Nosocomial infection in the NICU: a medical complication or unavoidable problem?

Characteristics and Outcomes of Intrahospital Transfers from Neonatal Intensive Care to Pediatric Intensive Care Units

OBJECTIVE

 Critically ill children may be transferred from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) for further critical care, but the frequency and outcomes of this patient population are unknown. The aims of this study are to describe the characteristics and outcomes in patients transferred from NICU to PICUs. We hypothesized that a higher-than-expected mortality would be present for patients with respiratory or cardiovascular diagnoses that underwent a NICU to PICU transition and that specific factors (timing of transfer, illness severity, and critical care interventions) are associated with a higher risk of mortality in the cardiovascular group.

STUDY DESIGN

 Retrospective analysis of Virtual Pediatric Systems, LLC (2011-2019) deidentified cardiovascular and respiratory NICU to PICU subject data. We evaluated demographics, PICU length of stay, procedures, disposition, and mortality scores. Pediatric Index of Mortality 2 (PIM2) score was utilized to determine the standardized mortality ratio (SMR).

RESULTS

 SMR of 4,547 included subjects (3,607 [79.3%] cardiovascular and 940 [20.7%] respiratory) was 1.795 (95% confidence interval: 1.62-1.97, p < 0.0001). Multivariable logistic regression analysis demonstrated transfer age (cardiovascular: odds ratio, 1.246 [1.10-1.41], p = 0.0005; respiratory: 1.254 [1.07-1.47], p = 0.0046) and PIM2 scores (cardiovascular: 1.404 [1.25-1.58], p < 0.0001; respiratory: 1.353 [1.08-1.70], p = 0.0095) were significantly associated with increased odds of mortality.

CONCLUSION

 In this present study, we found that NICU to PICU observed deaths were high and various factors, particularly transfer age, were associated with increased odds of mortality. While the type of patients evaluated in this study likely influenced mortality, further investigation is warranted to determine if transfer timing is also a factor.

KEY POINTS

· NICU patients may be transitioned to the PICU.. · NICU to PICU observed deaths were high.. · Transfer timing may be a factor..

Genomic and Epidemiological Features of Two Dominant Methicillin-Susceptible Staphylococcus aureus Clones from a Neonatal Intensive Care Unit Surveillance Effort

Methicillin-susceptible Staphylococcus aureus (MSSA) is a more prevalent neonatal intensive care unit (NICU) pathogen than methicillin-resistant S. aureus (MRSA). However, the introduction and spread of MSSA, the role of systematic decolonization, and optimal infection prevention and control strategies remain incompletely understood. We previously screened infants hospitalized in a university-affiliated level III to IV NICU twice monthly over 18 months for S. aureus colonization and identified several prevalent staphylococcal protein A (spa) types. Here, we performed whole-genome sequencing (WGS) and phylogenetic comparisons of 140 isolates from predominant spa types t279, t1451, and t571 to examine possible transmission routes and identify genomic and epidemiologic features associated with the spread of dominant clones. We identified two major MSSA clones: sequence type 398 (ST398), common in the local community, and ST1898, not previously encountered in the region. ST398 NICU isolates formed distinct clusters with closely related community isolates from previously published data sets, suggesting multiple sources of acquisition, such as family members or staff, including residents of the local community. In contrast, ST1898 isolates were nearly identical, pointing to clonal expansion within the NICU. Almost all ST1898 isolates harbored plasmids encoding mupirocin resistance (mupA), suggesting an association between the proliferation of this clone and decolonization efforts with mupirocin. Comparative genomics indicated genotype-specific pathways of introduction and spread of MSSA via community-associated (ST398) or health care-associated (ST1898) sources and the potential role of mupirocin resistance in dissemination of ST1898. Future surveillance efforts could benefit from routine genotyping to inform clone-specific infection prevention strategies. IMPORTANCE Methicillin-susceptible Staphylococcus aureus (MSSA) is a significant pathogen in neonates. However, surveillance efforts in neonatal intensive care units (NICUs) have focused primarily on methicillin-resistant S. aureus (MRSA), limiting our understanding of colonizing and infectious MSSA clones which are prevalent in the NICU. Here, we identify two dominant colonizing MSSA clones during an 18-month surveillance effort in a level III to IV NICU, ST398 and ST1898. Using genomic surveillance and phylogenetic analysis, coupled with epidemiological investigation, we found that these two sequence types had distinct modes of spread, namely the suggested exchange with community reservoirs for ST398 and the contribution of antibiotic resistance to dissemination of ST1898 in the health care setting. This study highlights the additional benefits of whole-genome surveillance for colonizing pathogens, beyond routine species identification and genotyping, to inform targeted infection prevention strategies.

