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Rangelova V, Kevorkyan A, Raycheva R, Krasteva M. Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit-Incidence and Strategies for Prevention. Diagnostics (Basel) 2024; 14:240. [PMID: 38337756 PMCID: PMC10854825 DOI: 10.3390/diagnostics14030240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
The second most prevalent healthcare-associated infection in neonatal intensive care units (NICUs) is ventilator-associated pneumonia (VAP). This review aims to update the knowledge regarding the incidence of neonatal VAP and to summarize possible strategies for prevention. The VAP incidence ranges from 1.4 to 7 episodes per 1000 ventilator days in developed countries and from 16.1 to 89 episodes per 1000 ventilator days in developing countries. This nosocomial infection is linked to higher rates of illness, death, and longer hospital stays, which imposes a substantial financial burden on both the healthcare system and families. Due to the complex nature of the pathophysiology of VAP, various approaches for its prevention in the neonatal intensive care unit have been suggested. There are two main categories of preventative measures: those that attempt to reduce infections in general (such as decontamination and hand hygiene) and those that target VAP in particular (such as VAP care bundles, head of bed elevation, and early extubation). Some of the interventions, including practicing good hand hygiene and feeding regimens, are easy to implement and have a significant impact. One of the measures that seems very promising and encompasses a lot of the preventive measures for VAP are the bundles. Some preventive measures still need to be studied.
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Affiliation(s)
- Vanya Rangelova
- Department of Epidemiology and Disaster Medicine, Faculty of Public Health, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
| | - Ani Kevorkyan
- Department of Epidemiology and Disaster Medicine, Faculty of Public Health, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
| | - Ralitsa Raycheva
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
| | - Maya Krasteva
- Department of Obstetrics and Gynecology, Neonatology Unit, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria;
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2
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Zhai Q, Li S, Zhang L, Yang Y, Jiang S, Cao Y. Changes in pathogens of neonatal bacterial meningitis over the past 12 years: a single-center retrospective study. Transl Pediatr 2022; 11:1595-1603. [PMID: 36345456 PMCID: PMC9636462 DOI: 10.21037/tp-22-103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 08/25/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Bacterial meningitis is a serious central nervous system infection associated with high morbidity and mortality during the neonatal period, while the pathogen distribution was rarely reported on a large scale in China. This study aimed to investigate the distribution and change trends of neonatal bacterial meningitis pathogens in Children's Hospital of Fudan University over the past 12 years. METHODS This retrospective study included all cases diagnosed with neonatal bacterial meningitis and admitted to our hospital from 2009 to 2020. RESULTS Totally 231 cases were enrolled, including 128 (55.4%) for male, 72 (31.2%) for premature infants, 48 (20.8%) for early-onset meningitis. The most common pathogens were Escherichia coli (E. coli) (39.0%) and Group B Streptococcus (GBS) (22.1%). Gram-negative bacteria were more common in preterm infants than in full-term infants (P=0.005). GBS was more common in term infants (P=0.000); Klebsiella pneumoniae (P=0.000) and Enterobacter cloacae (P=0.034) were more common in preterm infants. Gram-positive bacteria were more frequent in early-onset meningitis than in late-onset meningitis (P=0.002). Both E. coli (46.3% vs. 30.9%, P=0.017) and GBS (29.8% vs. 13.6%, P=0.003) increased, and Enterococcus (3.3% vs. 12.7%, P=0.008) decreased significantly in the epoch from 2015 to 2020 compared with the epoch from 2009 to 2014. CONCLUSIONS GBS and E. coli are the most common pathogens of neonatal bacterial meningitis in our hospital, and both have shown an upward trend over the past 12 years.
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Affiliation(s)
- Qian Zhai
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Shujuan Li
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Lan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yi Yang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Shanghai, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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3
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Dramowski A, Aucamp M, Beales E, Bekker A, Cotton MF, Fitzgerald FC, Labi AK, Russell N, Strysko J, Whitelaw A, Coffin S. Healthcare-Associated Infection Prevention Interventions for Neonates in Resource-Limited Settings. Front Pediatr 2022; 10:919403. [PMID: 35874586 PMCID: PMC9301049 DOI: 10.3389/fped.2022.919403] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Healthcare-associated infections (HAIs) and antimicrobial-resistant (AMR) infections are leading causes of neonatal morbidity and mortality, contributing to an extended hospital stay and increased healthcare costs. Although the burden and impact of HAI/AMR in resource-limited neonatal units are substantial, there are few HAI/AMR prevention studies in these settings. We reviewed the mechanism of action and evidence supporting HAI/AMR prevention interventions, including care bundles, for hospitalized neonates in low- and middle-income countries (LMIC).
