Use of palivizumab to control an outbreak of syncytial respiratory virus in a neonatal intensive care unit

Respiratory syncytial virus nosocomial outbreak in neonatal intensive care: A review of the incidence, management, and outcomes

BACKGROUND

The main objective was to determine the incidence, management, and outcomes of respiratory syncytial virus nosocomial infection (RSVNI) outbreaks in neonatal intensive care units.

METHODS

A comprehensive search of RSVNI in 9 databases was conducted from January 1, 2000 to May 1, 2021, of which the Cochrane Library comprised the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. Two hundred and twenty-eight articles were retrieved and 17 were retained. A descriptive analysis was performed, and frequencies are reported as mean, median, and range where pertinent.

RESULTS

One hundred and seventeen infants were analyzed and comprised preterms (88.1%) and those with pre-existing co-morbidities. The estimated proportional incidence of RSVNI was 23.8% (177/744) infants. Outbreaks were principally managed by conventional protective measures, neonatal intensive care unit closure, and visitor restriction. Palivizumab was used to control RSVNI in 10 studies. RSVNI-related mortality was 8.5% (15/177) and 8.0% (7/87) among infants where infection control was solely employed.

CONCLUSION

RSVNI is associated with significant morbidity and mortality. The use of palivizumab should be a multidisciplinary decision, based on rapidly spreading infection. Prospective studies are essential to determine the cost-benefit of palivizumab versus standard prevention control for an RSVNI outbreak.

An outbreak of RSV infections in a neonatology clinic during the RSV-season

BACKGROUND

Respiratory syncytial virus (RSV) is the predominant cause of lower respiratory tract infections (LRTI) in infancy. Preterm infants with bronchopulmonary dysplasia (BPD) are at the highest risk of severe RSV-LRTI. This is a retrospective study that analyses a nosocomial outbreak of RSV infections in the Neonatology clinic of the University Hospital of Obstetrics and Gynecology, Sofia, 2019.

METHODS

Two groups of infants without contact between them were diagnosed with RSV-infection: 14 infants were treated in the Department for healthy newborns - Group 1, and 7 preterm infants were treated in the Neonatal Intensive Care Unit (NICU) - Group 2. The detection of RSV was performed using Real-Time PCR in nasal/throat swabs.

RESULTS

Respiratory symptoms occurred 2-5 days after discharge in 14 of 148 healthy term infants born February 5 to 18, 2019; 12 babies were re-hospitalized with LRTI and recovered in a few days. RSV-PCR was positive in 6 infants, while in the others, RSV etiology was suggested, due to similar symptoms and contact between them. The first NICU patient with RSV-LRTI was one of the 26 gestational weeks (GW) twins, who had severe BPD. The other twin was always discharged home without LRTI-symptoms. In the period February 19 to March 15, 2019, 26 premature babies born at 26-34 GW, were tested for RSV (33 nasal/throat swabs). They received a first or subsequent palivizumab injection. We identified 11 positive samples in 7 of the babies. Despite the clinical recovery, the second RSV-PCR remained positive in 4 babies. Six of the 7 NICU patients had symptoms of LRTI, and two of them needed mechanical ventilation. Six babies were discharged home after stabilization, one was transferred to the Pediatric department for further treatment of BPD and later discharged too.

CONCLUSIONS

This was the most serious outbreak of RSV infections in neonates since the RSV-PCR diagnostic in Bulgaria was introduced. The course of RSV-LRTI was severe in extremely preterm patients with underlying BPD. So, routine in-hospital RSV-prophylaxis with palivizumab should be considered for infants at the highest risk.

Multiple Respiratory Syncytial Virus Introductions Into a Neonatal Intensive Care Unit

BACKGROUND

Outbreaks of respiratory syncytial virus (RSV) in neonatal intensive care units (NICUs) are of concern because of the risk of severe disease in young infants. We describe an outbreak of RSV in a NICU and use whole genome sequencing (WGS) to better understand the relatedness of viruses among patients.

METHODS

An investigation was conducted to identify patients and describe their clinical course. Infection control measures were implemented to prevent further spread. Respiratory specimens from outbreak-related patients and the community were tested using WGS. Phylogenetic trees were constructed to understand relatedness of the viruses.

