Reducing neonatal nosocomial bloodstream infections through participation in a national surveillance system

A 6-year prospective surveillance of healthcare-associated infections in a neonatal intensive care unit from southern part of Turkey

AIM

To report the incidence of healthcare-associated infections (HAIs), site of infection and bacterial epidemiology in the Neonatal Intensive Care Unit in a university hospital in Adana, Turkey, between 2001 and 2006.

METHODS

During these years, HAIs were collected by an active surveillance system.

RESULTS

Five hundred one of 2832 infants hospitalised more than 72 h had 1124 HAI. The HAI incidence and incidence density ranged between 14.1 and 29.7 infections/100 patients, and 10.9-17.3 infections/1000 patient days within the study period; 61.5% of HAIs were ventilator-associated infections; 26.2% were bloodstream infections; 3.5% were urinary tract infections; 3.5% were necrotising enterocolitis (Stages II and III) and 1.4% was meningitis. The most frequent pathogens were gram-negative pathogens (75.6% of all infections) followed by gram-positive micro-organisms (21.4%) and Candida species (3.0%). Birthweight, gestational age and Apgar scores were lower and overall mortality rate (32.9% vs. 19.7%) and number of inpatient days were higher in patients with HAIs (for all P<0.001) when compared with those who did not have HAIs. Furthermore, HAI rate was inversely related to birthweight (P<0.001).

CONCLUSION

In this study, the overall infection rate is high compared with developed countries and predominant micro-organisms are gram-negative enteric rods. These results strongly suggest the need for improving measures for prevention and control of HAIs in this hospital.

Neonatal rates and risk factors of device-associated bloodstream infection in a tertiary care center in Saudi Arabia

In a prospective surveillance study, we examine the risk of device-associated bloodstream infection (BSI) in a neonatal intensive care unit at Riyadh, Saudi Arabia, during 2006 and 2007. The incidence per 1000 device-days was 8.2 for central line-associated BSI and 10.5 for umbilical catheter-associated BSI. Both rates were higher with more umbilical catheter and less central line utilization ratios compared with those reported by the American National Healthcare Safety Network hospitals. Concurrent with implementation of more strict infection control practices, BSI rates declined over the course of the study. Prolonged device duration was an independent risk factor for device-associated BSI.

Reproducibility of the surveillance effect to decrease nosocomial infection rates

OBJECTIVE

To investigate whether the reduction effect due to participation in a nosocomial infection surveillance system for laboratory-confirmed central venous catheter (CVC)-associated primary bloodstream infection (BSI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI) is reproducible for different time periods, independent of confounding factors that might occur during a specific time period.

METHODS

Data from the German national nosocomial infection surveillance system from the period January 1997 through June 2008 were used. CVC-associated BSI data and SSI data were analyzed for 3 starting periods, and VAP data were analyzed for 2 starting periods. Monthly infection rates were calculated for the following 36 months, and relative risks comparing the first and third surveillance years of each period were calculated.

RESULTS

A total of 2,399 CVC-associated BSI cases from 267 intensive care units, 3,637 VAP cases from 150 intensive care units, and 829 SSIs following 3 different procedures from 113 departments were analyzed. A significant reduction in VAP was shown for both starting periods investigated (overall relative risk [RR], 0.80 [95% CI, 0.74-0.86]). A significant reduction in CVC-associated BSI was demonstrated for 2 of 3 starting periods (overall RR, 0.83 [95% CI, 0.75-0.91]). A significant reduction in SSI was found for 2 starting periods for knee prosthesis insertion (overall RR, 0.56 [95% CI, 0.38-0.82]), for all of the 3 starting periods for cesarean delivery (overall RR, 0.75 [95% CI, 0.61-0.93]), and for none of the 3 starting periods for endoscopically performed cholecystectomy (overall RR, 0.89 [95% CI, 0.62-1.27]).

CONCLUSIONS

The surveillance effect, manifest as a significant reduction of nosocomial infection rates between the first and third years of participation in a surveillance system, was observed independently from the calendar year in which the surveillance activities started.