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Affiliation(s)
- Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marina Aucamp
- Infection Prevention and Control Service, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Emily Beales
- Center for Neonatal and Pediatric Infection, St George's University of London, London, United Kingdom
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mark Frederic Cotton
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Felicity C. Fitzgerald
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Appiah-Korang Labi
- Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
| | - Neal Russell
- Center for Neonatal and Pediatric Infection, St George's University of London, London, United Kingdom
| | - Jonathan Strysko
- Department of Paediatric and Adolescent Health, Princess Marina Hospital, Gaborone, Botswana
- Department of Global Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Andrew Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Susan Coffin
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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4
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Dutta S, Kumar P, Paulpandian R, Sajan Saini S, Sreenivasan P, Mukhopadhyay K, Sundaram V, Kumar J, Ray P. Relationship Between COVID-19 Lockdown and Epidemiology of Neonatal Sepsis. Pediatr Infect Dis J 2022; 41:482-489. [PMID: 35195565 PMCID: PMC9083315 DOI: 10.1097/inf.0000000000003489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND We compared the hospital-based epidemiology of neonatal sepsis after the coronavirus disease 2019 lockdown (LD) versus historical epochs and the LD period versus phases of unlocking. METHODS This retrospective cohort study was conducted in a level 3 neonatal unit. We compared neonates born in three 24-week periods-Group LD: 22 March 2020 to 5 September 2020-the reference group, Group pre-LD: 29 September 2019 to 14 March 2020 and Group temporally corresponding to LD in 2019 (corres-LD): 24 March 2019 to 7 September 2019. We also studied linear trends from LD phase 1.0 until Unlock 4.0. The key outcome was culture-positive sepsis. RESULTS There were 1622, 2744 and 2700 subjects in groups LD, pre-LD and corres-LD, respectively. The incidence of any culture-positive sepsis in pre-LD was higher than LD [odds ratio (95% CI) = 1.61 (1.02-2.56)]. This was mainly due to a statistically significant reduction in Acinetobacter baumannii sepsis, with incidence rate differences of pre-LD versus LD [0.67 (95% CI: 0.37-0.97), P = 0.0001] and corres-LD versus LD [0.40 (95% CI: 0.16-0.64), P = 0.0024]. Groups pre-LD and corres-LD had higher proportion of multi-drug resistant (MDR)/extreme drug resistance/pan drug resistance sepsis than LD [77%, 77% and 44%, respectively (P values of both groups vs. LD = 0.01)]. From LD 1.0 to unlock 4.0, there were fewer episodes of MDR sepsis (Plinear trends = 0.047). On multivariable analysis, group pre-LD (vs. reference group LD), male sex, birth weight and Apgar score independently predicted culture-positive sepsis. CONCLUSIONS LD favorably impacted the epidemiology of neonatal sepsis in a hospital setting, with less A. baumannii and MDR sepsis, which persisted during unlocking.
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Affiliation(s)
| | | | | | | | - Priya Sreenivasan
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | | | | | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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5
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Fitzgerald FC, Zingg W, Chimhini G, Chimhuya S, Wittmann S, Brotherton H, Olaru ID, Neal SR, Russell N, da Silva ARA, Sharland M, Seale AC, Cotton MF, Coffin S, Dramowski A. The Impact of Interventions to Prevent Neonatal Healthcare-associated Infections in Low- and Middle-income Countries: A Systematic Review. Pediatr Infect Dis J 2022; 41:S26-S35. [PMID: 35134037 PMCID: PMC8815829 DOI: 10.1097/inf.0000000000003320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinically suspected and laboratory-confirmed bloodstream infections are frequent causes of morbidity and mortality during neonatal care. The most effective infection prevention and control interventions for neonates in low- and middle-income countries (LMIC) are unknown. AIM To identify effective interventions in the prevention of hospital-acquired bloodstream infections in LMIC neonatal units. METHODS Medline, PUBMED, the Cochrane Database of Systematic Reviews, EMBASE and PsychInfo (January 2003 to October 2020) were searched to identify studies reporting single or bundled interventions for prevention of bloodstream infections in LMIC neonatal units. RESULTS Our initial search identified 5206 articles; following application of filters, 27 publications met the inclusion and Integrated Quality Criteria for the Review of Multiple Study Designs assessment criteria and were summarized in the final analysis. No studies were carried out in low-income countries, only 1 in Sub-Saharan Africa and just 2 in multiple countries. Of the 18 single-intervention studies, most targeted skin (n = 4) and gastrointestinal mucosal integrity (n = 5). Whereas emollient therapy and lactoferrin achieved significant reductions in proven neonatal infection, glutamine and mixed probiotics showed no benefit. Chlorhexidine gluconate for cord care and kangaroo mother care reduced infection in individual single-center studies. Of the 9 studies evaluating bundles, most focused on prevention of device-associated infections and achieved significant reductions in catheter- and ventilator-associated infections. CONCLUSIONS There is a limited evidence base for the effectiveness of infection prevention and control interventions in LMIC neonatal units; bundled interventions targeting device-associated infections were most effective. More multisite studies with robust study designs are needed to inform infection prevention and control intervention strategies in low-resource neonatal units.
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Affiliation(s)
- Felicity C. Fitzgerald
- From the Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Walter Zingg
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gwendoline Chimhini
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Zimbabwe
| | - Simbarashe Chimhuya
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Zimbabwe
| | - Stefanie Wittmann
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Brotherton
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Unit, The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Ioana D. Olaru
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samuel R. Neal
- From the Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Neal Russell
- Paediatric Infectious Diseases Research Group, St George’s University of London, United Kingdom
| | - André Ricardo Araujo da Silva
- Laboratory of Teaching of Prevention and Control of Healthcare-Associated Infections, Federal Fluminense University, Brazil
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George’s University of London, United Kingdom
| | - Anna C. Seale
- From the Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mark F. Cotton
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Stellenbosch University, South Africa, and
| | - Susan Coffin
- Children’s Hospital of Philadelphia, Pennsylvania, Philadelphia
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Stellenbosch University, South Africa, and
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Molina García A, Cross JH, Fitchett EJ, Kawaza K, Okomo U, Spotswood NE, Chiume M, Ezeaka VC, Irimu G, Salim N, Molyneux EM, Lawn JE. Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review. EClinicalMedicine 2022; 44:101259. [PMID: 35059614 PMCID: PMC8760419 DOI: 10.1016/j.eclinm.2021.101259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements). METHODS Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively. FINDINGS 3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control. INTERPRETATION The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap. FUNDING This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).