RESULTS

Seven patients developed respiratory symptoms within an 11-day span in December 2017 and were diagnosed with RSV; 6 patients (86%) were preterm and 1 had chronic lung disease. Three patients required additional respiratory support after symptom onset, and none died. Six of 7 patients were part of the same cluster based on > 99.99% nucleotide agreement with each other and 3 unique single-nucleotide polymorphisms were identified in viruses sequenced from those patients. The seventh patient was admitted from the community with respiratory symptoms and had a genetically distinct virus that was not related to the other 6. Implementation of enhanced infection control measures likely limited the spread.

CONCLUSIONS

Using WGS, we found 2 distinct introductions of RSV into a NICU, highlighting the risk of healthcare-associated infections during RSV season. Early recognition and infection control measures likely limited spread, emphasizing the importance of considering RSV in the differential diagnosis of respiratory infections in healthcare settings.

Pulmonary Deposition of Radionucleotide-Labeled Palivizumab: Proof-of-Concept Study

Objective

Current prevention and/or treatment options for respiratory syncytial virus (RSV) infections are limited as no vaccine is available. Prophylaxis with palivizumab is very expensive and requires multiple intramuscular injections over the RSV season. Here we present proof-of-concept data using nebulized palivizumab delivery as a promising new approach for the prevention or treatment of severe RSV infections, documenting both aerosol characteristics and pulmonary deposition patterns in the lungs of lambs.

Design

Prospective animal study.

Setting

Biosecurity Control Level 2-designated large animal research facility at the Murdoch Children’s Research Institute, Melbourne, Australia.

Subjects

Four weaned Border-Leicester/Suffolk lambs at 5 months of age.

Interventions

Four lambs were administered aerosolized palivizumab conjugated to Tc-99m, under gaseous anesthesia, using either the commercially available AeroNeb Go^® or the investigational HYDRA device, placed in-line with the inspiratory limb of a breathing circuit. Lambs were scanned in a single-photon emission computed tomography (SPECT/CT) scanner in the supine position during the administration procedure.

Measurements and Main Results

Both the HYDRA and AeroNeb Go^® produced palivizumab aerosols in the 1–5 µm range with similar median (geometric standard deviation and range) aerosol droplet diameters for the HYDRA device (1.84 ± 1.40 μm, range = 0.54–5.41μm) and the AeroNeb Go^® (3.07 ± 1.56 μm, range = 0.86–10 μm). Aerosolized palivizumab was delivered to the lungs at 88.79–94.13% of the total aerosolized amount for all lambs, with a small proportion localized to either the trachea or stomach. No difference between devices were found. Pulmonary deposition ranged from 6.57 to 9.25% of the total dose of palivizumab loaded in the devices, mostly in the central right lung.

Conclusions

Aerosolized palivizumab deposition patterns were similar in all lambs, suggesting a promising approach in the control of severe RSV lung infections.

Use of palivizumab with other infection control measures to control respiratory syncytial virus outbreaks in neonatal care units

OBJECTIVE

No guidelines exist on the use of palivizumab during outbreaks of Respiratory Syncytial Virus (RSV) in Neonatal Intensive Care Units (NICUs). We aimed to describe an outbreak of RSV in NICU settings and the role of palivizumab in controlling the outbreak.

METHODS

The index case was a 30-day-old premature infant. During the outbreak, 13 cases of RSV were confirmed by RT-PCR. All infants in the NICU received palivizumab after RSV diagnosis.

RESULTS

Of the 13 cases, seven were male; and the median (interquartile) of birth weight was 1585 (IQR: 1480-1705) g. All cases were premature under 34-weeks-gestation. Age at onset of disease varies between 10 and 160 days. Only four cases occurred after administering palivizumab and applying other infection control measures.

CONCLUSION

During nosocomial outbreaks of RSV, administration of palivizumab to all infants in NICU appears to be rational and may help contain outbreaks.

Risk of nosocomial respiratory syncytial virus infection and effectiveness of control measures to prevent transmission events: a systematic review