Convergence of Biofilm Formation and Antibiotic Resistance in Acinetobacter baumannii Infection

Acinetobacter baumannii (A. baumannii) is a leading cause of nosocomial infections as this pathogen has certain attributes that facilitate the subversion of natural defenses of the human body. A. baumannii acquires antibiotic resistance determinants easily and can thrive on both biotic and abiotic surfaces. Different resistance mechanisms or determinants, both transmissible and non-transmissible, have aided in this victory over antibiotics. In addition, the propensity to form biofilms (communities of organism attached to a surface) allows the organism to persist in hospitals on various medical surfaces (cardiac valves, artificial joints, catheters, endotracheal tubes, and ventilators) and also evade antibiotics simply by shielding the bacteria and increasing its ability to acquire foreign genetic material through lateral gene transfer. The biofilm formation rate in A. baumannii is higher than in other species. Recent research has shown how A. baumannii biofilm-forming capacity exerts its effect on resistance phenotypes, development of resistome, and dissemination of resistance genes within biofilms by conjugation or transformation, thereby making biofilm a hotspot for genetic exchange. Various genes control the formation of A. baumannii biofilms and a beneficial relationship between biofilm formation and "antimicrobial resistance" (AMR) exists in the organism. This review discusses these various attributes of the organism that act independently or synergistically to cause hospital infections. Evolution of AMR in A. baumannii, resistance mechanisms including both transmissible (hydrolyzing enzymes) and non-transmissible (efflux pumps and chromosomal mutations) are presented. Intrinsic factors [biofilm-associated protein, outer membrane protein A, chaperon-usher pilus, iron uptake mechanism, poly-β-(1, 6)-N-acetyl glucosamine, BfmS/BfmR two-component system, PER-1, quorum sensing] involved in biofilm production, extrinsic factors (surface property, growth temperature, growth medium) associated with the process, the impact of biofilms on high antimicrobial tolerance and regulation of the process, gene transfer within the biofilm, are elaborated. The infections associated with colonization of A. baumannii on medical devices are discussed. Each important device-related infection is dealt with and both adult and pediatric studies are separately mentioned. Furthermore, the strategies of preventing A. baumannii biofilms with antibiotic combinations, quorum sensing quenchers, natural products, efflux pump inhibitors, antimicrobial peptides, nanoparticles, and phage therapy are enumerated.

Infants' prenatal exposure to opioids and the association with birth outcomes: A systematic review and meta-analysis

BACKGROUND

Prenatal exposure to opioids (PEO) is a worldwide public health issue. Opioids cross the placental barrier and may affect the developing foetus and the birth outcomes.

OBJECTIVES

This review aimed to explore newborns' weight, length and head circumference, preterm birth, and perinatal death as primary outcomes in relation to PEO. The secondary outcomes were gestational age at birth, Apgar scores and length of hospitalisation after delivery.

DATA SOURCES

PubMed, Embase, PsycInfo and the Web of Science.

STUDY SELECTION AND DATA EXTRACTION

Inclusion criteria were (i) cohort, case-control or cross-sectional peer-reviewed studies published in English through 1 March 2021; (ii) comparing outcomes between prenatal exposed and unexposed groups to opioids (prescribed or obtained illegally). Exclusion criteria were foetal alcohol syndrome and non-opioid primary exposure.