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Affiliation(s)
| | - James H. Cross
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kondwani Kawaza
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Uduak Okomo
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Naomi E. Spotswood
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | | | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Kenya
| | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Elizabeth M. Molyneux
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Joy E. Lawn
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - with the NEST360 Infection Prevention, Detection and Care Collaborative Group
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Paediatrics, College of Medicine, University of Lagos, Nigeria
- Department of Paediatrics and Child Health, University of Nairobi, Kenya
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
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7
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Wastnedge E, Waters D, Murray SR, McGowan B, Chipeta E, Nyondo-Mipando AL, Gadama L, Gadama G, Masamba M, Malata M, Taulo F, Dube Q, Kawaza K, Khomani PM, Whyte S, Crampin M, Freyne B, Norman JE, Reynolds RM. Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review. J Glob Health 2021; 11:04050. [PMID: 35003711 PMCID: PMC8709903 DOI: 10.7189/jogh.11.04050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.
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Affiliation(s)
- Elizabeth Wastnedge
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Donald Waters
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Sarah R Murray
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Brian McGowan
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Effie Chipeta
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems & Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gladys Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Martha Masamba
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Malata
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sonia Whyte
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Mia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Research Program, Blantyre, Malawi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca M Reynolds
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
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8
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Wang W, van Wijngaarden J, Wang H, Buljac-Samardzic M, Yuan S, van de Klundert J. Factors Influencing the Implementation of Foreign Innovations in Organization and Management of Health Service Delivery in China: A Systematic Review. FRONTIERS IN HEALTH SERVICES 2021; 1:766677. [PMID: 36926484 PMCID: PMC10012679 DOI: 10.3389/frhs.2021.766677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022]
Abstract
Background: China has been encouraged to learn from international innovations in the organization and management of health service delivery to achieve the national health reform objectives. However, the success and effectiveness of implementing innovations is affected by the interactions of innovations with the Chinese context. Our aim is to synthesize evidence on factors influencing the implementation of non-Chinese innovations in organization and management of health service delivery in mainland China. Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched seven databases for peer-reviewed articles published between 2009 and 2020. Data were analyzed and combined to generate a list of factors influencing the implementation of foreign innovations in China. The factors were classified in the categories context, system, organization, innovation, users, resources, and implementation process. Results: The 110 studies meeting the inclusion criteria revealed 33 factors. Most supported by evidence is the factor integration in organizational policies, followed by the factors motivation & incentives and human resources. Some factors (e.g., governmental policies & regulations) were mentioned in multiple studies with little or no evidence. Conclusion: Evidence on factors influencing the implementation of foreign innovations in organization and management of health service delivery is scarce and of limited quality. Although many factors identified in this review have also been reported in reviews primarily considering Western literature, this review suggests that extrinsic motivation, financial incentives, governmental and organizational policies & regulations are more important while decentralization was found to be less important in China compare to Western countries. In addition, introducing innovations in rural China seems more challenging than in urban China, because of a lack of human resources and the more traditional rural culture.
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Affiliation(s)
- Wenxing Wang
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Jeroen van Wijngaarden
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Hujie Wang
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Martina Buljac-Samardzic
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Shasha Yuan
- Institute of Medical Information and Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Joris van de Klundert
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Mohammad Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia
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9
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Nair NS, Lewis LE, Dhyani VS, Murthy S, Godinho M, Lakiang T, Venkatesh BT. Factors Associated With Neonatal Pneumonia and its Mortality in India: A Systematic Review and Meta-Analysis. Indian Pediatr 2021. [PMID: 34837367 PMCID: PMC8639407 DOI: 10.1007/s13312-021-2374-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Neonatal pneumonia remains a significant contributor to infant mortality in India and responsible for increased prevalence of infant deaths globally. Objective To identify risk factors associated with neonatal pneumonia and its mortality in India. Study design A systematic review was conducted including both analytic study designs and descriptive study designs, which reported a quantitative analysis of factors associated with all the three types of pneumonia among neonates. The search was conducted from August to December, 2016 on the following databases; CINAHL, EMBASE, Ovid MEDLINE, PubMed, ProQuest, SCOPUS, Web of Science, WHO IMSEAR and IndMED. The search was restricted to Indian setting. Participants The population of interest was neonates. Outcomes The outcome measures included risk factors for incidences and mortality predictors of neonatal pneumonia. These could be related to neonate, maternal and pregnancy, caregiver, family, environment, healthcare system, iatrogenic and others. Results A total of three studies were included. For risk factors, two studies on ventilator-associated pneumonia were included with 194 neonates; whereas for mortality predictors, only one study with 150 neonates diagnosed with pneumonia was included. 11 risk factors were identified from two studies: duration of mechanical ventilation, postnatal age, birth weight, prematurity, sex of the neonate, length of stay in NICU, primary diagnosis, gestational age, number of re-intubation, birth asphyxia, and use of nasogastric tube. Metaanalysis with random-effects model was possible only for prematurity (<37 week) and very low birth weight (<1500 g) and very low birth weight was found to be significant (OR 5.61; 95% CI 1.76, 17.90). A single study was included on predictors of mortality. Mean alveolar arterial oxygen gradient (AaDO2) >250 mm Hg was found to be the single most significant predictor of mortality due to pneumonia in neonates. Conclusion The study found scant evidence from India on risk factors of neonatal pneumonia other than ventilator-associated pneumonia. Electronic Supplementary Material Supplementary material is available in the online version of this article at 10.1007/s13312-021-2374-4
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Affiliation(s)
- N Sreekumaran Nair
- Department of Statistics, Public Health Evidence South Asia (PHESA), Manipal Academy of Higher Education, Manipal, Karnataka
| | - Leslie Edward Lewis
- Department of Pediatrics, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, Karnataka
| | - Vijay Shree Dhyani
- Department of Statistics, Public Health Evidence South Asia (PHESA), Manipal Academy of Higher Education, Manipal, Karnataka
| | - Shruti Murthy
- Department of Statistics, Public Health Evidence South Asia (PHESA), Manipal Academy of Higher Education, Manipal, Karnataka
| | - Myron Godinho
- Department of Statistics, Public Health Evidence South Asia (PHESA), Manipal Academy of Higher Education, Manipal, Karnataka
| | - Theophilus Lakiang
- Department of Statistics, Public Health Evidence South Asia (PHESA), Manipal Academy of Higher Education, Manipal, Karnataka
| | - Bhumika T Venkatesh
- Department of Statistics, Public Health Evidence South Asia (PHESA), Manipal Academy of Higher Education, Manipal, Karnataka. Correspondence to: Dr Bhumika T Venkatesh, Room no. 35, Public Health Evidence South Asia (PHESA), Prasanna School of Public Health, Manipal Academy of Higher Education, Madhav Nagar, Manipal, Karnataka.
