pathogen-related BSI vs. CoNS-related BSI (P < .01). There were no differences in severe morbidity and mortality between proven and possible CoNS BSIs. In possible BSI, S. epidermidis was associated with a lower risk of severe morbidity than other CoNS (P < .01), notably S. capitis and S. haemolyticus.

Conclusions

In BSIs in the NICU, severe morbidity/mortality was associated with low CGA at infection, FGR, and proven pathogen-related BSIs. When only one blood culture was positive, severe morbidity/mortality were less frequent if it grew with S. epidermidis compared to other CoNS. Further studies to help distinguish real CoNS BSIs from contaminations are needed.

Study registration

ClinicalTrials.gov (NCT02598609).

Early Diagnosis of Late-Onset Neonatal Sepsis Using a Sepsis Prediction Score

Sepsis represents a common cause of morbidity in the Neonatal Intensive Care Unit (NICU). Our objective was to assess the value of clinical and laboratory parameters in predicting septicemia (positive blood culture) in NICU infants. In the first part of the present study (derivation cohort) we retrospectively reviewed the clinical files of 120 neonates with symptoms of suspected sepsis and identified clinical and laboratory parameters associated with proven sepsis on the day the blood culture was taken, as well as 24 h and 48 h earlier. These parameters were combined into a sepsis prediction score (SPS). Subsequently (validation study), we prospectively validated the performance of the SPS in a cohort of 145 neonates. The identified parameters were: temperature instability, platelet count < 150,000/mm³, feeding volume decrease > 20%, changes in blood glucose > 50%, CRP > 1 mg/dL, circulatory and respiratory deterioration. In the retrospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 82.54% sensitivity, 85.96% specificity, 5.88 PLR (Positive Likelihood Ratio), 0.20 NLR (Negative Likelihood Ratio), 86.67% PPV (Positive Predictive Value), 81.67% NPV (Negative Predictive Value) and 84.17% accuracy. In the prospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 76.60% sensitivity, 72.55% specificity, 2.79 PLR, 0.32 NLR, 83.72% PPV, 62.71% NPV and 75.17% accuracy. We concluded that this combination of clinical and laboratory parameters may assist in the prediction of septicemia in NICUs.

Evaluating the Use of Neonatal Colonization Screening for Empiric Antibiotic Therapy of Sepsis and Pneumonia

(1) Background: Since 2013, weekly screening for multidrug-resistant Gram-negative (MDRGN) bacteria has been performed in German neonatal intensive care units (NICU). National guidelines recommend considering these colonization analyses for antibiotic treatment regimens. Our retrospective single center study provides insight into the clinical dichotomy of bacterial colonization and infection rates in neonates. (2) Methods: We analyzed microbiological data of neonates admitted to our tertiary level NICU over nine years. Colonization with MDRGN/Serratia marcescens (SERMA) was compared to microbiological findings in sepsis and pneumonia. (3) Results: We analyzed 917 blood and 1799 tracheal aspirate samples. After applying criteria from the Nosocomial Infection Surveillance for Neonates (NEO-KISS), we included 52 and 55 cases of sepsis and pneumonia, respectively; 19.2% of sepsis patients and 34.5% of pneumonia patients had a prior colonization with MDRGN bacteria or SERMA. In these patients, sepsis was not attributable to MDRGN bacteria yet one SERMA, while in pneumonias, ten MDRGN bacteria and one SERMA were identified. We identified late-onset pneumonia and cesarean section as risk factors for MDRGN/SERMA acquisition. (4) Conclusions: Colonization screening is a useful tool for hygiene surveillance. However, our data suggest that consideration of colonization with MDRGN/SERMA might promote extensive use of last resort antibiotics in neonates.

Persistent Coagulase-Negative Staphylococcal Bacteremia in Neonates: Clinical, Microbiological Characteristics and Changes within a Decade

Atypical outbreaks of persistent coagulase-negative staphylococci (CoNS) bacteremias, defined as three or more consecutive positive blood cultures with the same CoNS species, at least 48 h apart, have been reported in neonatal intensive-care units (NICUs). Our aim was to describe the profile of these cases in our NICU over a two-year period with the objective of assessing possible changes within a decade. Demographics, clinical and microbiological data were recorded for all CoNS bacteremias in our tertiary NICU during 2016–2017 and compared with the results of the same study in 2006–2007. Fifty-six cases of CoNS sepsis were recorded. Fourteen (25%) of them were persistent. There were no significant differences in demographic and clinical characteristics between cases with persistent vs. non-persistent bacteremia. Staphylococcus epidermidis was the most common species. In logistic regression analysis, biofilm production (β = 2.464, p = 0.04) was the most significant determinant for the development of persistent CoNS bacteremia. Our isolates were less likely to produce biofilm and carry ica operon as compared to those of 2006–2007. The cases of persistent CoNS sepsis have decreased within a decade, which could be attributed to the implementation of intensive infection control practices. Biofilm production remains the most important risk factor.

Development and validation of a sepsis diagnostic scoring model for neonates with suspected sepsis

BACKGROUND

We aimed to develop and validate a diagnostic model for sepsis among neonates evaluated for suspected sepsis, by incorporating thromboelastometry parameters, maternal/neonatal risk factors, clinical signs/symptoms and laboratory results.

METHODS

This retrospective cohort study included 291 neonates with presumed sepsis, hospitalized in a NICU, from 07/2014 to 07/2021. Laboratory tests were obtained on disease onset and prior to initiating antibiotic therapy. Τhromboelastometry extrinsically activated (EXTEM) assay was performed simultaneously and Tοllner and nSOFA scores were calculated. Sepsis diagnosis was the outcome variable. A 10-fold cross-validation least absolute shrinkage and selection operator logit regression procedure was applied to derive the final multivariable score. Clinical utility was evaluated by decision curve analysis.

RESULTS

Gestational age, CRP, considerable skin discoloration, liver enlargement, neutrophil left shift, and EXTEM A10, were identified as the strongest predictors and included in the Neonatal Sepsis Diagnostic (NeoSeD) model. NeoSeD score demonstrated excellent discrimination capacity for sepsis and septic shock with an AUC: 0.918 (95% CI, 0.884-0.952) and 0.974 (95% CI, 0.958-0.989) respectively, which was significantly higher compared to Töllner and nSOFA scores.