SYNTHESIS

Data were extracted by two authors. The Newcastle-Ottawa Quality Assessment Scale was used for study quality assessment. Due to heterogeneity across studies, we used random effects models to obtain pooled standardised mean difference (SMD), pooled risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Data from 80 studies were extracted. In meta-analyses, opioid-exposed neonates had lower birthweight (SMD -0.77, 95% CI -0.90, -0.64, I²  = 82%), smaller head circumference (SMD -0.67, 95% CI -0.86, -0.48, I²  = 84%), shorter birth length (SMD -0.97, 95% CI -1.24, -0.70, I²  = 91%) and gestational age (SMD -0.45, 95% CI -0.60, -0.30, I²  = 80%) than unexposed neonates. Pooled risks of neonatal death and preterm birth were higher among opioid-exposed compared to unexposed neonates (RR 4.05, 95% CI 2.12, 7.72, I²  = 73%; and RR 1.92, 95% CI 1.57, 2.35, I²  = 99%).

CONCLUSIONS

We found increased risks of adverse birth outcomes in relation to PEO. Caution should be used in interpreting the findings, as many studies were rated as poor quality, and with substantial inter-study heterogeneity. Future studies should ensure comparability of opioid-exposed and -unexposed group to strengthen internal validity.

Phenotypic and Molecular Characterization of Commensal, Community-Acquired and Nosocomial Klebsiella spp

Klebsiella spp. is a relevant pathogen that can present acquired resistance to almost all available antibiotics, thus representing a serious threat for public health. While most studies have been focused on isolates causing community-acquired and nosocomial infections, little is known about the commensal isolates colonizing healthy subjects. We describe the molecular identification and the phenotypic characterization of commensal Klebsiella spp. from breast milk of healthy women and faeces from healthy breast-fed infants, which were compared with isolates from community-acquired infections and from a nosocomial NICU outbreak. The phylogenetic analysis of a 454-bp sequence of the rpoB gene was useful for species identification (K. pneumoniae, K. variicola, K. quasipneumoniae, K. oxytoca, K. grimontii, K. michiganensis, Raoultella planticola and R. ornithinolytica), previously misidentified as K. pneumoniae or K. oxytoca by biochemical methods. Globally, we report that commensal strains present virulence traits (virulence genes, siderophores and biofilms) comparable to community-acquired and NICU-infective isolates, thus suggesting that the human microbiota could constitute a reservoir for infection. Isolates causing NICU outbreak were multi-drug resistant (MDR) and ESBLs producers, although an imipenem-resistant commensal MDR K. quasipneumoniae isolate was also found. A commensal K. pneumoniae strain showed a potent bacteriocin-like inhibitory activity against MDR Klebsiella isolates, thus highlighting the potential role of commensal Klebsiella spp. in health and disease.

Optimizing Meropenem Therapy for Severe Nosocomial Infections in Neonates

Meropenem pharmacokinetics in neonates exhibits large interindividual variability due to developmental changes occurring during the first month of life. The objective was to characterize meropenem pharmacokinetics through a population approach to determine effective dosing recommendations in neonates with severe nosocomial infections. Three blood samples from forty neonates were obtained once steady-state blood levels were achieved and plasma concentrations were determined with a validated chromatographic method. Data were used to develop and validate the one-compartment with first-order elimination population pharmacokinetic model obtained by non-linear mixed effect modeling. The final model was Clearance (L/h) = 2.23 × Creatinine Clearance (L/h) and Volume of distribution(L) = 6.06 × Body Surface Area(m²) × (1 + 0.60 if Fluticasone comedication). Doses should be adjusted based on said covariates to increase the likelihood of achieving therapeutic targets. This model explains 12.9% of the interindividual variability for meropenem clearance and 19.1% for volume of distribution. Stochastic simulations to establish initial dosing regimens to maximize the time above the MIC showed that the mean probabilities to achieve the PK/PD target (PTA) for microorganisms with a MIC of 2 and 8 µg/mL were 0.8 and 0.7 following i.v. bolus of 250 and 500 mg/m²/dose q8h, respectively. Meropenem extended 4h infusion would improve PTA in neonates with augmented creatinine clearance.

Clinical impact and direct costs of nosocomial respiratory syncytial virus infections in the neonatal intensive care unit

BACKGROUND

Nosocomial infections are a leading cause of morbidity, costs, and mortality in preterm newborns. Most reports regarding nosocomial infections in neonatal intensive care units (NICU) are focused on bacterial infections and there is limited information regarding the impact of nosocomial viruses. The objective of this study was to assess the impact of nosocomial respiratory syncytial virus (RSV) infections in a NICU.

