Hospital-acquired viral respiratory infections in neonates hospitalized since birth in a tertiary neonatal intensive care unit

SHEA NICU white paper series: Practical approaches for the prevention of viral respiratory infections

This white paper provides clinicians and hospital leaders with practical guidance on the prevention and control of viral respiratory infections in the neonatal intensive care unit (NICU). This document serves as a companion to Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC)'s "Prophylaxis and Screening for Prevention of Viral Respiratory Infections in Neonatal Intensive Care Unit Patients: A Systematic Review." It provides practical, expert opinion and/or evidence-based answers to frequently asked questions about viral respiratory detection and prevention in the NICU. It was developed by a writing panel of pediatric and pathogen-specific experts who collaborated with members of the HICPAC systematic review writing panel and the SHEA Pediatric Leadership Council to identify questions that should be addressed. The document has been endorsed by SHEA, the American Hospital Association (AHA), The Joint Commission, the Pediatric Infectious Diseases Society (PIDS), the Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the National Association of Neonatal Nurses (NANN).

Next Steps for Health Care-Associated Infections in the Neonatal Intensive Care Unit

We discuss the burden of health care-associated infections (HAIs) in the neonatal ICU and the role of quality improvement (QI) in infection prevention and control. We examine specific QI opportunities and approaches to prevent HAIs caused by Staphylococcus aureus , multidrug-resistant gram-negative pathogens, Candida species, and respiratory viruses, and to prevent central line-associated bloodstream infections (CLABSIs) and surgical site infections. We explore the emerging recognition that many hospital-onset bacteremia episodes are not CLABSIs. Finally, we describe the core tenets of QI, including engagement with multidisciplinary teams and families, data transparency, accountability, and the impact of larger collaborative efforts to reduce HAIs.

Impact of human coronavirus infections on paediatric patients at a tertiary paediatric hospital: a retrospective study of the prepandemic era

BACKGROUND

Human coronaviruses (HCoVs) are important respiratory pathogens in humans and animals. Most HCoVs are emerging pathogens, with five known human pathogens identified in the last two decades.

AIM

To examine the clinical course of HCoV infection in children to improve understanding of severity and outcomes.

METHODS

A retrospective review was undertaken of all encounters of children with known HCoV infection at a tertiary paediatric hospital from January 2015 to January 2018. Electronic medical records were reviewed for demographic data, HCoV type, viral co-pathogens, time to testing, need for hospitalization, requirement for higher-level care (HLC) including intensive care unit management and requirement for oxygen support, radiographic findings suggestive of lower respiratory tract (LRT) disease, and length of stay (LOS).

FINDINGS

In total, 450 encounters for 430 different patients were identified, with the majority (85%) being inpatient. OC43 was the most common HCoV. Younger patients (age <5 years) had higher probability of hospitalization [adjusted odds ratio (aOR) 2.2, 95% confidence interval (CI) 1.2-4.1], requirement for HLC (aOR 1.8, 95% CI 1.0-3.1) and presence of LRT findings on chest radiographs (aOR 1.7, 95% CI 1.01-2.9). Clinical outcomes did not differ between HCoV types, except LOS which was longer for 229E. Fifty-two (11%) encounters were detected after 3 days of hospitalization (median 25.5 days), suggesting possible nosocomial infection.

CONCLUSION

HCoVs are important respiratory pathogens in the paediatric population, especially among patients aged <5 years who are at increased risk for severe disease. The role of HCoVs as hospital-acquired pathogens may be underappreciated.

Contrasting definitions and incidence of healthcare-associated respiratory viral infections in a pediatric hospital

OBJECTIVE

To determine the difference in the incidence of healthcare-associated respiratory viral infection (HARVI) in a pediatric hospital depending on the definition used.

DESIGN

Descriptive historical cohort study.

SETTING AND PARTICIPANTS

Patients aged 0-21 years old who were admitted between July 2013 and June 2018 to a 490-bed primary to quaternary-care pediatric hospital serving northern Texas.

METHODS

HARVI was defined using microbiologic confirmation, development of new symptoms while hospitalized, and exposure time greater than the minimum incubation period for each specific virus. Events that occurred following the maximum incubation period for that virus were classified as definite, otherwise they were classified as possible. This definition was compared to definitions using alternate timing of onset and symptomatology requirements. Data pertaining to demographics, diagnoses, and illness severity were collected.