Respiratory syncytial virus (RSV) causes a significant public health burden, and outbreaks among vulnerable patients in hospital settings are of particular concern. We reviewed published and unpublished literature from hospital settings to assess: (i) nosocomial RSV transmission risk (attack rate) during outbreaks, (ii) effectiveness of infection control measures. We searched the following databases: MEDLINE, EMBASE, CINAHL, Cochrane Library, together with key websites, journals and grey literature, to end of 2012. Risk of bias was assessed using the Cochrane risk of bias tool or Newcastle–Ottawa scale. A narrative synthesis was conducted. Forty studies were included (19 addressing research question one, 21 addressing question two). RSV transmission risk varied by hospital setting; 6–56% (median: 28·5%) in neonatal/paediatric settings (n = 14), 6–12% (median: 7%) in adult haematology and transplant units (n = 3), and 30–32% in other adult settings (n = 2). For question two, most studies (n = 13) employed multi‐component interventions (e.g. cohort nursing, personal protective equipment (PPE), isolation), and these were largely reported to be effective in reducing nosocomial transmission. Four studies examined staff PPE; eye protection appeared more effective than gowns and masks. One study reported on RSV prophylaxis for patients (RSV‐Ig/palivizumab); there was no statistical evidence of effectiveness although the sample size was small. Overall, risk of bias for included studies tended to be high. We conclude that RSV transmission risk varies widely during hospital outbreaks. Although multi‐component control strategies appear broadly successful, further research is required to disaggregate the effectiveness of individual components including the potential role of palivizumab prophylaxis.

Outcome of the Respiratory Syncytial Virus related acute lower respiratory tract infection among hospitalized newborns: a prospective multicenter study

AIM

To determine the incidence and outcomes of respiratory syncytial virus (RSV)-related acute lower respiratory tract infection (ALRI) including morbidity, nosocomial infection and mortality among newborn infants who were admitted to the neonatal intensive care units (NICUs).

METHODS

A multicenter, prospective study was conducted in newborns who were hospitalized with community acquired or nosocomial RSV infection in 44 NICUs throughout Turkey. Newborns with ALRI were screened for RSV infection by Respi-Strip®-test. Main outcome measures were the incidence of RSV-associated admissions in the NICUs and morbidity, mortality and epidemics results related to these admissions.

FINDINGS

The incidence of RSV infection was 1.24% (n: 250) and RSV infection constituted 19.6% of all ALRI hospitalizations, 226 newborns (90.4%) had community-acquired whereas 24 (9.6%) patients had nosocomial RSV infection in the NICUs. Of the 250 newborns, 171 (68.4%) were full-term infants, 183 (73.2%) had a BW >2500 g. RSV-related mortality rate was 1.2%. Four NICUs reported seven outbreaks on different months, which could be eliminated by palivizumab prophylaxis in one NICU.

CONCLUSION

RSV-associated ALRI both in preterm and term infants accounts an important percent of hospitalizations in the season, and may threat other high-risk patients in the NICU.

Effect of young sibling visitation on respiratory syncytial virus activity in a NICU

OBJECTIVE

To determine whether the restriction of young sibling (<13 years) visitation in the neonatal intensive care unit (NICU) during the respiratory syncytial virus (RSV) season was associated with a reduction in the rate of RSV infection among NICU patients.

STUDY DESIGN

A retrospective chart review of all RSV positive infants from the 2001-2010 RSV seasons. The 2001-2006 RSV seasons (group 1) contained 639 admissions and the 2007-2010 (group 2, with sibling restriction) contained 461 admissions. Groups were compared by using the Fisher's Exact Test.

RESULTS

There was a reduction of RSV positive infants from 6.7% in Group 1 to 1.7% in Group 2 (P<0.0001). There was a reduction of symptomatic infants from the number of infants with symptomatic RSV infection from 23/639 infants with young sibling visitation to 2/461 (P<0.001).

CONCLUSION

Exclusion of young sibling visitors <13 years of age during RSV season was associated with a significant reduction in the number of RSV positive infants in the NICU.

Infection Prevention and Control Guidance for Ronald McDonald Houses: A Needs Assessment

We surveyed Ronald McDonald Houses (RMHs) to assess infection prevention and control (IPC) practices. A diverse patient population is served by RMH. Most sites have locally written IPC guidelines, and consultation resources vary, increasing the potential for inconsistent IPC practices. RMH would benefit from a standardized IPC guideline.

Infect Control Hosp Epidemiol 2012;33(3):299-301

Nosocomial respiratory syncytial virus infections in the palivizumab-prophylaxis era with implications regarding high-risk infants

BACKGROUND

Although respiratory syncytial virus (RSV) infection continues to be a leading cause of infant hospitalization with a high transmission rate, recent data on nosocomial RSV infection are scarce. This study investigated the clinical and epidemiologic characteristics of nosocomial RSV infection in the palivizumab-prophylaxis era.