METHODS

This was a retrospective cohort design from a NICU in a general hospital in Mexico. We included 24 newborn infants with nosocomial RSV infection and 24 infants without RSV matched by gestational age, birth weight, and the period of time of hospitalization.

RESULTS

Infants with nosocomial RSV infection had longer hospitalization duration (median 24 days vs. 13 days; P = .05), increased antibiotic use (45.8% vs. 8.3%; P = .003), more mechanical ventilation requirement (54.2% vs. 0.4%; P <.001), more frequent nosocomial infections (45.8% vs. 0%; P <.001), and higher hospitalization direct costs (median 3,587.20 USD vs. 1,123.60 USD; P = .001) after nosocomial RSV detection.

CONCLUSIONS

Nosocomial RSV infections are associated to a significant increase of costs in infants hospitalized in the NICU. Evaluation of interventions that may reduce the incidence of nosocomial RSV infections in this setting is warranted.

Extensively-Drug Resistant Klebsiella pneumoniae Recovered From Neonatal Sepsis Cases From a Major NICU in Egypt

Background

Neonatal sepsis is a nuisance to clinicians and medical microbiologists, particularly those cases caused by Klebsiella pneumoniae. Thus, we aimed at investigating the profile and mechanisms of antibiotic resistance and the clonal relationships between K. pneumoniae isolated from neonates at the largest tertiary care hospital’s neonatal intensive care units (NICUs) in Minia, Egypt.

Methods

This study comprised 156 neonates diagnosed with culture-proven sepsis from February 2019 to September 2019, at a major NICU of Minia City. All K. pneumoniae isolates were collected and characterized by antimicrobial profile, resistance genotype, and pulsed-field gel electrophoresis typing.

Results

Twenty-four K. pneumoniae isolates (15.3%) were collected out of the 156 sepsis diagnosed neonates. These samples showed extensive drug resistance (XDR) to most of the tested antimicrobials, except fluoroquinolones. All the K. pneumoniae isolates possessed bla_VIM and bla_NDM carbapenemase genes, while bla_KPC gene was detected in 95.8%. Considering extended-spectrum β-lactamases genes, bla_CTX–M was found in all the isolates and bla_OXA–1 gene in 75% of them. The plasmid-mediated quinolone resistance gene qnrS, was predominantly found among our isolates in comparison to qnrB or qnrA. A moderate degree of clonal relatedness was observed between the isolates.

Conclusion

To the best of our knowledge, this the first report of an alarming occurrence of XDR among K. penumoniae isolates recovered from neonatal sepsis in Egypt. Our data necessitate proper antimicrobial stewardship as the choices will be very limited.

Disparities in Health Care-Associated Infections in the NICU

OBJECTIVES

This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals.

STUDY DESIGN

This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative.

RESULTS

Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection.

CONCLUSION

Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.

Rotavirus Gastroenteritis Outbreaks in a neonate intermediate care unit: Direct detection of rotavirus from a computer keyboard and mouse

BACKGROUND

During one week in September, one index case, followed by two cases of rotavirus gastroenteritis infection, was identified in a neonate intermediate care unit of a tertiary teaching children's hospital. An outbreak investigation was launched to clarify the possible infection source and to stop the spread of infection.

METHODS

Cohort care and environmental disinfection were immediately implemented. We screened rotavirus in all the unit neonates' stool samples as well as environmental swab samples. The precautionary measures with regard to hand hygiene and contact isolation taken by healthcare providers and family members were re-examined.

RESULTS

The fourth case was identified 5 days after commencement of the outbreak investigation. There were total 39 contacts, including 6 neonates, 8 family members, and 25 healthcare providers. Nineteen stool samples collected from other neonates in the units revealed one positive case (the fourth case). However, one sample taken from the computer keyboard and mouse in the ward was also positive. The observation of hygiene precautions and the use of isolation gowns by healthcare workers were found to be inadequate. Following the intensification of infection control measures, no further cases of infection were reported.