CONCLUSIONS

The NeoSeD score is simple, accurate, practical, and may contribute to a timely diagnosis of sepsis in neonates with suspected sepsis. External validation in multinational cohorts is necessary before clinical application.

Investigations of Staphylococcal contamination on environmental surfaces of a neonatal intensive care unit of a children's hospital

Staphylococci species are known to cause healthcare-associated infections in neonatal intensive care (NICU) unit patients. Little is known about Staphylococcal contamination of NICU environments. Swabs from 25 of 46 (54%) surfaces sampled in a NICU had viable Staphylococcal contamination, with 11% contaminated by methicillin resistant Staphylococcus aureus [MRSA]. Floors by sinks and return air ducts in the NICU were the most contaminated (67% positive), possibly serving as reservoirs for Staphylococci.

The current state of immunization against Gram-negative bacteria in children: a review of the literature

PURPOSE OF REVIEW

Gram-negative bacteria (GNB) are a major cause of infection worldwide and multidrug resistance in infants and children. The major pathogens include Klebsiella pneumoniae, Escherichia coli, Enterobacter spp., Pseudomonas aeruginosa and Acinetobacter baumannii. With new antibiotic options limited, immunization is likely to play a critical role in prevention. This review discusses their epidemiology, the current state of vaccine research and potential immunization strategies to protect children. A comprehensive review of the literature, conference abstracts along with web searches was performed to identify current and investigational vaccines against the major GNB in children.

RECENT FINDINGS

Phase I--III vaccine trials have been undertaken for the major Gram-negative bacteria but not in infants or children. E. coli is a common infection in immune-competent children, including neonatal sepsis. Several vaccines are in late-phase clinical trials, with some already licensed for recurrent urinary tract infections in women. Klebsiella spp. causes community-acquired and hospital-acquired infections, including sepsis in neonates and immunocompromised children although no vaccine trials have extended beyond early phase 2 trials. P. aeruginosa is a common pathogen in patients with cystic fibrosis. Phase 1--3 vaccine and monoclonal antibody trials are in progress, although candidates provide limited coverage against pathogenic strains. Enterobacter spp. and A. baumannii largely cause hospital-acquired infections with experimental vaccines limited to phase 1 research.

SUMMARY

The current immunization pipelines for the most prevalent GNB are years away from licensure. Similar to incentives for new antibiotics, global efforts are warranted to expedite the development of effective vaccines.

Faucet aerator design influences aerosol size distribution and microbial contamination level

Faucet aerators have been linked to multiple opportunistic pathogen outbreaks in hospital, especially Pseudomonas aeruginosa, their complex structure promoting biofilm development. The importance of bacteria aerosolization by faucet aerators and their incidence on the risk of infection remain to be established. In this study, ten different types of aerators varying in complexity, flow rates and type of flow were evaluated in a controlled experimental setup to determine the production of aerosols and the level of contamination. The aerosol particle number density and size distribution were assessed using a particle spectrometer. The bacterial load was quantified with a 14-stage cascade impactor, where aerosol particles were captured and separated by size, then analysed by culture and flow cytometry. The water was seeded with Pseudomonas fluorescens as a bacterial indicator. Aerosol particle size and mean mass distribution varied depending on the aerator model. Devices without aeration or with laminar flow produced the lowest number and mass of aerosol particles when measured with spectrometry. Models with aeration displayed wide differences in their potential production of aerosol particles. A new aerator with a low flow, no air inlet in its structure, and a spray stream produced 12 to 395 times fewer aerosol particles containing bacteria. However, the impact of low flow on biofilm development and incorporation of pathogens should be further investigated. Repeated use of aerators resulted in fouling which increased the quantity of bacteria released through aerosol particles. An in-depth mechanical cleaning including complete dismantling of the aerator was required to recover initial performances. Aerators should be selected to minimize aerosol production, considering the ease of maintenance and the main water usage at each sink. Low flow aerators produced a lower number of contaminated aerosol particles when new but may be more susceptible to fouling and quickly lose their initial advantage.

Bacterial contamination of neonatal intensive care units: How safe are the neonates?

Background

Intensive care units (ICU) are essential healthcare facility for life threatening conditions. Bacterial contamination of objects/instruments in ICU is an important source of nosocomial infections. This study is aimed to determine the level of bacterial contamination of instruments/objects which are commonly touched by healthcare workers and frequently come in contact with the neonates.

Methods

This hospital based prospective study was conducted in neonatal intensive care unit (NICU) of Manipal Teaching Hospital, Pokhara, Nepal. A total of 146 samples collected from surfaces of incubators, radiant warmers, suction tips, ventilators, stethoscopes, door handles, weighing machines, mothers’ beds, phototherapy beds, laryngoscope, telephone sets, blood pressure machine, etc. formed the material of the study. Isolation, identification and antibiotic susceptibility of the bacterial isolates was performed by standard techniques. Blood culture isolates from NICU patients during the study period were compared with the environmental isolates.

Results

Out of 146 samples, bacterial growth was observed in 109. A total of 119 bacterial isolates were retrieved from 109 samples. Three common potential pathogens isolated were Escherichia coli (n = 27), Klebsiella species (n = 21) and Staphylococcus aureus (n = 18). Majority of E. coli and Klebsiella isolates were from incubators, suction tips and mothers’ beds. Majority of S. aureus isolates were cultured from radiant warmers. Among S. aureus isolates, 33.3% (6/18) were methicillin resistant. Majority of the bacterial isolates were susceptible to gentamicin and amikacin. Common potential pathogens isolated from blood culture of NICU patients were S. aureus and Klebsiella species.

Conclusion

High degree of bacterial contamination of objects/instruments in NICU was recorded. Isolation of potential pathogens like E. coli, Klebsiella species and S. aureus is a major threat of nosocomial infections. Blood culture data of NICU reflects possibility of nosocomial infections from contaminated sites. Gentamicin and amikacin may be used for empirical therapy in suspected cases of nosocomial infections in NICU.