METHODS

The database of a tertiary pediatric medical center was searched for all hospitalized patients with RSV-positive respiratory disease in 2008-2010. Data were compared between patients with community-associated and nosocomial disease, and the qualification of the latter group for palivizumab was evaluated.

RESULTS

Of the 873 children identified, 30 (3.4%) had a nosocomial infection. This group accounted for 0.06% of all admissions during the study period. The nosocomial infection group had higher rates of preterm birth and severe underlying disease than the community-associated RSV group and a longer mean hospital stay. The nosocomial infection group also had higher rates of intensive care unit admission and mechanical ventilation. Although 73% had underlying conditions, most (80%) did not qualify for RSV immunoprophylaxis, including 7 children (23%) with immune deficiency.

CONCLUSION

Nosocomial RSV infection is a significant cause of morbidity among hospitalized infants, especially those with comorbidities and lengthy hospital stay, and is associated with a complicated clinical course. In addition to strict infection-control measures, extending palivizumab prophylaxis to additional selected high-risk populations should be considered.

Prevention and treatment of respiratory syncytial virus infection in infants: an update

Respiratory syncytial virus (RSV) is a serious pathogen causing significant mortality and morbidity, especially in premature infants and infants with chronic lung disease or significant congenital heart disease. Therapy for RSV infection is essentially supportive, although several new compounds are under investigation. Therefore, immunoprophylaxis to prevent severe RSV disease in high-risk infants assumes great significance. Palivizumab, a humanized monoclonal antibody to RSV, significantly reduces hospitalization in the first 6 months in premature infants born at less than 35 weeks, infants less than 24 months of age with chronic lung disease and requiring treatment in the last 6 months, and in children 24 months or younger with hemodynamically significant heart disease. A new ultrapotent anti-RSV antibody (MEDI-524) appears to be more effective in animals than palivizumab and is undergoing clinical evaluation. There has been considerable progress in the development of vaccines; namely subunit, live attenuated, genetically recombinant virus and polypeptide vaccines. Plasmid DNA vaccines coding for parts of the F and G surface glycoproteins and vaccinia vector vaccines are also being evaluated. Maternal immunization has the potential to prevent RSV disease in early infancy. RSV prophylaxis has seen tremendous progress in the last decade.

Palivizumab prophylaxis during nosocomial outbreaks of respiratory syncytial virus in a neonatal intensive care unit: predicting effectiveness with an artificial neural network model

STUDY OBJECTIVE

To identify subgroups of premature infants who may benefit from palivizumab prophylaxis during nosocomial outbreaks of respiratory syncytial virus (RSV) infection.

DESIGN

Retrospective analysis using an artificial intelligence model.

SETTING

Level IIIB, 35-bed, neonatal intensive care unit (NICU) at a tertiary care hospital in the United Arab Emirates.

PATIENTS

One hundred seventy six premature infants, born at a gestational age of 22-34 weeks, and hospitalized during four RSV outbreaks that occurred between April 2005 and July 2007.

MEASUREMENTS AND MAIN RESULTS

We collected demographic and clinical data for each patient by using a standardized form. Input data consisted of seven categoric and continuous variables each. We trained, tested, and validated artificial neural networks for three outcomes of interest: mortality, days of supplemental oxygen, and length of NICU stay after the index case was identified. We compared variable impacts and performed reassignments with live predictions to evaluate the effect of palivizumab. Of the 176 infants, 31 (17.6%) received palivizumab during the outbreaks. All neural network configurations converged within 4 seconds in less than 400 training cycles. Infants who received palivizumab required supplemental oxygen for a shorter duration compared with controls (105.2 ± 7.2 days vs 113.2 ± 10.4 days, p=0.003). This benefit was statistically significant in male infants whose birth weight was less than 0.7 kg and who had hemodynamically significant congenital heart disease. Length of NICU stay after identification of the index case and mortality were independent of palivizumab use.

CONCLUSION

Palivizumab may be an effective intervention during nosocomial outbreaks of RSV in a subgroup of extremely low-birth-weight male infants with hemodynamically significant congenital heart disease.

Respiratory syncytial virus outbreak in neonatal intensive care unit: Impact of infection control measures plus palivizumab use

BACKGROUND

The occurrence of a respiratory syncytial virus (RSV) outbreak in a Neonatal Intensive Care Unit (NICU) is related to unfavorable outcomes, as this infection can lead to respiratory distress and death in premature in infants. Report the successful control of an outbreak that occurred in April 2010 in a NICU.