CONCLUSIONS

Hand hygiene and an intensive isolation strategy remained the most critical precautions for preventing an outbreak of healthcare-associated viral gastroenteritis in the neonate care unit.

Less is More: Modern Neonatology

Iatrogenesis is more common in neonatal intensive care units (NICUs) because the infants are vulnerable and exposed to prolonged intensive care. Sixty percent of extremely low-birth-weight infants are exposed to iatrogenesis. The risk factors for iatrogenesis in NICUs include prematurity, mechanical or non-invasive ventilation, central lines, and prolonged length of stay. This led to the notion that "less is more." In the delivery room delayed cord clamping is recommended for term and preterm infants, and suction for the airways in newborns with meconium-stained fluid is not performed anymore. As a symbol for a less aggressive attitude we use the term neonatal stabilization rather than resuscitation. Lower levels of oxygen saturations are accepted as normal during the first 10 minutes of life, and if respiratory assistance is needed, we no longer use 100% oxygen but 0.21-0.3 FiO₂, depending on gestational age and the level of oxygen saturation. We try to avoid endotracheal ventilation by using non-invasive respiratory support and administering continuous positive airway pressure early on, starting in the delivery room. If surfactant is needed, non-invasive methods of surfactant administration are utilized. Use of central lines is shortened, and early feeding of human milk is the routine. Permissive hypercapnia is allowed, and continuous non-invasive monitoring not only of the O₂ but also of CO₂ is warranted. "Kangaroo care" and Newborn Individualized Developmental Care and Assessment Program (NIDCAP) together with a calm atmosphere with parental involvement are encouraged. Whether "less is more," or not enough, is to be seen in future studies.

Risk Factors for Staphylococcus aureus Acquisition in the Neonatal Intensive Care Unit: A Matched Case-Case-Control Study

OBJECTIVE To determine risk factors independent of length of stay (LOS) for Staphylococcus aureus acquisition in infants admitted to the neonatal intensive care unit (NICU). DESIGN Retrospective matched case-case-control study. SETTING Quaternary-care referral NICU at a large academic children's hospital. METHODS Infants admitted between January 2014 and March 2016 at a level IV NICU who acquired methicillin resistant (MRSA) or susceptible (MSSA) S. aureus were matched with controls by duration of exposure to determine risk factors for acquisition. A secondary post hoc analysis was performed on the entire cohort of at-risk infants for risk factors identified in the primary analysis to further quantify risk. RESULTS In total, 1,751 infants were admitted during the study period with 199 infants identified as having S. aureus prevalent on admission. There were 246 incident S. aureus acquisitions in the remaining at-risk infant cohort. On matched analysis, infants housed in a single-bed unit were associated with a significantly decreased risk of both MRSA (P=.03) and MSSA (P=.01) acquisition compared with infants housed in multibed pods. Across the entire cohort, pooled S. aureus acquisition was significantly lower in infants housed in single-bed units (hazard ratio,=0.46; confidence interval, 0.34-0.62). CONCLUSIONS NICU bed design is significantly associated with S. aureus acquisition in hospitalized infants independent of LOS. Infect Control Hosp Epidemiol 2018;39:46-52.

Neonatal Group B Streptococcal Disease in Otherwise Healthy Infants: Failure of Specific Neonatal Immune Responses

Only a small proportion of newborn infants exposed to a pathogenic microorganism develop overt infection. Susceptibility to infection in preterm infants and infants with known comorbidities has a likely multifactorial origin and can be often attributed to the concurrence of iatrogenic factors, environmental determinants, underlying pathogenic processes, and probably genetic predisposition. Conversely, infection occurring in otherwise healthy full-term newborn infants is unexplained in most cases. Microbial virulence factors and the unique characteristics of the neonatal immune system only partially account for the interindividual variability in the neonatal immune responses to pathogens. We here suggest that neonatal infection occurring in otherwise healthy infants is caused by a failure of the specific protective immunity to the microorganism. To explain infection in term and preterm infants, we propose an extension of the previously proposed model of the genetic architecture of infectious diseases in humans. We then focus on group B streptococcus (GBS) disease, the best characterized neonatal infection, and outline the potential molecular mechanisms underlying the selective failure of the immune responses against GBS. In light of the recent discoveries of pathogen-specific primary immunodeficiencies and of the role of anticytokine autoantibodies in increasing susceptibility to specific infections, we hypothesize that GBS disease occurring in otherwise healthy infants could reflect an immunodeficiency caused either by rare genetic defects in the infant or by transmitted maternal neutralizing antibodies. These hypotheses are consistent with available epidemiological data, with clinical and epidemiological observations, and with the state of the art of neonatal physiology and disease. Studies should now be designed to comprehensively search for genetic or immunological factors involved in susceptibility to severe neonatal infections.