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

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

Neonate Bloodstream Infections in Organization for Economic Cooperation and Development Countries: An Update on Epidemiology and Prevention

The term neonatal sepsis is used to describe a generalized bloodstream infection of bacterial, viral, or fungal origin which is associated with hemodynamic changes and other clinical symptoms and signs, however, there is no unified definition. There are no basic criteria regarding differentiation of early-onset sepsis (EOS) versus late-onset sepsis (LOS). Stratification used in studies on neonatal sepsis also rarely includes the general condition of the newborn according to unambiguous assessment at birth, which hampers the establishment of a clear, uniform epidemiological description of neonatal sepsis. We aim to review the published data about the epidemiology and microbiology of sepsis in Organization for Economic Cooperation and Development (OECD) countries. Data was also collected on sepsis prevention programs that can be implemented in neonatal units. The outcomes of interest were incidence or incidence density of EOS and LOS, microbiology of EOS and LOS, and data on the methodology of the research, in particular the criteria for inclusion and exclusion of newborns from the study. Pubmed, EMBASE, LILACS Embase, Scopus, and Google Scholar were used. For the preselection step, inclusion criteria included: "bloodstream infection" or "neonatal sepsis" (MesH), "very low birth weight", and "country" full-text studies, human, and English language. Exclusion criteria included: studies published in languages other than English and studies available only as an abstracts. For proper selection, inclusion criteria included: information about epidemiology or microbiology bloodstream infection (BSI), study population and case definitions, exclusion criteria, narrative reviews, commentaries, case studies, pilot studies, study protocols, pediatric studies, and only clinical data (without microbiology or epidemiology) or studies with only one etiological factor analysis. The data review indicated the lack of an unequivocal, unified definition and no unambiguous basic criteria with regard to differentiation of EOS versus LOS. Among infants <1500 g, studies reported an EOS rate from 7% to 2%. For studies using other definitions (mostly all inborn babies), the rate of EOS ranged from 1% to 3%. The LOS incidences were much more varied among countries; the highest rates were in the multicenter studies focused on very low birth weight (VLBW) infants. The main pathogens in EOS are GBS and Gram-negative bacteria in LOS. Our review data shows that LOS microbiology is very diverse and that Gram-positive cocci, especially staphylococci, predominate versus Gram-negative rods. Unfortunately, the lack of uniform, international prevention programs results in high newborn morbidity and insufficient postnatal prevention of late-onset infections.

NON-INVASIVE PREDICTION MODEL FOR DEVELOPING COUNTRIES TO PREDICT SEPSIS IN NEONATES

Majority of global neonatal deaths is due to sepsis. A vast portion of these deaths occurs in developing countries due to inaccessibility of hospitals or lack of resources. Blood culture is the test to confirm sepsis, but it requires the presence of laboratory and is time-consuming. Therefore, we require simple, easy to use methods to predict sepsis in homes. Majority of the available prediction models need invasive parameters and hence become useless in the rural areas of developing countries where laboratory facilities do not exist. Non-invasive prediction models overcome these challenges to predict neonatal sepsis in places where there is a scarcity of laboratories. The aim and objective of this study are as follows: (i) to develop a practical, non-invasive prediction-model for neonatal sepsis which can be used in the rural areas of developing countries and to validate its performance. (ii) To compare the prognostic performance of the non-invasive prediction model with invasive prediction model and (iii) to create a prototype of the hardware which calculates the probability of the sepsis in neonates and sends the real-time data to the cloud. For this retrospective analysis, we extracted the data of 1446 neonates from Medical Information Mart for Intensive care III (MIMIC) database. Using stepwise logistic regression analysis, we developed and validated two prediction models. These two models were named as model NI and model O. Model O contains invasive as well as non-invasive parameters whereas model NI contains only non-invasive parameters. Model NI performed equally well in comparison to Model O despite using different predictors. The area under ROC curves for model NI and model O were 0.879 (95% CI: 0.857 to 0.899) and 0.861 (95% CI: 0.838 to 0.881) respectively. Both models were statistically significant with [Formula: see text]-value[Formula: see text].

Trends in the incidence and associated factors of late-onset sepsis associated with improved survival in extremely preterm infants born at 23-26 weeks' gestation: a retrospective study

Background

To investigate the trends in the incidence and associated factors of late-onset sepsis (LOS) associated with improved survival in extremely preterm infants.

Methods

Medical records of 364 infants who were born at 23–26 weeks’ gestation from 2000 to 2005 (period I, n = 124) and from 2006 to 2011 (period II, n = 240) were retrospectively reviewed. The infants were stratified into subgroups of 23–24 and 25–26 weeks’ gestation within each period, and survival, LOS rate, and clinical characteristics were analyzed. Multivariate logistic regression analyses were completed to identify the clinical factors associated with LOS.

Results

The survival rate of 75.8% during period I significantly improved to 85.4% during period II, especially in infants at 23–24 weeks’ gestation (55.1% vs. 78.1%, respectively). The LOS rate of 33.1% during period I significantly reduced to 15.8% during period II, especially in infants at 25–26 weeks’ gestation (32.0% vs. 8.9%, respectively). The LOS rate per 1000 hospital days of 4.0 during period I significantly reduced to 1.8 during period II. Candida presence reduced from 21.3% during period I to 4.7% during period II. In multivariate analyses, during period I, prolonged intubation, especially in infants at 25–26 weeks’ gestation, and necrotizing enterocolitis, especially in infants at 23–24 weeks’ gestation, were significantly associated with LOS.

Conclusions

Improved survival of infants at 23–24 weeks’ gestation was associated with a simultaneous reduction of LOS incidence in infants at 25–26 weeks’ gestation. Less-invasive assisted ventilation may be one of the details of improved perinatal and neonatal care that has contributed to lowering risk of infection or death among periviable infants.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1130-y) contains supplementary material, which is available to authorized users.

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.