RESULTS

In total, 498 HARVIs (320 definite and 178 possible) were identified, with an incidence rate of 0.98 per 1,000 patient days (0.63 and 0.35, respectively). Rhinovirus or enterovirus and respiratory syncytial virus were the most identified viruses (58% and 10%, respectively). The median time from admission until HARVI was 10.5 days (interquartile range [IQR], 5-30 days). When alternate definitions were employed, the incidence of HARVI ranged from 0.96 to 2.00 per 1,000 admitted patient days.

CONCLUSIONS

HARVI remain a common nosocomial infection in pediatric hospitals and the measured incidence is dependent on the definition used. Because of the endemic and pandemic potential of respiratory viruses, standardized definitions are needed to facilitate intra- and interhospital comparisons.

Filaggrin and cytokines in respiratory samples of preterm infants at risk for respiratory viral infection

Respiratory viral infections (RVIs) are frequent in preterm infants possibly inducing long-term impact on respiratory morbidity. Immune response and respiratory barriers are key defense elements against viral insults in premature infants admitted to Neonatal Intensive Care Units (NICUs). Our main goals were to describe the local immune response in respiratory secretions of preterm infants with RVIs during NICU admission and to evaluate the expression and synthesis of lung barrier regulators, both in respiratory samples and in vitro models. Samples from preterm infants that went on to develop RVIs had lower filaggrin gene and protein levels at a cellular level were compared to never-infected neonates (controls). Filaggrin, MIP-1α/CCL3 and MCP-1 levels were higher in pre-infection supernatants compared to controls. Filaggrin, HIF-1α, VEGF, RANTES/CCL5, IL-17A, IL-1β, MIP-1α and MIP-1β/CCL5 levels were higher during and after infection. ROC curve and logistic regression analysis shows that these molecules could be used as infection risk biomarkers. Small airway epithelial cells stimulated by poly:IC presented reduced filaggrin gene expression and increased levels in supernatant. We conclude that filaggrin gene and protein dysregulation is a risk factor of RVI in newborns admitted at the NICU.

Viral Respiratory Infections in Hospitalized Children With Symptomatic Caregivers

OBJECTIVES

The burden of healthcare-associated viral respiratory infections (HAVRIs) among children is significant. While healthcare workers are often the focus for infection prevention strategies, little is known about the impact of sick caregivers and hospital visitors on the incidence of pediatric HAVRIs. The objective of this descriptive study was to determine the proportion of pediatric HAVRIs following contact with a sick caregiver or visitor.

METHODS

A retrospective chart review was performed of all HAVRIs that occurred between December 2017 and July 2019 in a pediatric tertiary care center. A HAVRI was defined as a laboratory-confirmed respiratory viral illness occurring more than 72 hours after admission.

RESULTS

Forty-four HAVRIs occurred in 37 patients during the study, predominantly among patients aged <24 months (n = 32, 72.7%) and with comorbidities (n = 42, 95.5%). For 9 HAVRIs (20.5%), contact with a sick caregiver (n = 8, 18.2%) or visitor (n = 2, 4.5%) in the 7 days before diagnosis was documented. In the 72 hours before HAVRI onset, 18 of the 44 patients (40.9%) were in a single-bed room and 6 of them (33.3%) were under additional precautions. Twelve patients (27.3%) had new or increased oxygen requirements and 4 (9.1%) were transferred to the ICU. There were no associated deaths.

CONCLUSIONS

Contact with a sick caregiver or visitor is a potential risk factor for acquiring a HAVRI. Our study reinforces the importance of engaging family caregivers in infection prevention and control strategies in pediatric care settings.

In-hospital respiratory viral infections for patients with established BPD in the SARS-CoV-2 era

OBJECTIVE

Our objective was to test the hypothesis that in-hospital respiratory viral infections (RVI) would be significantly lower in a cohort of patients with established bronchopulmonary dysplasia (BPD) exposed to a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection prevention protocol when compared to historical controls.

STUDY DESIGN

On April 1, 2020, we implemented a universal infection prevention protocol to minimize the risk of nosocomial SARS-CoV-2 transmission in a dedicated BPD intensive care unit. We performed a retrospective cohort study and included patients with established BPD, as defined by the 2019 Neonatal Research Network criteria, admitted to our center who underwent real-time polymerase-chain-reaction RVI testing between January 1, 2015 and March 31, 2021. We excluded patients readmitted from home. We compared the proportion of positive tests to the number of tests performed and the distribution of viral respiratory pathogens in the pre- and post-SARS-CoV-2 eras.