METHODS

After the index case, of 18 premature infants placed in the same room 10 infants were infected. Of those 10, 6 developed mild to moderate respiratory symptoms, 4 persisted asymptomatic and no death occurred. Contact and respiratory precautions were rapidly initiated, the infants were cohorted in 3 different rooms and palivizumab was administered to all contacts.

RESULTS

The outbreak was controlled and no new cases were subsequently indentified.

CONCLUSION

Standard infection control measures plus palivizumab prophylaxis were efficient in rapid control of the outbreak.

Use of palivizumab and infection control measures to control an outbreak of respiratory syncytial virus in a neonatal intensive care unit confirmed by real-time polymerase chain reaction

Respiratory syncytial virus (RSV) is a potentially life-threatening infection in premature infants. We report an outbreak involving four infants in the neonatal intensive care unit (NICU) of our hospital that occurred in February 2010. RSV A infection was confirmed by real-time polymerase chain reaction. Palivizumab was administered to all infants in the NICU. There were no additional symptomatic cases and repeat RSV surveillance confirmed that there was no further cross-transmission within the unit. The outbreak highlighted the infection control challenge of very high bed occupancy in the unit and the usefulness of molecular methods in facilitating detection and management.

Detection and control of a nosocomial respiratory syncytial virus outbreak in a stem cell transplantation unit: the role of palivizumab

Respiratory syncytial virus (RSV) is a common community-acquired virus that causes upper and lower respiratory tract infections in children, hematologic malignancy patients, and hematopoietic stem cell transplant (HSCT) recipients. Nosocomial transmission of RSV in immunocompromised patients can significantly affect morbidity, mortality, and duration of hospitalization. Stringent infection control measurements are needed to control further hospital transmission. Prophylactic palivizumab was found to result in a significant reduction in hospitalization rates in high-risk children. In this article, we report a nosocomial outbreak of RSV in an adult HSCT unit (4 pods) from January 16 to February 4, 2004, including the infection control interventions used and the prophylactic administration of palivizumab in high-risk patients. Active surveillance identified 5 cases, a substantial increase from previous seasons (2 or 3 cases per season). All infected patients were isolated to 1 nursing pod and placed on contact isolation. All patients on the HSCT unit underwent rapid RSV antigen screening using nasal washes; this was repeated 1 week later, and 1 additional RSV case was identified. Patients identified to be at increased risk for RSV infection received prophylactic palivizumab. Routine screenings of the staff and visitors were undertaken. All patient and visitor areas were thoroughly cleaned with bleach. We educated health care workers about RSV transmission, highlighting proper hand hygiene and contact precautions. Four of 6 patients with RSV infection developed RSV pneumonia, and 2 of these patients died. Staff and visitors with upper respiratory symptoms were screened, and all were negative for RSV. Prophylactic palivizumab was administered in 16 patients who tested negative for RSV, but were considered to be at increased risk for RSV infection. None of these patients developed RSV infections. An RSV outbreak was controlled using prompt preventive measures, including cohorting patients, with a dedicated health care staff; contact isolation of patients; strict adherence to hand hygiene; and screening of visitors, family members, and health care staff for upper respiratory infection symptoms. Immunoprophylaxis with palivizumab, administered to high-risk patients, complemented strict infection control intervention. Thus, the role of palivizumab in the control of RSV hospital outbreaks merits further investigation.

[Consensus conference on acute bronchiolitis (v): prevention of acute bronchiolitis. Review of scientific evidence]

A review of the evidence on prevention of acute bronchiolitis is presented. Acute bronchiolitis prevention arises from three basic approaches: preventive treatment to reduce recurrent wheezing following an episode of acute bronchiolitis, preventive treatment to reduce the frequency and severity of RSV bronchiolitis in the population at risk (prematurity, bronchopulmonary dysplasia, congenital heart disease, etc.), and general preventive measures to reduce nosocomial infection with RSV. There is sufficient evidence on the lack of efficacy of inhaled corticosteroids, oral corticosteroids and montelukast. Intravenous RSV immunoglobulin has an unfavorable risk-benefit balance, particularly with the availability of monoclonal antibodies. Palivizumab is effective as preventive treatment of RSV infection in risk populations (high risk preterm infants and hemodynamically significant congenital heart disease), but not in the frequency and severity (ICU admission, need for mechanical ventilation and mortality) of the acute bronchiolitis. The benefits of palivizumab (less admissions) seem to be worth the adverse effects, but we do not know the cost-benefit ratio. The control and prevention measures of nosocomial transmission of RSV infection (isolation, hand washing, use of mask, gloves, cap and shoes) are based on indirect evidence.