Evaluation of Vancomycin Use in Late-Onset Neonatal Sepsis Using the Area Under the Concentration-Time Curve to the Minimum Inhibitory Concentration ≥400 Target

AIM

To develop a vancomycin population pharmacokinetic model and assess the probability of attaining a pharmacodynamic target associated with clinical and microbiological success, a ratio of the 24-hour area under the concentration-time curve to the minimum inhibitory concentration (MIC) ≥ 400, in a 5-year clinical cohort of preterm and term neonatal patients with late-onset staphylococcal sepsis.

METHODS

Therapeutic drug monitoring data were obtained from septic neonates with ≥1 vancomycin concentration(s) from January 2006 to September 2011. Only neonates with a postnatal age of >72 hours and a positive microbiological culture were included. Population pharmacokinetic model was developed using nonlinear mixed effects modeling (NONMEM 7.2). Eleven demographic characteristics were evaluated as covariates. Probabilities of achieving the pharmacodynamic target were evaluated.

RESULTS

A 1-compartment model with first-order elimination was constructed from 528 vancomycin concentrations collected from 152 preterm and term neonates. Body weight, creatinine clearance (CL), and postmenstrual age were identified as significant covariates. Estimated vancomycin CL and volume of distribution for typical neonates were 0.068 ± 0.03 L·h·kg and 0.62 ± 0.13 L/kg, respectively. Coagulase-negative staphylococci (85.5%) and Staphylococcus aureus (14.5%) were the common pathogenic organisms. The distribution of vancomycin MIC breakpoints was composed of approximately 70% MIC breakpoint of ≤2 mcg/mL. Approximately 54% of neonates, with a median serum creatinine concentration of 0.44 mg/dL, achieved the target ratio of 24-hour area under the concentration-time curve to the MIC ≥ 400 with a median daily dose of 30 (interquartile range, 21-42) mg/kg.

CONCLUSIONS

Body weight, creatinine CL, and postmenstrual age significantly influenced vancomycin CL. The current vancomycin doses are acceptable at MICs ≤1 mcg/mL because they are likely to achieve the pharmacodynamic target in the majority of neonatal patients, although higher doses may be considered for more resistant staphylococcal infections.

Epidemiology of Neonatal Sepsis and Implicated Pathogens: A Study from Egypt

Prospective analytic study was conducted in NICUs of three Egyptian Neonatal Network (EGNN) participants in Mansoura Hospitals in Egypt over a period of 18 months from March 2011 to August 2012. By using EGNN 28-day discharge form, all demographic, clinical, and laboratory data were recorded and studied. During the study period, 357 neonates were diagnosed as suspected sepsis with an incidence of 45.9% (357/778) among the admitted neonates at the three neonatal intensive care units. 344 neonates (sex ratio = 1.3:1) were enrolled in the study in which 152 (44.2%) were classified as early onset sepsis EOS (≤72 hr) and 192 (55.8%) as late onset sepsis LOS (>72 hr). Among the LOS cases, 33.9% (65/192) were caused by nosocomial infections. In 40.7% (140/344), sepsis was confirmed by positive blood culture. The total mortality rate for the proven neonatal sepsis was 51% (25/49) and 42.9% (39/91) for EOS and LOS, respectively. Coagulase negative staphylococci were predominant isolates in both EOS and LOS, followed by Klebsiella pneumoniae. Most of the bacterial isolates had low sensitivity to the commonly used empiric antibiotics. However, 70.1% (89/127) exhibited multidrug resistance. Best sensitivities among Gram-positive isolates were found against imipenem, ciprofloxacin, vancomycin, and amikacin.