RESULTS

Among 176 patients included in the study, 663 RVI tests were performed and 172 (26%) tests were positive. The median number of tests performed, measured in tests per patient per month, in the SARS-CoV-2 era was not significantly different compared to the pre-SARS-CoV-2 era (0.45 vs. 0.34 tests per patient per month, p = .07). The proportion of positive RVI tests was significantly lower in the SARS-CoV-2 era when compared to the pre-SARS-CoV-2 era (0.06 vs. 0.30, p < .0001). No patients tested positive for SARS-CoV-2 in the SARS-CoV-2 era.

CONCLUSIONS

Infection prevention measures developed in response to the SARS-CoV-2 pandemic may reduce the risk of RVIs in hospitalized patients with established BPD.

Antibiotic Stewardship for the Neonatologist and Perinatologist

Antibiotic use is common in the neonatal intensive care unit. The density and heterogeneity of antibiotic prescribing suggests inappropriate and overuse of these agents. Potential antibiotic stewardship targets include sepsis, necrotizing enterocolitis, and perioperative prophylaxis. Diagnostic stewardship principles, including appropriately obtained cultures, may be leveraged to decrease unnecessary antibiotic prescribing. Strategies including guideline development, prospective audit and feedback, and formulary restriction have been successfully deployed in the neonatal intensive care unit to improve the quality of antibiotic prescribing. Implementation of antibiotic stewardship in the neonatal intensive care unit requires multidisciplinary collaboration between neonatologists, surgeons, infectious diseases specialists, pharmacists, and nurses.

Respiratory morbidity associated with viral respiratory infections during neonatal stage in premature infants

BACKGROUND AND OBJECTIVE

Very low birth weight (VLBW) infants are highly susceptible to viral respiratory infections (VRIs), even during admission to the neonatal intensive care unit (NICU). Although the role of VRI in childhood in the development of recurrent wheezing and long-term asthma is well known, information on the impact in later morbidity of VRI in the neonatal period is lacking. We aimed to explore the occurrence of recurrent wheezing over the first 2 years of life according to VRI status during NICU admission.

METHODS

During April 2016 and December 2017, infants below 32 weeks of gestation were prospectively studied in VRI surveillance during NICU admission. Families were contacted between September 2018 and May 2019 by a telephone questionnaire.

RESULTS

A total of 99 patients were enrolled. The mean gestational age and birth weight were 28.8 (1.9) weeks and 1118 (329) g, respectively. During the first 2 years of life, neither episodes of wheezing nor the respiratory impairment-related hospital admissions differed between positive and negative VRI infants. Episodes of wheezing and respiratory impairment-related hospital admissions, as well as specific respiratory treatment prescription, were more frequent within the first 2 years in infants who had suffered symptomatic VRI during NICU admission.

CONCLUSION

Symptomatic VRI in VLBW infants is associated with long-term respiratory morbidity. The early surveillance of VRI in the preterm infant during NICU admission is justified for prognostic counseling and closely monitoring after discharge. Routine instruction on asthma-related risk factors and early prescription of antiasthmatic treatments, when indicated, should be established.

Beyond personal protective equipment: adjunctive methods for control of healthcare-associated respiratory viral infections

PURPOSE OF REVIEW

Prevention of nosocomial transmission of respiratory viruses is a priority in all healthcare settings and often achieved with the use of personal protective equipment. Several adjunctive infection prevention methods are in common use but their effectiveness in reducing healthcare-associated respiratory viral infections is unclear. In this review, recent advances regarding the effectiveness of several adjunctive infection prevention methods to reduce healthcare-associated respiratory viral infections are discussed.

RECENT FINDINGS

Training and education on hand hygiene guidelines, mandatory influenza vaccination for healthcare personnel, access to paid sick leave to reduce ill presenteeism, cohorting of patients with the same infection or clinical syndrome, neuraminidase inhibitor chemoprophylaxis during influenza outbreaks, and enhanced visitor restrictions in pediatric hospitals all have shown some degree of effectiveness in observational or quasi-experimental studies.

SUMMARY

Most of the studies evaluating the effect of adjunctive infection prevention methods on healthcare-associated respiratory viral infections are observational or quasi-experimental and are often combined with other interventions. Therefore, it is difficult to determine the precise effectiveness or efficacy of these interventions and more controlled trials are needed. Multimodal infection prevention policies are likely to be most effective in reducing healthcare-associated respiratory viral infections.