Development of a statewide collaborative to decrease NICU central line-associated bloodstream infections

OBJECTIVE

To characterize hospital-acquired bloodstream infection rates among New York State's 19 regional referral NICUs (at regional perinatal centers; RPCs) and develop strategies to promote best practices to reduce central line-associated bloodstream infections (CLABSIs).

STUDY DESIGN

During 2006 and 2007, RPC NICUs reported bloodstream infections, patient-days and central line-days to the Department of Health, and shared their results. Aiming to improve, participants created a central line-care bundle based on visiting a potentially best performing NICU and reviewing the literature.

RESULT

All 19 RPCs participated in this quality initiative, contributing 218,096 patient-days and 56,911 central line-days of observation. Individual RPC nosocomial sepsis infection (NI) rates ranged from 1.0 to 5.8 NIs per 1000 patient-days (2006), and CLABSI rates ranged from 2.6 to 15.1 CLABSIs per 1000 central line-days (2007). A six-fold rate variation among RPC NICUs was observed. Participants unanimously approved a level-1 evidence-based central line-care bundle.

CONCLUSION

Individual RPC rates and consequent morbidity and resource use attributable to these infections were substantial and varied greatly. No center was without infections. It is hoped that the cooperation and accountability exhibited by the RPCs will result in a major network for characterizing performance and improving outcomes.

Risk-adjusted surveillance of hospital-acquired infections in neonatal intensive care units: a systematic review

Comparisons of bacteraemia incidence between neonatal intensive care units (NICUs) can identify centres with effective infection control, whose practices can be shared with other units. For fair comparisons, infection incidence must be risk-adjusted to control for differences between centres in the vulnerability of babies and the intensity of invasive procedures which can introduce infection. We reviewed risk adjustment methods for between-NICU comparisons of bacteraemia incidence, both in the published literature and in regional and national NICU infection monitoring systems. PubMed and Embase were searched for studies reporting risk-adjusted bacteraemia incidence in more than one NICU. An internet search found NICU infection monitoring systems in Western industrialised countries. In all nine studies that met the inclusion criteria, risk adjustment reduced but did not eliminate variation in bacteraemia incidence between NICUs. In both the studies and the regional monitoring systems, adjustment for baby susceptibility generally involved stratification by factors measured at birth. Adjustment for Length of stay and invasive procedures involved reporting incidence by days with a device, such as central venous catheter days. Methods for NICU infection monitoring lack consistency. Adjustment for factors measured at birth fails to capture changes in susceptibility throughout admission and adjustment for device days does not adequately reflect risk to babies not treated with the device. Further research should address variation in risk for all babies throughout their NICU stay.

Infecção hospitalar em Unidade de Terapia Intensiva Neonatal: há influência do local de nascimento?

OBJETIVO: Analisar comparativamente a incidência e o perfil etiológico da infecção hospitalar em recém-nascidos (RN) de origem interna e externa, admitidos em Unidade de Terapia Intensiva Neonatal (UTIN). MÉTODOS: Estudo de coorte em RN internados na UTIN em 2002 e 2003. A vigilância epidemiológica das infecções hospitalares foi realizada prospectivamente, seguindo-se os métodos do National Nosocomial Infections Surveillance System. Compararam-se as características clínicas, demográficas, a incidência de infecção hospitalar precoce e tardia e o perfil dos microrganismos isolados dos RN com infecção tardia, segundo o local de nascimento. RESULTADOS: Incluíram-se no estudo 426 RN de origem interna (88%) e 60 de origem externa (12%). A incidência de infecção hospitalar precoce foi 10% e tardia, 21%, sem diferença estatística entre os RN internos e externos quanto à ocorrência de infecção hospitalar precoce (p=0,40) e tardia (p=0,41). Entre os micro-organismos isolados na infecção tardia, 52% foram Gram-positivos, com predomínio do Staphylococcus coagulase negativo, tanto para as infecções em RN externos (33%) quanto internos (41%). Dentre os Gram-negativos, Pseudomonas spp. e Enterobacter spp. foram isolados com maior frequência nos RN externos. A sepse (54%) e a pneumonia (20%) foram as infecções mais frequentes. CONCLUSÕES: Entre os grupos de RN separados de acordo com o local de nascimento, não houve diferença na incidência de infecção hospitalar precoce e tardia e no agente etiológico predominante da infecção hospitalar tardia.