Respiratory syncytial virus outbreak defined by rapid screening in a neonatal intensive care unit

Palivizumab is currently licensed for the prevention of respiratory syncytial virus (RSV) lower respiratory tract disease in infants and children with chronic lung disease, with a history of preterm birth, or with haemodynamically significant congenital heart disease, but its routine use during outbreaks in neonatal intensive care units (NICUs) is not currently recommended. Here we report an outbreak in a NICU detected during a screening trial for RSV infection using a rapid antigen test (Respi-Strip^®). Eleven preterm infants in our NICU tested positive for RSV during January 2009. Subsequent testing of the remaining infants in the NICU revealed two additional asymptomatic cases. In addition to precautions against cross-infection, palivizumab prophylaxis was administered to the remaining 37 premature infants. Two days after treatment, RSV was detected in two additional infants who had become symptomatic. To our knowledge this is the largest RSV outbreak in a NICU to be identified at an early stage by rapid testing and effectively controlled by infection control measures and palivizumab prophylaxis.

Respiratory syncytial virus prophylaxis in a tertiary care neonatal intensive care unit

Nosocomial transmission of respiratory syncytial virus (RSV) is a serious, preventable cause of RSV infection. Passive RSV prophylaxis became available in 1996. We compared the RSV nosocomial infection rate in our neonatal intensive care unit before and after RSV prophylaxis, using nosocomial rotavirus infections as a comparator. There were no significant differences between nosocomial RSV infection rates before and after institution of prophylaxis.

Experience with the use of palivizumab together with infection control measures to prevent respiratory syncytial virus outbreaks in neonatal intensive care units

Respiratory syncytial virus (RSV) frequently causes nosocomial outbreaks in general paediatric wards and occasionally in neonatal intensive care units (NICUs). Conventional infection control measures often fail to prevent the spread of RSV, and it can cause significant morbidity especially in preterm and young infants. We report our experience in preventing an outbreak on a NICU after RSV had been detected in a premature infant. The index case was a 34-day-old premature infant who presented with clinical infection and RSV was detected in a clinical specimen. There were 11 patients in the ward at the time including the index case. The RSV-positive patient was isolated, the ward closed to admissions and infection control measures were implemented. Two patients were transferred to another hospital. Palivizumab 15 mg/kg i.m. was given to all patients and no further cases occurred. All subsequent RSV tests on nasal secretions were negative. Palivizumab combined with conventional infection control measures appeared to prevent the spread of RSV in this NICU. Strategies for the prevention of RSV outbreaks on NICUs all recommend the reinforcement of routine infection control measures. Recommendations concerning the use of palivizumab range from monthly prophylaxis to all infants at risk, to prophylaxis of selected cases only. Currently there are no guidelines for the use of palivizumab in NICUs or for the control of RSV outbreaks.

Nosocomial infection: A risk factor for a complicated course in children with respiratory syncytial virus infection – Results from a prospective multicenter German surveillance study

BACKGROUND

Nosocomially acquired respiratory syncytial virus infections (RSV-NI) may cause serious problems in hospitalized paediatric patients. Hitherto, prospectively collected representative data on RSV-NI from multicenter studies in Germany are limited.

METHODS

The DMS RSV Ped database was designed for the prospective multicenter documentation and analysis of clinically relevant aspects of the management of inpatients with RSV-infection. The study covered six consecutive seasons (1999-2005); the surveillance took place in 14 paediatric hospitals in Germany.

RESULTS

Of the 1568 prospectively documented RSV-infections, 6% (n=90) were NI and 94% (n=1478) were community acquired (CA). A significantly higher proportion in the NI group displayed additional risk factors like prematurity, chronic lung disease, mechanical ventilation (med. history), congenital heart disease, and neuromuscular impairment. Of all NI, 55% occurred in preterms (30.6% of all RSV-infections in preterms with severe chronic lung disease of prematurity were NI). Illness severity as well as the total mortality, but not the attributable mortality was significantly higher in the NI group. In the multivariate analysis, NI was significantly associated with the combined outcome 'complicated course of disease'.