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Jiang S, Zhang L, Yan W, Li S, Han J, Zhou Q, Yang Y, Lee SK, Cao Y. Antibiotic Use in Neonatal Intensive Care Units in China: A Multicenter Cohort Study. J Pediatr 2021; 239:136-142.e4. [PMID: 34461063 DOI: 10.1016/j.jpeds.2021.08.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/21/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To provide national-level antibiotic use data from Chinese neonatal intensive care units to inform future antimicrobial stewardship using a large contemporary cohort of preterm infants in China. STUDY DESIGN This retrospective cohort study enrolled all infants less than 340/7 weeks of gestation admitted to 25 tertiary neonatal intensive care units across China between May 1, 2015, and April 30, 2018. The antibiotic use rate (AUR) was defined as the number of days an infant was prescribed with 1 or more antibiotics divided by the total length of hospital stay. RESULTS Among 24 597 eligible infants, 21 736 (88.4%) infants received antibiotics. The median AUR was 441 per 1000 patient-days (IQR, 242-692 per 1000 patient-days). The median duration of each antibiotic course was 9 days (IQR, 6-14 days). Overall, 64.6% infants received broad-spectrum antibiotics, with a median broad-spectrum AUR of 250 per 1000 patient-days (IQR, 0-500 per 1000 patient-days), accounting for 70.7% of all antibiotic use days. Overall, 68.7% of all antibiotic use occurred among infants without infection-related morbidities, with a median duration of 8 days (IQR, 6-13 days) for each course. Only 22.9% episodes of culture-negative sepsis were prescribed with antibiotics for 7 or fewer days, and 34.7% were treated with antibiotics for more than 14 days. For early antibiotic use, the median duration of antibiotic therapy within 7 days after birth was 7 days (IQR, 4-7 days). CONCLUSIONS A high AUR among infants without infections, prolonged antibiotic durations, and excessive use of broad-spectrum antibiotics were the main problems of antibiotic use in Chinese neonatal intensive care units and should be high-impact focuses for future stewardship interventions.
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Affiliation(s)
- Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Lan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Weili Yan
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China
| | - Shujuan Li
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Junyan Han
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Qi Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Yang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre and Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
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11
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Abstract
BACKGROUND Culture-negative late-onset sepsis (LOS) is commonly diagnosed in neonatal intensive care units, while the outcomes of neonatal culture-negative LOS are not reported for large cohorts. This study aimed to examine the incidence and neonatal outcomes for culture-negative LOS in a contemporary multicenter cohort of preterm infants. METHODS We performed a retrospective analysis of data from a cluster-randomized controlled study. Infants <34 weeks of gestation and admitted to 25 neonatal intensive care units between May 1, 2015, and April 30, 2018, were included. Culture-negative LOS was diagnosed if infants had abnormal manifestations and laboratory tests but negative blood cultures. The primary outcome was a composite of mortality or morbidities including periventricular leukomalacia (PVL), retinopathy of prematurity (ROP) ≥ stage 3 or bronchopulmonary dysplasia (BPD). RESULTS Of 22,346 eligible infants, 1505 (6.7%) infants had culture-negative and 761 (3.4%) infants had culture-positive LOS. Compared with infants without LOS, infants with culture-negative LOS had higher rates of composite outcome (24.1% vs. 9.6%), death (3.8% vs. 1.8%), PVL (4.8% vs. 2.2%), severe ROP (3.3% vs. 1.1%) and BPD (18.1% vs. 7.0%). After adjustment, culture-negative LOS was independently associated with increased risk of composite outcome {adjusted odds ratio [aOR]: 1.8 [95% confidence interval (CI): 1.5-2.1]}, PVL [aOR: 2.0 (95% CI: 1.4-2.8)] and BPD [aOR: 1.8 (95% CI: 1.5-2.2)] relative to the absence of LOS. CONCLUSION Culture-negative LOS was frequently diagnosed in preterm infants and was associated with increased risks of adverse outcomes. There is an emerging need for more precise diagnosis and treatment strategies for culture-negative LOS.