Strategies to prevent bacterial and fungal infection in the neonatal intensive care unit

Hospital-acquired infections are one of the leading causes of preventable morbidity and mortality in neonatal intensive care units (NICUs). Device-related infections, such as catheter-associated blood stream infections (CABSIs) and ventilator-associated pneumonia (VAP), are the most common nosocomial infections. This review examines the pathogenesis of CABSIs and methods, widely accepted and novel, that can be used to help prevent them. Strategies to prevent fungal infections, which are often associated with the presence of a central venous catheter, are also reviewed. Finally, the dilemmas in the diagnosis and prevention of VAP in the NICU are discussed.

Which factors predict hospital-acquired late-onset neonatal sepsis?

Neonates are one of the highest risk groups of hospitalized patients for sepsis. There is a wide variation in the incidence and microbial causes of late-onset neonatal sepsis, owing to differences in both patient populations and standards of care in the individual neonatal units. Stratification according to risk factors is required to allow the meaningful comparison of infection rates between units. Knowledge of risk factors is also important in order to target interventions on high-risk aspects of neonatal care. Few independent risk factors for late-onset sepsis have been identified, the most common being birth gestational age and parenteral nutrition. Further work is required to validate that these observations can be generalized, and that they could, therefore, be used to stratify infection rates in multicenter surveillance schemes.

Incidence of healthcare-associated infections in high-risk neonates: results from the German surveillance system for very-low-birthweight infants

Infants with birthweight <1500g (VLBW) are at high risk of healthcare-associated infection (HAI). We present surveillance data from the NEO-KISS surveillance system, collected between 2000 and 2005 by 52 neonatology departments in Germany. Infants were stratified into two birthweight categories (<1000 and 1000-1499 g), and rates of nosocomial bloodstream infection (BSI), nosocomial pneumonia and necrotising enterocolitis (NEC) were calculated. The data presented comprise 8677 VLBW and 339,972 patient-days. The incidence of bloodstream infection was 6.5 per 1000 patient-days (8.5 and 4.0 according to birthweight category). The incidence of central venous catheter (CVC)-associated BSI was 11.1 per 1000 CVC-days and the incidence of peripheral venous catheter (PVC)-associated BSI was 7.8 per 1000 PVC-days. The incidence of pneumonia was 0.9 per 1000 patient-days (1.3 and 0.4 according to birthweight category). The incidence of pneumonia among intubated patients was 2.7 per 1000 ventilator-days, while the incidence of pneumonia among patients receiving continuous nasel positive airway pressure (CPAP) was 1.0 per 1000 CPAP-days. The incidence of NEC was 0.9 per 1000 patient-days (1.1 and 0.6 according to birthweight category). HAI is frequent among VLBW and shows wide variation between neonatology departments. Preventive strategies to reduce infections in these infants should be prioritised.

European perspective on surveillance

International comparisons yield interesting insights regarding quality of care, beyond the field of healthcare-associated infection (HAI) prevention. Therefore, the exchange of experiences of national surveillance systems should be encouraged. However, the interpretation of differences of HAI rates should be made very carefully. Differences in healthcare systems, legal and cultural aspects, as well as differences in the methods of the surveillance systems, may have an enormous influence. One of the most crucial aspects of surveillance data is their validity, therefore it would be very helpful to combine the experience of all European validation studies performed in order to develop a protocol for a meaningful and cost-effective method for performing validation studies. Meanwhile some national surveillance systems have shown their effectiveness with reductions of 24 57% for surgical site infections (SSIs) and 20 29% for HAI in ICUs. Today, mandatory public reporting is probably the most demanding problem for the national HAI surveillance systems in Europe. The exchange of experience between the European surveillance networks in this respect in particular--remains a cornerstone and will motivate further activities in the individual countries.