CONCLUSION

This is the first prospective multicenter study from Germany, which confirms the increased risk of a severe clinical course in nosocomially acquired RSV-infection. Of great concern is the high rate of (preventable) NI in preterms, in particular in those with severe chronic lung disease or with mechanical ventilation due to other reasons.

Strategies for prevention of RSV nosocomial infection

OBJECTIVE

To review the literature on respiratory syncytial virus (RSV) as a cause of nosocomial infections (NI) on neonatal intensive care units (NICUs) and pediatric wards, and the effectiveness of various containment strategies.

STUDY DESIGN

We conducted a literature review to define characteristics of RSV NI, and to evaluate the relative effectiveness of various infection containment programs, including the use of palivizumab on the reported incidence of RSV NI on NICUs and pediatric wards.

RESULT

Highly variable rates of RSV NI have not significantly changed since RSV was first identified. The evaluation of the effectiveness of containment strategies has relied on before/after study designs. Focus on rapid patient diagnosis, compliance of acceptable handwashing techniques and cohorting of patients and staff appears to form the backbone of most prevention and containment programs. When these or other measures have failed, the administration of palivizumab has been useful in halting the spread of RSV NI in children.

CONCLUSION

RSV NI continues to be prevalent in the NICU despite adoption of infection control programs. Preventive measures should be employed to lower the risk of RSV NI and, if identified, appropriate containment strategies should be rapidly implemented.

Molecular epidemiological analysis of a nosocomial outbreak of respiratory syncytial virus associated pneumonia in a kangaroo mother care unit in South Africa

Respiratory syncytial virus (RSV) may cause severe lower respiratory tract disease in premature infants. Prolonged viral shedding has been reported in patients with underlying immunosuppressive disorders, such as human immunodeficiency virus 1 (HIV-1) infection. During March to May 2006, 23 preterm pediatric patients developed nosocomial pneumonia in a district hospital in the Gauteng Province of South Africa due to RSV infection. The patients were identified using routine diagnostic testing. All had been admitted with their mothers to a Kangaroo Mother Care (KMC) ward from birth--a low care unit for the management of stable low birth weight infants. The HIV-1 seroprevalence among the mothers to these infants was 52.6%, translating to a 52.6% perinatal exposure. A multiplex nested RT-PCR was used to subtype RSV positive nasopharyngeal aspirates. Sequencing and phylogenetic analysis of part of the G-protein gene was used for molecular epidemiological analysis of the outbreak. In total, 19 of the 23 RSV positive specimens could be PCR amplified and sequenced. The subtype A, GA5 genotype was identified in 14 specimens and the BA genotype, a new subtype B genotype not previously recognized in South Africa, in seven. One patient had an infection with both genotypes. Phylogenetic analysis demonstrated eight separate introductions. Two of the strains identified in this outbreak were identical to strains circulating in a general pediatric ward of this hospital during the preceding month. Inadequate infection control measures by health care providers and mothers to children in KMC units may increase potentially the risk of severe RSV infection in a population group with compounded risk factors.

Respiratory syncytial virus infection in 406 hospitalized premature infants: results from a prospective German multicentre database

Premature birth, chronic lung disease of prematurity (CLD), congenital heart disease and immunodeficiency predispose to a higher morbidity and mortality in respiratory syncytial virus (RSV) infection. This study describes the preterms hospitalised with RSV infection from the prospective German DSM RSV Paed database. The DMS RSV Paed database was designed for the prospective multicentre documentation and analysis of clinically relevant aspects of the management of inpatients with RSV infection. This study covers six consecutive RSV seasons (1999-2005); the surveillance took place in 14 paediatric hospitals in Germany. Of the 1,568 prospectively documented RSV infections, 26% (n=406) were observed in preterms [vs. 1,162 children born at term (74%)] and 3% (n=50) had CLD, of which 49 had received treatment in the last 6 months ('CLDplus'). A significantly higher proportion in the preterm group had congenital heart disease, nosocomial infection, and neuromuscular impairment. There were significantly more children older than 24 months in the preterm group. The attributable mortality was 0.2% (n=2) in children born at term vs. 1.2% (n=5) in the preterm group (p=0.015) [preterm plus CLD 8.0% (n=4 of 50); McIntosh grade 1, 8.6% (n=3 of 35) and McIntosh Grade 4, 15% (n=3 of 20)]. Eight patients were categorized as 'palivizumab failures'. In the multivariate analysis, premature birth, CLD(plus), and nosocomial infection were significantly and independently associated with the combined outcome 'complicated course of disease'. In conclusion, this is the first prospective multicentre study from Germany that confirms the increased risk for severe RSV disease in preterms, in particular in those with CLD treated in the last 6 months before the onset of the infection. From the perspective of our results, the statements of the German Society of Paediatric Infectious Diseases considering the use of passive immunisation (2003) seem reasonable.