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Cao Y, Jiang S, Zhou Q. Introducing evidence-based practice improvement in Chinese neonatal intensive care units. Transl Pediatr 2019; 8:257-261. [PMID: 31413959 PMCID: PMC6675685 DOI: 10.21037/tp.2019.07.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
China has the largest population in the world. With rapid economic growth, the incidence of premature birth has shown an increasing trend and more neonatal intensive care units (NICUs) are being established across the country. However, there is substantial variability in clinical practice and variations in short- and long-term outcomes among patients in different NICUs. There remains a big gap between China and developed countries in terms of infant outcomes. The Evidence-based Practice for Improving Quality (EPIQ) is a successful model that has been implemented in NICUs across Canada to improve infant outcomes. We applied EPIQ in a single NICU in china and successfully reduced the incidence of ventilator-associated pneumonia, central line (CL) associated bloodstream infection (CLABSIs), and improved the breastmilk use in NICU. In the next phase, we are extending EPIQ to another 24 centers in China and have established the Chinese Neonatal Network for national collaboration, to improve infant outcomes across China.
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Affiliation(s)
- Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Qi Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China
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13
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Prevalence of Gram-Negative Bacteria in Ventilator-Associated Pneumonia in Neonatal Intensive Care Units. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wright N, Abantanga F, Amoah M, Appeadu-Mensah W, Bokhary Z, Bvulani B, Davies J, Miti S, Nandi B, Nimako B, Poenaru D, Tabiri S, Yifieyeh A, Ade-Ajayi N, Sevdalis N, Leather A. Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings. Wellcome Open Res 2019; 4:46. [PMID: 30984879 PMCID: PMC6456836 DOI: 10.12688/wellcomeopenres.15113.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols. Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.
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Affiliation(s)
- Naomi Wright
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, SE5 9RJ, UK
| | - Francis Abantanga
- Department of Surgery, Tamale Teaching Hospital, Tamale, P.O. Box TL 16, Ghana
| | - Michael Amoah
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, P.O.Box 1934, Ghana
| | | | - Zaitun Bokhary
- Department of Paediatric Surgery, Muhimbili National Hospital, Dar es Salaam, P.O Box 65000, Tanzania
| | - Bruce Bvulani
- Department of Paediatric Surgery, University Teaching Hospital of Lusaka, Lusaka, 10101, Zambia
| | - Justine Davies
- Global Health and Education Department, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sam Miti
- Department of Paediatrics, Arthur Davison Children's Hospital, Ndola, Zambia
| | - Bip Nandi
- Department of Paediatric Surgery, Kamuzu Central Hospital, Lilongwe, P.O. Box 149, Malawi
| | - Boateng Nimako
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, P.O.Box 1934, Ghana
| | - Dan Poenaru
- McGill University, Montreal, Quebec, H3A 0G4, Canada
| | - Stephen Tabiri
- Department of Surgery, Tamale Teaching Hospital, Tamale, P.O. Box TL 16, Ghana
| | - Abiboye Yifieyeh
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, P.O.Box 1934, Ghana
| | - Niyi Ade-Ajayi
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, SE5 8AF, UK
| | - Andy Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, SE5 9RJ, UK
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Wang J, Liu F, Tan JBX, Harbarth S, Pittet D, Zingg W. Implementation of infection prevention and control in acute care hospitals in Mainland China - a systematic review. Antimicrob Resist Infect Control 2019; 8:32. [PMID: 30792854 PMCID: PMC6371478 DOI: 10.1186/s13756-019-0481-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/30/2019] [Indexed: 01/15/2023] Open
Abstract
Background Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) affect patients in acute-care hospitals worldwide. No systematic review has been published on adoption and implementation of the infection prevention and control (IPC) key components. The objective of this systematic review was to assess adoption and implementation of the three areas issued by the “National Health Commission of the People’s Republic of China” in acute-care hospitals in Mainland China, and to compare the findings with the key and core components on effective IPC, issued by the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO). Methods We searched PubMed and the Chinese National Knowledge Infrastructure for reports on the areas “structure, organisation and management of IPC”, “education and training in IPC”, and “surveillance of outcome and process indicators in IPC” in acute-care facilities in Mainland China, published between January 2012 and October 2017. Results were stratified into primary care hospitals and secondary/tertiary care hospitals. Results A total of 6580 publications were retrieved, of which 56 were eligible for final analysis. Most of them were survey reports (n = 27), followed by observational studies (n = 17), and interventional studies (n = 12), either on hand hygiene promotion and best practice interventions (n = 7), or by applying education and training programmes (n = 5). More elements on IPC were reported by secondary/tertiary care hospitals than by primary care hospitals. Gaps were identified in the lack of detailing on organisation and management of IPC, education and training activities, and targets of surveillance such as central line-associated bloodstream infections, ventilator associated pneumonia, catheter-associated urinary tract infections, and Clostridium difficile infections. Information was available on adoption and implementation of 7 out of the 10 ECDC key components, and 7 out of the 8 WHO core components. Conclusion To variable degrees, there is evidence on implementation of all NHCPRC areas and of most of the ECDC key components and the WHO core components in acute care hospitals in Mainland China. The results are encouraging, but gaps in effective IPC were identified that may be used to guide future national policy-making in Mainland China. Electronic supplementary material The online version of this article (10.1186/s13756-019-0481-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jiancong Wang
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland.,2Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Infection Control, Dong Guan Hospital of Traditional Chinese Medicine, Dong Guan City, Guang Dong Province China
| | - Fangfei Liu
- 4Department of Nosocomial Infection Management, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province China
| | - Jamie Bee Xian Tan
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland.,5Department of Microbiology, Singapore General Hospital, Singapore, Singapore
| | - Stephan Harbarth
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Didier Pittet
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Walter Zingg
- Infection Control Program and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland.,6National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College of London, London, UK
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Rocha G, Soares P, Gonçalves A, Silva AI, Almeida D, Figueiredo S, Pissarra S, Costa S, Soares H, Flôr-de-Lima F, Guimarães H. Respiratory Care for the Ventilated Neonate. Can Respir J 2018; 2018:7472964. [PMID: 30186538 PMCID: PMC6110042 DOI: 10.1155/2018/7472964] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/12/2018] [Indexed: 11/19/2022] Open
Abstract
Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.