Risk Factors for Health Care-Associated Bloodstream Infections in a Neonatal Intensive Care Unit

Background

Healthcare-associated bloodstream infections (HCA-BSI) are a major cause of morbidity and mortality in neonatal intensive care units (NICUs).

Objectives

We aimed to determine the causative organisms and risk factors of HCA-BSIs in NICUs.

Methods

This study was performed between January 2011 and December 2014 in the neonatal intensive care unit of Dicle university, Turkey. The study consisted of 126 patients (infected group) with positive blood culture and 126 randomly selected patients (uninfected control group) with negative blood culture after four days of hospitalization.

Results

We found that the most common causative agents isolated from nosocomial infections (NIs) were 20.7% Staphylococcus epidermidis, 26.7% Klebsiella spp., and 13.3% Acinetobacter spp. Incidences of low gestational age, low birth weight, vaginal birth type, and long length of hospitalization were higher in the infected neonates than in the uninfected neonates. In the univariate analysis, surgical operation, ventriculoperitoneal shunt, use of umbilical catheter, nasogastric or orogastric tube, urinary catheter, mechanical ventilation, surfactant treatment, erythrocyte transfusion, plasma transfusion, thrombocyte transfusion, total parenteral nutrition infusion, intracranial hemorrhage, length of hospital stay, fifth-minute Apgar score, and total parenteral nutrition time were significantly associated with NIs. In the multiple logistic regression analysis, fifth-minute Apgar, use of erythrocyte transfusion and surgical operation were found as the independent risk factors for HCA-BSI.

Conclusions

This study determined the causative organisms and risk factors of HCA-BSIs in NICUs.

Impact of healthcare-associated sepsis on mortality in critically ill infants

Healthcare-associated sepsis (HAS) is a life-threatening complication in neonatal intensive care. Research into the impact of HAS on mortality adjusted for comorbidities is however limited. We conducted a historical cohort study to evaluate impact of HAS on mortality stratified by birth weight and risk factors for mortality in the HAS cohort. HAS was defined according to the National Institute of Child Health and Human Development criteria. Logistic regression was used to calculate adjusted odds of mortality. Of 5134 admissions, 342 infants developed HAS (6.7 %). Mortality in the total and HAS cohort was 5.6 and 10.5 %, respectively. The majority of HAS was caused by commensals (HAS-COM, 59.4 %) and 40.6 % by recognized pathogens (HAS-REC). Adjusted for comorbidities, "HAS-REC" is only a risk factor for mortality in newborns >1500 g (adjusted odds ratio [aOR] 2.3, confidence interval [CI] 1.1-4.9). Post-hoc analysis identified HAS-REC as an independent risk factor for mortality in infants with gastrointestinal disease (aOR 4.8, CI 2.1-10.8). "Renal insufficiency," "focal intestinal perforation," and "necrotizing enterocolitis" are independent risk factors for mortality in the HAS cohort (aOR 13.5, CI 4.9-36.6; aOR 7.7, CI 1.5-39.2; aOR 2.1, CI 1.0-4.7, respectively).

CONCLUSION

For very low birth weight infants (≤1500 g), several comorbidities overrule the impact of HAS on mortality. After adjustment for comorbidities, HAS-REC independently predicts in-hospital mortality in heavier infants and in those with gastrointestinal disease.

WHAT IS KNOWN

• The relationship between healthcare-associated sepsis and mortality is influenced by the causative pathogen and is confounded by comorbidities. • Research on impact of healthcare-associated sepsis on mortality adjusted for comorbidities is limited as well as research on independent risk factors for mortality in neonates with sepsis. What is New: • We included a large list of comorbidities and stratified risk by birth weight in order to assess the true effect of healthcare-associated sepsis on mortality. • Risk for mortality was calculated for commensal flora and for recognized pathogens as causative micro-organisms.

Risk Factors for Health Care-Associated Sepsis in Critically Ill Neonates Stratified by Birth Weight

BACKGROUND

Health care-associated bloodstream infection (HABSI) is a frequent complication in neonatal intensive care. Research on risk factors stratified by birth weight and adjusted for severity of illness and comorbidities is limited. Our objective is to describe independent risk factors for HABSI in critically ill neonates with emphasis on risk variation between birth weight groups.

METHODS

We performed a single-center historical cohort study in a tertiary referral center. A neonatal intensive care-audit system was used to identify eligible neonates admitted for ≥72 hours (2002-2011). HABSI is defined according to National Institute of Child Health and Human Development criteria. Risk factors for HABSI were assessed by univariate and logistic regression analysis for the total cohort and for birth weight subgroups, that is, neonates ≤1500 g and >1500 g.

RESULTS

A total of 342 neonates developed HABSI in 5134 admissions of ≥72 hours (6.7%). Very low birth weight, total parenteral nutrition (TPN), mechanical ventilation, gastrointestinal disease, surgery (cardiac and other type), and renal insufficiency are independent risk factors for the total cohort. Gastrointestinal disease and cardiac surgery are independent risk factors in both birth weight groups; mechanical ventilation (odds ratio [OR]: 2.6; confidence interval [CI]: 1.6-4.0) and other type of surgery (OR: 4.3; CI: 2.1-8.8) are solely independent risk factors in the ≤1500-g cohort; TPN is exclusively an independent risk factor (OR: 7.9; CI: 3.9-16.2) in the >1500-g cohort.

CONCLUSIONS

In our neonatal intensive care unit, risk stratification by birth weight revealed some difference. Special attention concerning infection control practices is for neonates receiving TPN, mechanical ventilation, cardiac surgery, and with a gastrointestinal disease.

Nosocomial infections in a neonatal intensive care unit in South Brazil

Objective

The aim of this study was to describe the incidence and epidemiology of nosocomial infection in newborns who were admitted to a neonatal intensive care unit in a hospital in south Santa Catarina, Brazil.

Methods

A prospective cohort study was conducted for 1 year among 239 neonates who remained as in-patients 48 hours after admission. The criteria that were used to diagnose infection were in accordance with the Centers for Disease Control and Prevention and the National Health Surveillance Agency.