Nosocomial respiratory syncytial virus infection: Impact of prospective surveillance and targeted infection control

BACKGROUND

Nosocomially acquired respiratory syncytial virus (RSV) infections cause serious problems in hospitalized patients. An increased effort should be made to describe the problems connected with such infections in pediatric hospitals, with the aim of reducing the occurrence of nosocomial RSV infections (NI).

METHODS

A specialized database was introduced for surveillance and a multifaceted barrier concept based on the CDC recommendations was developed for the control of NI in a university children's hospital in Germany.

RESULTS

Between 1999 and 2002 (November 1-April 30), 283 RSV infections (general population) were prospectively documented. Thirty-nine cases (13.8%) were nosocomial infections (NI) with an incidence density (ID) of 0.99/1000 patient days; 48.7% of all NI were found in prematurely born infants. Following the introduction of a surveillance and prevention policy, a 9-fold decrease of the ID (1.67 vs. 0.18/1000 patient-days) was found when comparing the first and the last season. Intensive care treatment was required in 18% of all documented RSV-infections, in 48.7% of all NI cases and in 43.5% of all RSV-infected prematurely born infants. Overall RSV-related mortality was 0.71%.

CONCLUSIONS

Early diagnosis, a strict cohorting and contact isolation policy, and prospective surveillance contribute to the reduction of nosocomial RSV infection.

Health care-associated infections in the neonatal intensive care unit

Neonates represent a unique and highly vulnerable patient population. Advances in medical technology that have occurred over the last few decades have improved the survival and quality of life for neonates, particularly those infants born with extreme prematurity or with congenital defects. Although immunologic immaturity and altered cutaneous barriers play some role in the vulnerability of neonates to nosocomial infections, clearly, therapeutic interventions that have proven to be lifesaving for these fragile infants also appear to be associated with the majority of infectious complications resulting in neonatal morbidity and mortality. Rates of infections in neonatal intensive care units (NICUs) have varied from 6% to 40% of neonatal patients, with the highest rates in those facilities having larger proportions of very low-birth-weight infants (birthweight < or =1000 grams) or neonates requiring surgery. Efforts to protect the vulnerable NICU infants include the following: (1) optimal infection control practices, especially good hand hygiene and good nursery design; (2) prudent use of invasive interventions with particular attention to early removal of invasive devices after they are no longer essential; and (3) judicious use of antimicrobial agents, with an emphasis on targeted (narrow spectrum) rather than broad-spectrum antibiotics and appropriate indications (proven or suspected bacterial infections).

Development, implementation, and evaluation of a community- and hospital-based respiratory syncytial virus prophylaxis program

PURPOSE

To implement and deliver a respiratory syncytial virus prophylaxis (RSVP) program in response to the Canadian Pediatric Society recommendations.

METHODS

A novel program was designed to provide inpatient RSVP for at-risk infants cared for in 1 tertiary care newborn intensive care unit (NICU). This inpatient program was part of a coordinated approach to RSVP, designed and implemented by 3 hospitals. An RSVP program logic model was created and used by a multidisciplinary team to evaluate the in-house program and identify areas of program activity requiring improvement.

RESULTS

Following the 2000 to 2001 RSV season, a compliance and outcomes audit was performed in the tertiary center; 193 infants were enrolled in the RSVP program and 162 infants had received RSVP in the NICU [Mean = 1.64 doses]. Telephone follow-up with the parents of discharged infants identified that 159 infants (98%) had successfully completed their full course of RSVP. Using the RSVP program logic model, 5 areas for program improvement were identified including infant recruitment, patient transfer/discharge processes, product procurement, preparation/distribution/administration of doses, and healthcare team communication.

CONCLUSIONS

Interdisciplinary collaboration is an important factor in the success of the RSVP program and has supported a consistent model of care for the delivery of RSVP. The program logic model provided a useful structure to systematically review the RSVP program in this organization.