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Affiliation(s)
- Gustavo Rocha
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Paulo Soares
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Américo Gonçalves
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Ana Isabel Silva
- Department of Physical and Rehabilitation Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Diana Almeida
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Sara Figueiredo
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Susana Pissarra
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sandra Costa
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Henrique Soares
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Filipa Flôr-de-Lima
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hercília Guimarães
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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Ju M, Hou D, Chen S, Wang Y, Tang X, Liu J, Chen C, Song Y, Li H. Risk factors for mortality in ICU patients with Acinetobacter baumannii ventilator-associated pneumonia: impact of bacterial cytotoxicity. J Thorac Dis 2018; 10:2608-2617. [PMID: 29997922 DOI: 10.21037/jtd.2018.04.86] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Acinetobacter baumannii (A. baumannii) ventilator-associated pneumonia (VAP) in intensive care unit (ICU) is associated with high morbidity and mortality in patients with critical illness. However, the literatures that focused on the short-term prognosis and the risk factors for mortality are limited. The aim of this study was to evaluate the risk factors for mortality in ICU patients with A. baumannii VAP. Methods A retrospective cohort study was conducted in the medical/surgical ICU at Zhongshan Hospital in Shanghai, China. Adult patients meeting the criteria of A. baumannii VAP from January 2012 to October 2015 were enrolled. Apart from collecting clinical and microbiologic data, we performed biofilm-formation and cytotoxicity testing using A. baumannii strains which are isolated from patients. Multivariate logistic regression analysis was used to determine the independent risk factors for 30-day mortality in ICU. Results Seventy-eight patients were included in this study. The 30-day mortality rate in ICU for the patients was 37.2%. Multivariate analysis revealed that short-term mortality was significantly associated with prior surgery [OR, 0.277; 95% confidence interval (CI), 0.089-0.866; P=0.027], higher APACHEII score (OR, 1.140; 95% CI, 1.007-1.291; P=0.038) and an increased bacterial cytotoxicity (OR, 1.029 ; 95% CI, 1.001-1.058; P=0.047). Conclusions The main finding of our study was that increased bacterial cytotoxicity might be a risk factor for short-term mortality in ICU patients with A. baumannii VAP.
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Affiliation(s)
- Mohan Ju
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Dongni Hou
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Shu Chen
- Department of Infectious Disease, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Ying Wang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xinjun Tang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jie Liu
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Cuicui Chen
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yuanlin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Huayin Li
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Zaka N, Alexander EC, Manikam L, Norman ICF, Akhbari M, Moxon S, Ram PK, Murphy G, English M, Niermeyer S, Pearson L. Quality improvement initiatives for hospitalised small and sick newborns in low- and middle-income countries: a systematic review. Implement Sci 2018; 13:20. [PMID: 29370845 PMCID: PMC5784730 DOI: 10.1186/s13012-018-0712-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND An estimated 2.6 million newborns died in 2016; over 98.5% of deaths occurred in low- and middle-income countries (LMICs). Neonates born preterm and small for gestational age are particularly at risk given the high incidence of infectious complications, cardiopulmonary, and neurodevelopmental disorders in this group. Quality improvement (QI) initiatives can reduce the burden of mortality and morbidity for hospitalised newborns in these settings. We undertook a systematic review to synthesise evidence from LMICs on QI approaches used, outcome measures employed to estimate effects, and the nature of implementation challenges. METHODS We searched Medline, EMBASE, WHO Global Health Library, Cochrane Library, WHO ICTRP, and ClinicalTrials.gov and scanned the references of identified studies and systematic reviews. Searches covered January 2000 until April 2017. Search terms were "quality improvement", "newborns", "hospitalised", and their derivatives. Studies were excluded if they took place in high-income countries, did not include QI interventions, or did not include small and sick hospitalised newborns. Cochrane Risk of Bias tools were used to quality appraise the studies. RESULTS From 8110 results, 28 studies were included, covering 23 LMICs and 65,642 participants. Most interventions were meso level (district and clinic level); fewer were micro (patient-provider level) or macro (above district level). In-service training was the most common intervention subtype; service organisation and distribution of referencing materials were also frequently identified. The most commonly assessed outcome was mortality, followed by length of admission, sepsis rates, and infection rates. Key barriers to implementation of quality improvement initiatives included overburdened staff and lack of sufficient equipment. CONCLUSIONS The frequency of meso level, single centre, and educational interventions suggests that these interventions may be easier for programme planners to implement. The success of some interventions in reducing morbidity and mortality rates suggests that QI approaches have a high potential for benefit to newborns. Going forward, there are opportunities to strengthen the focus of QI initiatives and to develop improved, larger-scale, collaborative research into implementation of quality improvement initiatives for this high-risk group. TRIAL REGISTRATION PROSPERO CRD42017055459 .
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Affiliation(s)
- Nabila Zaka
- UNICEF New York, UNICEF House, 3 United Nations Plaza, New York, NY, 10017, USA
| | - Emma C Alexander
- King's College London GKT School of Medical Education, Guy's Campus, London, SE1 1UL, UK
| | - Logan Manikam
- UNICEF New York, UNICEF House, 3 United Nations Plaza, New York, NY, 10017, USA.