Results

The incidence of nosocomial infection was 45.8%. The primary reasons for admission were primary bloodstream infection (80.7%) and pneumonia (6.7%). Coagulase-negative Staphylococcus was the most commonly identified agent in the blood cultures and in the hospital unit. Prematurity was the most prevalent reason for admission. The general mortality rate was 12.1%, and mortality from nosocomial infection was 33.8%.

Conclusions

The incidence of nosocomial infection in the hospital unit was higher than rates that have been reported in other national studies. The major types of nosocomial infection were primary bloodstream infection and pneumonia.

Neonatal sepsis in a rapidly growing, tertiary neonatal intensive care unit: Trends over 18 years

BACKGROUND

We investigated changes in the admission patterns of neonatal intensive care units and the epidemiology of neonatal sepsis following the rapid expansion and improvements in neonatal intensive care.

METHODS

Data on the admission of neonates with culture-proven sepsis between 1996 and 2013 (period I, 1996-2005; period II, 2006-2013) were collected retrospectively.

RESULTS

The admission of extremely low-birthweight (ELBW) infants increased between periods I and II (11.1 vs 28.7 infants per 1000 live births, P < 0.001). The survival rate of the ELBW infants improved (57.5 vs 80.1%, P < 0.001), and duration of hospital stay increased (median, 64 vs 80 days, P = 0.001). The incidence of sepsis among all infants and ELBW infants increased (all infants, 5.9 vs 12.7 cases per 1000 live births; ELBW infants, 189.5 vs 290.1 cases per 1000 live births). In ELBW infants, the incidence of sepsis caused by coagulase-negative Staphylococcus (CONS), significantly increased during period II (8.8 vs 25.4%, P = 0.039). On multivariate analysis, central vascular catheters and prolonged hospitalization were independently associated with increased sepsis rate, particularly CONS in ELBW infants.

CONCLUSIONS

The inborn admission rate for ELBW infants has increased significantly and is accompanied by improved survival and longer hospital stay. The incidence of neonatal sepsis, particularly in ELBW infants, has also increased, and CONS has emerged as a major pathogen. Central vascular catheters and prolonged hospitalization could be independent risk factors for the increased sepsis rate, particularly sepsis due to CONS.

Infections and risk-adjusted length of stay and hospital mortality in Polish Neonatology Intensive Care Units

BACKGROUND

The objectives of this study were to analyze the impact of infections on prolonging hospital stay with consideration of underlying risk factors and determining the mortality rates and its association with infections.

METHODS

An electronic database developed from a continuous prospective targeted infection surveillance program was used in the study. Data were collected from 2009 to 2012 in five Polish tertiary academic neonatal intensive care units (NICUs). The length of stay (LOS) of 2,003 very low birth weight (VLBW) neonates was calculated as the sum of the number of days since birth until death or until reaching a weight of 1,800g.

RESULTS

The median LOS for neonates with infections was twice as high as for neonates without infection. LOS was significantly affected by the overall general condition of the neonate, as expressed by both gestational age and birth weight as well as by the Clinical Risk Index for Babies (CRIB) score; another independent factor was presence of at least one infection. Risk of in-hospital mortality was significantly increased by male sex and vaginal birth and was lower among breastfed neonates. Deaths were significantly more frequent in neonates without infection.

CONCLUSIONS

The general condition of VLBW infants statistically increase both their risk of mortality and LOS; this is in contrast to the presence of infection, which significantly prolonged LOS only.

Prediction models for neonatal health care-associated sepsis: a meta-analysis

BACKGROUND AND OBJECTIVES

Blood culture is the gold standard to diagnose bloodstream infection but is usually time-consuming. Prediction models aim to facilitate early preliminary diagnosis and treatment. We systematically reviewed prediction models for health care-associated bloodstream infection (HABSI) in neonates, identified superior models, and pooled clinical predictors.

DATA SOURCES

LibHub, PubMed, and Web of Science.

METHODS

The studies included designed prediction models for laboratory-confirmed HABSI or sepsis. The target population was a consecutive series of neonates with suspicion of sepsis hospitalized for ≥ 48 hours. Clinical predictors had to be recorded at time of or before culturing. Methodologic quality of the studies was assessed. Data extracted included population characteristics, total suspected and laboratory-confirmed episodes and definition, clinical parameter definitions and odds ratios, and diagnostic accuracy parameters.

RESULTS

The systematic search revealed 9 articles with 12 prediction models representing 1295 suspected and 434 laboratory-confirmed sepsis episodes. Models exhibit moderate-good methodologic quality, large pretest probability range, and insufficient diagnostic accuracy. Random effects meta-analysis showed that lethargy, pallor/mottling, total parenteral nutrition, lipid infusion, and postnatal corticosteroids were predictive for HABSI. Post hoc analysis with low-gestational-age neonates demonstrated that apnea/bradycardia, lethargy, pallor/mottling, and poor peripheral perfusion were predictive for HABSI. Limitations include clinical and statistical heterogeneity.

CONCLUSIONS

Prediction models should be considered as guidance rather than an absolute indicator because they all have limited diagnostic accuracy. Lethargy and pallor and/or mottling for all neonates as well as apnea and/or bradycardia and poor peripheral perfusion for very low birth weight neonates are the most powerful clinical signs. However, the clinical context of the neonate should always be considered.

Pattern of Culture-Proven Neonatal Sepsis in a District General Hospital in the United Kingdom

Objective:

To determine the incidence, clinical characteristics, and risk factors associated with the first culture-proven episode of sepsis among neonates in a neonatal intensive care unit (NICU).

Setting:

Level-II NICU in the United Kingdom.

Patients:

Neonates with their first culture-proven sepsis between January 1, 1996, and December 31, 2000.

Methods:

Demographic data were obtained from the NICU database and chart review. Sepsis was considered early (EOS; < 72 hours old) or late (LOS; > 72 hours old). Data were also collected on potential risk factors.

Results:

Among 14,767 live births, 1,612 (11%) neonates were admitted to the NICU during the study period. Nine hundred eight were screened for sepsis. One hundred twenty-four had at least one positive culture (overall sepsis rate of 8.4 per 1,000 live births [1%] or 77 per 1,000 NICU admissions). Twenty-four neonates had EOS and 100 had LOS. Coagulase-negative staphylococci (CoNS) and group B Streptococcus were the most frequent organisms causing EOS, whereas CoNS and Escherichia coli most frequently caused LOS. Birth before 30 weeks' gestation and birth weight less than 1,500 g were risk factors for sepsis. Resuscitation at birth was the leading risk factor for EOS and respiratory support prior to sepsis, presence of a central or peripheral catheter, and total parenteral nutrition were leading risk factors for LOS.

Conclusions:

A strong inverse relationship existed between gestational age of 30 weeks or younger and birth weight of 1,500 g or less and LOS. Resuscitation and indwelling intravenous catheters were also risk factors.

A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units

BACKGROUND

Infection is the most common problem with central venous catheters (CVCs) in neonates. There are two published guidelines, including the Centers for Disease Control and Prevention (CDC), for the prevention of intravascular catheter-related infection that describes evidence-based practice to reduce nosocomial infection.

OBJECTIVE

Our aims were to survey current medical and nursing management of central venous catheters in tertiary neonatal intensive care units in Australia and New Zealand and to compare with the CDC evidence-based practice guideline.

METHODS

A cross sectional survey was performed across 27 Australian and New Zealand neonatal units in September 2012. Two web-based questionnaires were distributed, one to medical directors related to the insertion of CVCs while CVC "maintenance" surveys were sent to nurse unit managers.

RESULTS

Seventy percent (19/27) medical management and 59% (16/27) on nursing management surveys were completed. In all neonatal intensive care units (NICUs) there were guidelines for CVC maintenance and for 18 out of 19 there were guidelines for insertion. In the seven units using femoral lines, three had a guideline on insertion and four for maintenance. CVC insertion was restricted to credentialed staff in 57.9% of neonatal units. Only 26.5% used full maximal sterile barriers for insertion. Skin disinfection practices widely varied. Dressing use and dressing change regimens were standardised; all using a semi-permeable dressing. Duration of cleaning time of the access point varied significantly; however, the majority used a chlorhexidine with alcohol solution (68.8%). Line and fluid changes varied from daily to 96 h. The majority used sterile gloves and a sterile dressing pack to access the CVC (68.8%). In the majority of NICUs stopcocks were used (62.5%) with a needle-less access point attached (87.5%). In less than 50% of NICUs education was provided on insertion and maintenance.

CONCLUSION

There is diversity of current practices and some aspects vary from the CDC guideline. There is a need to review NICU current practices to align with evidence based guidelines. The introduction of a common guideline may reduce variations in practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Outbreak of ampicillin/piperacillin-resistant Klebsiella pneumoniae in a neonatal intensive care unit (NICU): investigation and control measures

Klebsiella pneumoniae is a frequent cause of infectious outbreaks in Neonatal Intensive Care Units (NICUs). The aim of this paper is to describe an outbreak occurred in a 13-bed NICU and the control measures adopted in order to interrupt the chain of transmission. We described the microbiological investigations, the NICU staff compliance to the infection control measures by means of a specifically designed check-list and the control measures adopted. Six cases of primary bloodstream infections sustained by ampicillin/piperacillin-resistant Klebsiella pneumoniae were observed over a two-month period. One culture obtained from a 12% saccarose multiple-dose solution allowed the growth of Klebsiella pneumoniae. During the inspections performed by the Hospital Infection Control Team, using the check-list for the evaluation of the NICU staff compliance to the infection control measures, several breaches in the infection control policy were identified and control measures were adopted. In our case the definition of a specific check-list led to the adoption of the correct control measures. Further studies would be helpful in order to develop a standard check-list able to identify critical flows in the adhesion to the guidelines. It could be used in different NICUs and allow to obtain reproducible levels of infection control.

Distinguishing true coagulase-negative Staphylococcus infections from contaminants in the neonatal intensive care unit

OBJECTIVE

To characterize true coagulase-negative Staphylococcus (CoNS) infections in infants receiving neonatal intensive care.

STUDY DESIGN

Retrospective cohort study of neonatal intensive care unit (NICU) infants with clinical sepsis and CoNS isolated from ≥ 2 blood cultures (BCs) or one BC and a sterile site (proved infection) or CoNS isolated from one BC and deemed significant after blinded data review (probable infection).

RESULT

In all, 98% of 40 proved and 96% of 55 probable infections occurred in infants with birth weight (BW) <2000 g and gestation <34 weeks. Total central lines (CLs) placed, but not CL duration or presence in situ, predicted proved (odds ratio (OR) 3.5, 95% confidence interval (CI) 1.4 to 8.3; P=0.005) and probable infection (OR 2.7, 95% CI 1.3 to 5.6; P=0.007) by multivariate analysis as did lethargy and gastric residuals.

CONCLUSION

True CoNS infection is unlikely in infants with BW >2000 g and gestation >34 weeks. Total CL required for care, lethargy and gastric residuals predicted true CoNS infection.

Reduction in late-onset sepsis on relocating a neonatal intensive care nursery

AIMS

The aims of this study were to compare rates of late-onset sepsis (LOS) in very preterm or very low birthweight infants before and after relocation to a new nursery and to determine risk factors for LOS.

METHODS

The study was undertaken at The Royal Women's Hospital, Melbourne, which relocated to a new site in June 2008. Infants with birthweight <1500 g or <32 weeks' gestation, born between July and December 2007 (n= 149) and July and December 2008 (n= 152) were included. Each septic episode was identified from blood cultures taken from patients >48 h after birth and was categorised as definite, probable, uncertain or no sepsis.

RESULTS

Overall, 117 infants had 218 septic episodes. The proportion of infants with clinical LOS decreased from 29.5% in 2007 to 22.4% in 2008 after the relocation, although this was not statistically significant. There was a significant (P < 0.05) reduction in the severity (definite LOS = most severe) of sepsis in 2008 compared with 2007, and in rates of coagulase-negative staphylococcal LOS. Significant risk factors for LOS were: lower birthweight (g; mean -351, 95% confidence interval (CI) -446, -256); lower gestational age (weeks; mean -2.3, 95% CI -2.8, -1.7) and presence of a percutaneous inserted central catheter (odds ratio (OR) 2.56, 95% CI 1.03, 6.67).