- UCL Institute Epidemiology & Healthcare, 1 - 19 Torrington Place, London, WC1E 6BT, UK.
| | - Irena C F Norman
- King's College London GKT School of Medical Education, Guy's Campus, London, SE1 1UL, UK
| | - Melika Akhbari
- King's College London GKT School of Medical Education, Guy's Campus, London, SE1 1UL, UK
| | - Sarah Moxon
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Pavani Kalluri Ram
- Department of Epidemiology and Environmental Health, 237 Farber Hall, Buffalo, NY, 14214-8001, USA
- Office of Maternal and Child Health and Nutrition, USAID, Washington DC, USA
| | - Georgina Murphy
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Headington, Oxford, OX3 7FZ, UK
| | - Mike English
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Headington, Oxford, OX3 7FZ, UK
| | - Susan Niermeyer
- Office of Maternal and Child Health and Nutrition, USAID, Washington DC, USA
- Section of Neonatology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Luwei Pearson
- UNICEF New York, UNICEF House, 3 United Nations Plaza, New York, NY, 10017, USA
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Erfani Y, Rasti A, Janani L. Prevalence of Gram-negative bacteria in ventilator-associated pneumonia in neonatal intensive care units: a systematic review and meta-analysis protocol. BMJ Open 2016; 6:e012298. [PMID: 27729350 PMCID: PMC5073557 DOI: 10.1136/bmjopen-2016-012298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common and potentially lethal problem among mechanically ventilated neonates in neonatal intensive care units (NICUs). The main pathogenic bacteria of VAP in NICUs are Gram-negative pathogens, which show a general decline in sensitivities to commonly used antibiotics, but their true prevalence is not known. METHODS AND ANALYSIS We aim to provide a systematic review of studies measuring the prevalence of Gram-negative bacteria in VAP in NICUs. We will search PubMed, SCOPUS, EMBASE and the ISI Web of Science, as well as the Google Scholar search engine with no restriction on language. Full copies of articles will be identified by a defined search strategy and will be considered for inclusion against predefined criteria. Study selection and data extraction will be performed by 2 independent reviewers. Statistical analysis will include the identification of data sources and documentation of estimates, as well as the application of the random-effects and fixed-effects meta-analysis models. This will allow us to aggregate prevalence estimates and account for between-study variability in calculating the overall pooled estimates and 95% CI for the prevalence of Gram-negative bacteria in VAP in NICUs. Heterogeneity will be evaluated using the I2 and χ2 statistical tests to determine the extent of variation in effect estimates due to heterogeneity rather than chance. Publication bias and data synthesis will be assessed by funnel plots and Begg's and Egger's tests using STATA software V.13. This systematic review protocol was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P) 2015 Statement. ETHICS AND DISSEMINATION No ethical issues are predicted. These findings will be published in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER CRD42016036048.
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Affiliation(s)
- Yousef Erfani
- Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezoo Rasti
- Oncopathology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Janani
- Department of Biostatistics, School of Public health, Iran University of Medical Sciences, Tehran, Iran
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Effect of prophylactic CPAP in very low birth weight infants in South America. J Perinatol 2016; 36:629-34. [PMID: 27054844 DOI: 10.1038/jp.2016.56] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 01/29/2016] [Accepted: 02/08/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to examine the effect of prophylactic continuous positive airway pressure (CPAP) on infants born in 25 South American neonatal intensive care units affiliated with the Neocosur Neonatal Network using novel multivariate matching methods. STUDY DESIGN A prospective cohort was constructed of infants with a birth weight 500 to 1500 g born between 2005 and 2011 who clinically were eligible for prophylactic CPAP. Patients who received prophylactic CPAP were matched to those who did not on 23 clinical and sociodemographic variables (N=1268). Outcomes were analyzed using the McNemar's test. RESULTS Infants not receiving prophylactic CPAP had higher mortality rates (odds ratio (OR)=1.69, 95% confidence interval (CI) 1.17, 2.46), need for any mechanical ventilation (OR=1.68, 95% CI 1.33, 2.14) and death or bronchopulmonary dysplasia (BPD) (OR=1.47, 95% CI 1.09, 1.98). The benefit of prophylactic CPAP varied by birth weight and gender. CONCLUSIONS The implementation of this process was associated with a significant improvement in survival and survival free of BPD.
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21
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The neonatal preventable harm index: a high reliability tool. J Perinatol 2016; 36:676-80. [PMID: 27054841 DOI: 10.1038/jp.2016.50] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 02/02/2016] [Accepted: 02/02/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study is to identify, quantify and disseminate a novel set of safety indicators for monitoring the occurrence of preventable harm in the neonatal intensive care unit (NICU). STUDY DESIGN Literature review and experiences in an academic, level IV NICU identified prevalent, preventable safety events: hospital-acquired infections (catheter-associated bloodstream infection, ventilator-associated pneumonia), unscheduled extubations, intravenous infiltrates requiring intervention, first week readmissions, serious adverse drug events and miscellaneous events (unanticipated harm or serious near misses). Negative binominal regression evaluated the event incidence trends. RESULTS Of 226 preventable harm events occurring between March 2013 and January 2015, the most common were unscheduled extubations (98; 2/100 ventilator days) and intravenous infiltrates (62; 2.7/100 admissions). No trends were detected (rate ratio: 0.99; confidence limits: 0.96 to 1.01; P=0.38). CONCLUSION The Neonatal Preventable Harm Index represents a novel and transparent means to monitor serious safety events and direct harm prevention strategies in the NICU.