CONCLUSIONS

There was a significant reduction in the severity of LOS in very preterm and/or very low birthweight infants that correlated with the relocation from the old to new nursery. Smaller and more immature infants with percutaneous central catheters were more at risk.

Early-onset infections of very-low-birth-weight infants in Polish neonatal intensive care units

AIM

The objective of this study was to investigate the incidence, causes, the risk factors, etiologic agents and the outcomes of early-onset infections (EOIs) in very-low-birth-weight newborns in Polish neonatal intensive care units.

METHODS

Continuous prospective infection surveillance conducted during 2009 at 6 Polish neonatal intensive care units and included 910 newborns whose birth weight was lower than 1500 g. Infections were defined according to the Gastmeier's criteria. EOIs were diagnosed <3 days after delivery.

RESULTS

The frequency of early-onset septicemia (EOS) was 7.0% and of early-onset pneumonia (EO-pneumonia) 8.6%. The factors significantly increasing the risk of EOS were low gestational age, small birth weight, low score in the Clinical Risk Index for Babies and Apgar score as well as maternal chorioamnionitis. The perinatal prophylaxis did not have an influence on the occurrence of EOS. The factors considerably increasing the risk of EO-pneumonia were low scores in the Clinical Risk Index for Babies and Apgar scores, a low gestational age and bacterial vaginosis in the child's mother during pregnancy. The most important etiologic organisms were Gram-positive cocci (39.7% of all the infections, 47.8% in EOS), Streptococcus agalactiae (20% of the EOS), Gram-negative bacilli (33.3% isolates), yeast-like fungi (isolated in 7.9% of cases) and atypical bacteria (22% of the cases of EO-pneumonia).

CONCLUSIONS

The observed frequency of EOS did not differ from the one described in the literature, whereas the frequency of EO-pneumonia was higher. The bacterial etiologies suggest the vertical transmission of the pathogens and a close relationship between the observed EOIs with maternal environment. The applied perinatal antibiotic prophylaxis was ineffective.

Antibiotic therapy in neonatal and pediatric septic shock

Severe sepsis accounts for nearly 4,500 deaths (mortality rate 10%), and is responsible for nearly $2 billion annual healthcare expenditure in the United States. Early and speedy treatment of critically ill septic patients can halt or reduce the likelihood of physiologic progression to multi-system organ failure. A cornerstone of this therapeutic strategy is antibiotic administration. In this review, we discuss the empirical treatment strategies for the treatment of early and late neonatal sepsis, along with pediatric sepsis. Furthermore, we discuss the rationale that underlies the adoption of such treatment strategies. The present article also discusses the emergence of multi-drug organisms as the causative agents for sepsis, i.e. methicillin-resistant Staphylococcus aureus (MRSA), resistant enterococci and Klebsiella pneumoniae carbapenemases (KPC).

Prevalence and characterization of extended spectrum β-lactamases in Klebsiella-Enterobacter-Serratia group bacteria, in Algeria

OBJECTIVES

The authors had for aim to assess the local epidemiology, antibiotic resistance, and molecular typing of expanded spectrum betalactamase producing Klebsiella, Enterobacter, and Serratia (ESBL KES).

MATERIALS AND METHODS

Two hundred and seven strains of the KES group were isolated in the microbiology laboratory of the Annaba Ibn Rochd hospital in 2009. The antibiotic resistance (diffusion method and MIC) was tested and ESBL detection was performed as recommended by the Clinical Laboratory Standard Institute (CLSI). The characterization of genes for resistance to β-lactams (CTX-M-1, TEM, and SHV) and AmpC cephalosporinase (DHA-1) was performed by polymerase chain reaction. The epidemiological relationship among identified strains was analyzed by Pulsed Field Gel Electrophoresis (PFGE). Genetic transfers were performed by conjugation using sodium azide resistant Escherichia coli K(12)J(5) as recipient strain.

RESULTS

The overall incidence of ESBL KES was 31.4% (65/207) distributed as follows: 17.4% of Klebsiella spp., 7.2% Enterobacter spp., and 6.8% Serratia marcescens. The β-lactamase CTX-M 1 types were predominant (88%), followed by TEM (36.5%), and SHV (31.1%). Twenty-three strains expressed at least two bla genes. DHA-1 type cephalosporinase was found in 4 E. cloacae associated with CTX-M-1. Several epidemic clones were determined. Conjugation experiments showed that bla(CTX-M), bla(TEM), and bla(SHV) were carried by conjugative plasmids of high molecular weight (≥125kb).

CONCLUSIONS

This study revealed a high frequency of ESBL KES with a predominance of CTX-M-1. This high rate of ESBLs could be due to a clonal spread and the emergence of new epidemic clones.

Use of rifampin in persistent coagulase negative staphylococcal bacteremia in neonates

BACKGROUND

Coagulase negative staphylococci (CoNS) are the most common cause of neonatal sepsis in the Neonatal Intensive Care Unit (NICU). A minority of neonates does not respond to vancomycin therapy and develops persistent bacteremia, which may be treated with rifampin. We evaluated the use of rifampin in persistent CoNS bacteremia.

METHODS

Retrospective study of 137 neonates with CoNS bacteremia during admission to a tertiary NICU between July 2006 and July 2009. Main outcome measures were total duration of bacteremia and the adequacy of vancomycin and rifampin therapy.

RESULTS

137/1696 (8.0%) neonates developed a CoNS bacteremia. Eighteen were treated with rifampin because of persistent bacteremia (3 positive blood cultures at least 48 hours apart with clinical symptoms) or (a serious suspicion of) an intravascular thrombus. Duration of bacteremia prior to rifampin therapy (8.0 ± 3.6 days) was positively correlated (p < 0.001) to the total duration of bacteremia (10.3 ± 3.7 days). After starting rifampin therapy C-reactive protein (CRP) levels of all neonates declined and blood cultures became sterile after 2.3 ± 1.6 days. Vancomycin levels were not consistently measured in all neonates, resulting in late detection of subtherapeutic trough levels.

CONCLUSION

Rifampin may be effective in the treatment of persistent CoNS infections in neonates. Outcome may be improved by adequate monitoring of vancomycin trough levels.

Determinants of nosocomial infection in 6 neonatal intensive care units: an Italian multicenter prospective cohort study

BACKGROUND

Nosocomial infections are still a major cause of morbidity and mortality among neonates admitted to neonatal intensive care units (NICUs).

OBJECTIVE

To describe the epidemiology of nosocomial infections in NICUs and to assess the risk of nosocomial infection related to the therapeutic procedures performed and to the clinical characteristics of the neonates at birth and at admission to the NICU, taking into account the time between the exposure and the onset of infection.

DESIGN

A multicenter, prospective cohort study.

PATIENTS AND SETTING

A total of 1,692 neonates admitted to 6 NICUs in Italy were observed and monitored for the development of nosocomial infection during their hospital stay.

METHODS

Data were collected on the clinical characteristics of the neonates admitted to the NICUs, their therapeutic interventions and treatments, their infections, and their mortality rate. The cumulative probability of having at least 1 infection and the cumulative probability of having at least 1 infection or dying were estimated. The hazard ratio (HR) for the first infection and the HR for the first infection or death were also estimated.

RESULTS

A total of 255 episodes of nosocomial infection were diagnosed in 217 neonates, yielding an incidence density of 6.9 episodes per 1,000 patient-days. The risk factors related to nosocomial infection in very-low-birth-weight neonates were receipt of continuous positive airway pressure (HR, 3.8 [95% confidence interval {CI}, 1.7-8.1]), a Clinical Risk Index for Babies score of 4 or greater (HR, 2.2 [95% CI, 1.4-3.4]), and a gestational age of less than 28 weeks (HR, 2.1 [95% CI, 1.2-3.8]). Among heavier neonates, the risk factors for nosocomial infection were receipt of parenteral nutrition (HR, 8.1 [95% CI, 3.2-20.5]) and presence of malformations (HR, 2.3 [95% CI, 1.5-3.5]).

CONCLUSIONS

Patterns of risk factors for nosocomial infection differ between very-low-birth-weight neonates and heavier neonates. Therapeutic procedures appear to be strong determinants of nosocomial infection in both groups of neonates, after controlling for clinical characteristics.

Role of mannose-binding lectin in nosocomial sepsis in critically ill neonates

We investigated the association of mannose-binding lectin (MBL) serum levels with nosocomial sepsis (NS), their changes overtime during infection, their relation with pathogens, with the MBL2 genotype and their relationship with mortality. In a prospective observational study, we included 365 critically ill neonates: 261 had no infection and 104 had at least 1 septic event. The median MBL serum concentration was significantly lower in infected than in noninfected neonates (p < 0.001). Low MBL levels on admission increased the risk of infection, independently from gestational age and invasive procedures. The median peak MBL level during infection was higher than the median level on admission (p < 0.001) and was correlated with it (r(2) = 0.83, p < 0.001). Moreover, MBL levels on admission were not associated with death (OR = 0.80, 95% CI = 0.56-1.14, p = 0.21). Similarly, no association was found between MBL peak levels during infection and death among infected neonates (OR = 1.10, 95% CI = 0.78-1.57, p = 0.57). In 127 neonates (42 infected) genotyped for exon-1 and -221 promoter MBL2 variants, we did not find significant difference in the frequencies of MBL2 genotypes between infected and noninfected neonates. Moreover, no association was found between MBL2 genotypes and death.

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

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

Nosocomial sepsis risk score for preterm infants in low-resource settings

Sepsis is a leading cause of mortality for neonates in developing countries; however, little research has focused on clinical predictors of nosocomial infection of preterm neonates in the low-resource setting. We sought to validate the only existing feasible score introduced by Singh et al. in 2003 and to create an improved score. In a secondary analysis of daily evaluations of 497 neonates <or=33 weeks gestational age admitted to a tertiary care NICU in Dhaka, Bangladesh, we tested the Singh score and then constructed and internally validated our own bedside predictive score. The Singh score had low sensitivity of 56.6% but good positive predictive value (PPV) of 78.1% in our sample. Our five-sign model requiring at least one clinical sign of infection (apnea, hepatomegaly, jaundice, lethargy and pallor) had an area under the receiver operating characteristic of 0.70, sensitivity of 77.1%, and PPV of 64.9%. Our clinical sepsis score is the first bedside clinical screen exclusively for hospitalized, very premature neonates in a low-resource setting, and warrants external validation.

Hospital-acquired infection surveillance in a neonatal intensive care unit

BACKGROUND

Hospital-acquired infections (HAIs) represent an important cause of morbidity and mortality in neonatal intensive care units (NICUs).

METHODS

All neonates admitted for > 48 hours between January 2003 and December 2006 in the NICU of the teaching hospital Umberto I of Rome, Italy were considered.

RESULTS

Of the 575 neonates evaluated, 76 (13.2%) developed a total of 100 HAIs, including 36 bloodstream infections (BSIs), 33 pneumonias, 19 urinary tract infections, 8 conjunctivitis, and 4 onphalitis. There were 7.8 HAIs/1000 patient-days and 12.5 BSIs/1000 days of umbilical catheterization. Logistic analysis identified an association with mechanical ventilation (odds ratio [OR] = 3.05; 95% confidence interval [CI] = 1.75 to 5.31; P < .01) and birth weight <or= 1500 g (OR = 2.34; 95% CI = 1.36 to 4.03; P < .01). Thirty-five neonates (6.1%) died. Klebsiella pneumoniae (37.7%) and coagulase-negative staphylococci (28.6%) were the most frequently isolated microorganisms. Only 3 Candida spp determined BSIs (8.3%). BSI mortality was higher in infections with gram-negative pathogens (36.4%) than in infections with gram-positive pathogens (4.5%).

CONCLUSIONS

Although we found a low infection and mortality rate, attention should be directed toward antibiotic-resistant gram-negative pathogens.