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Device-associated pneumonia of very low birth weight infants in Polish Neonatal Intensive Care Units. Adv Med Sci 2016; 61:90-5. [PMID: 26583299 DOI: 10.1016/j.advms.2015.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 08/13/2015] [Accepted: 09/10/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Late-Onset Pneumonia (LO-PNEU) is still the most important complication associated with the hospitalization of infants with very low birth weight (<1501g). The purpose of this paper is to summarize the results of an ongoing surveillance program defining LO-PNEU as associated or not associated with respiratory support in the NICU and distribution of causative pathogens from the Polish Neonatology Surveillance Network (PNSN). MATERIALS AND METHODS Surveillance of infections was conducted in the years 2009-2011 at six Polish NICUs. RESULTS The incidence was 3.1/1000 NICU patient days (pds). The mean gestational age and birth weight among infants with LO-PNEU were significantly lower. The VAP incidence was of 18.2/1000 NICU pds for mechanically ventilated (MV) infants, while the rates for those receiving only CPAP were as low as 7.7/1000 NICU pds. MV significantly increased the risk of PNEU, but MV or CPAP for <10 days did not increase the risk of LO-PNEU. Significantly associated with LO-PNEU was the use of central or peripheral venous catheters and total parenteral nutrition for longer periods. Microorganisms isolated in cases of LO-PNEU were Gram-positive cocci (53.5%) and Gram-negative rods, with predominating E. coli. Non fermentative bacilli were significantly more frequent in cases of VAP than in other cases. CONCLUSIONS Observed incidence rates associated with VAP and CPAP-PNEU, were higher than in other national surveillance systems and expressing the feasibility of lowering the risk of LO-PNEU and increasing patient safety. The incidence of pneumonia was found to be lower when using CPAP as compared to using MV.
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One-week versus 2-day ventilator circuit change in neonates with prolonged ventilation: cost-effectiveness and impact on ventilator-associated pneumonia. Infect Control Hosp Epidemiol 2015; 36:287-93. [PMID: 25695170 DOI: 10.1017/ice.2014.48] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To investigate the impact of 1-week ventilator circuit change on ventilator-associated pneumonia and its cost-effectiveness compared with a 2-day change. DESIGN An observational cohort study. SETTING A tertiary level neonatal intensive care unit in a university-affiliated teaching hospital in Taiwan. Patients All neonates in the neonatal intensive care unit receiving invasive intubation for more than 1 week from July 1, 2011, through December 31, 2013. INTERVENTION We investigated the impact of 2 ventilator circuit change regimens, either every 2 days or 7 days, on ventilator-associated pneumonia of our cohort. MEASUREMENTS AND MAIN RESULTS A total of 361 patients were maintained on mechanical ventilators for 13,981 days. The 2 groups did not differ significantly in any demographic characteristics. The rate of ventilator-associated pneumonia was comparable between the 2-day group and the 7-day group (8.2 vs 9.5 per 1,000 ventilator-days, P=.439). The durations of mechanical ventilation and hospital stay, and rates of bloodstream infection and mortality, were also comparable between the 2 groups. Switching from a 2-day to a 7-day change policy would save our neonatal intensive care unit a yearly sum of US $29,350 and 525 working hours. CONCLUSION Decreasing the frequency of ventilator circuit changes from every 2 days to once per week is safe and cost-effective in neonates requiring prolonged intubation for more than 1 week.
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Zhou Q, Lee SK, Hu XJ, Jiang SY, Chen C, Wang CQ, Cao Y. Successful reduction in central line-associated bloodstream infections in a Chinese neonatal intensive care unit. Am J Infect Control 2015; 43:275-9. [PMID: 25728154 DOI: 10.1016/j.ajic.2014.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/27/2014] [Accepted: 12/01/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few data are available on central-line associated bloodstream infections (CLABSIs) in Chinese neonatal intensive care units (NICUs). The aims of this study were to characterize CLABSIs among neonates in a Chinese NICU and evaluate the impact of a multifaceted evidence-based practice for improving quality program to decrease CLABSI. METHODS We conducted a prospective before-after intervention study with a 1-year follow-up among patients with central lines at the NICU of the Children's Hospital of Fudan University between January 2008 and December 2010. The study was conducted in 3 phases: before, during, and after the intervention. A multifaceted infection control program was introduced in phase 2 with successive surveillance. CLABSIs were prospectively monitored and compared. RESULTS A total of 171 patients with central lines (CLs) were observed; 29 of them developed CLABSI corresponding to 7.35 per 1,000 catheter days, with a CL utilization ratio of 37.9%. Overall CLABSI rate decreased gradually from 16.7 per 1,000 CL days in phase 1 to 7.6 per 1,000 CL days in phase 2 (P = .08) to 5.2 per 1,000 CL days in phase 3 (P < .01). Gram-negative bacterium (54.5%) was the predominant pathogen in CLABSIs. CONCLUSION A multifaceted infection control program is effective in reducing the CLABSI rate among neonates. Such interventions could be extended to other resource-limited countries.
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Affiliation(s)
- Qi Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Xiao-jing Hu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Si-yuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chuan-qing Wang
- Department of Microbiology, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
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Abstract
Quality improvement (QI) is now a central part of the work of clinicians throughout healthcare. It is based on clear scientific principles, a valid way of measuring change and has theories of reliability and human factors that underpin the interventions. The Neonatal Intensive Care Unit (NICU) is a highly complex adaptive system that lends itself to the application of QI principles. This will require the development of a safety culture that continually seeks to improve. Clinicians and all those who work in NICU will require training in the methodologies of QI and patient safety to effect change. Working together in collaborative networks can accelerate change. In this paper we discuss some of the key concepts and provide some examples of improvement in the NICU.
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Aelami MH, Lotfi M, Zingg W. Ventilator-associated pneumonia in neonates, infants and children. Antimicrob Resist Infect Control 2014. [DOI: 10.1186/2047-2994-3-30] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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