Variability in Vancomycin Use in Newborn Intensive Care Units Determined From Data in an Electronic Medical Record

Data from an electronic medical record were used to demonstrate a large variation in the proportion of patients treated with vancomycin in 56 newborn intensive care units, which ranged from 18% to 70% . Use of oxacillin or nafcillin instead of vancomycin was rare during the first few years of the study period but was routine in 13% of the newborn intensive care units during the last fewyears of the study period. The use of electronic medical record data for studies of antibiotic use is discussed here.

Validation of nosocomial infection in neonatology: a new method for standardized surveillance

BACKGROUND

Nosocomial infections (NIs) are a leading cause of mortality and morbidity in premature infants. We present a new method for detecting and confirming NIs in a neonatal intensive care unit.

METHODS

Newborns with birth weight < 1,500 g or gestational age (GA) < 33 weeks were included prospectively over 2 years in a single-center tertiary neonatal intensive care unit. The computerized physician order entry system (CPOE) generated alerts when antibiotics were prescribed for at least 5 consecutive days and these cases were reviewed by an expert group following international recommendations.

RESULTS

Four hundred sixty-one neonates were included, with a mean GA of 30 weeks (range, 26-32 weeks) and mean birth weight 1,270 g (range, 950-1600 g). The CPOE flagged 158 cases of potential NI, 85.1% of which were classified as true NI and 14.9% of which were false positive. Incidence and device-associated nosocomial bloodstream infection rates were 21.9% and 10.8 per 1,000 central venous catheter days, respectively. GA ≤ 28 weeks (odds ratio, 2.18; 95% confidence interval, 1.2-4) and > 7 central venous catheter days (odds ratio, 1.47; 95% confidence interval, 1.3-1.7) were independently associated with the risk of nosocomial bloodstream infection.

CONCLUSION

Combining CPOE and interdisciplinary review may improve the accuracy of NI recording in a neonatal intensive care unit.

Determination of vancomycin pharmacokinetics in neonates to develop practical initial dosing recommendations

Variability in neonatal vancomycin pharmacokinetics and the lack of consensus for optimal trough concentrations in neonatal intensive care units pose challenges to dosing vancomycin in neonates. Our objective was to determine vancomycin pharmacokinetics in neonates and evaluate dosing regimens to identify whether practical initial recommendations that targeted trough concentrations most commonly used in neonatal intensive care units could be determined. Fifty neonates who received vancomycin with at least one set of steady-state levels were evaluated retrospectively. Mean pharmacokinetic values were determined using first-order pharmacokinetic equations, and Monte Carlo simulation was used to evaluate initial dosing recommendations for target trough concentrations of 15 to 20 mg/liter, 5 to 20 mg/liter, and ≤20 mg/liter. Monte Carlo simulation revealed that dosing by mg/kg of body weight was optimal where intermittent dosing of 9 to 12 mg/kg intravenously (i.v.) every 8 h (q8h) had the highest probability of attaining a target trough concentration of 15 to 20 mg/liter. However, continuous infusion with a loading dose of 10 mg/kg followed by 25 to 30 mg/kg per day infused over 24 h had the best overall probability of target attainment. Initial intermittent dosing of 9 to 15 mg/kg i.v. q12h was optimal for target trough concentrations of 5 to 20 mg/liter and ≤20 mg/liter. In conclusion, we determined that the practical initial vancomycin dose of 10 mg/kg vancomycin i.v. q12h was optimal for vancomycin trough concentrations of either 5 to 20 mg/liter or ≤20 mg/liter and that the same initial dose q8h was optimal for target trough concentrations of 15 to 20 mg/liter. However, due to large interpatient vancomycin pharmacokinetic variability in neonates, monitoring of serum concentrations is recommended when trough concentrations between 15 and 20 mg/liter or 5 and 20 mg/liter are desired.

Work-Arounds Observed by Fourth-Year Nursing Students

Much has been written about the need for health care professionals to consistently promote policies and best practices that create safe, high-quality care environments. At times, nurses deviate from established policies and procedures to create work-arounds or changes in work patterns to accomplish patient care goals. The purpose of this study was to identify common work-arounds and describe what influenced the nurse to engage in the work-around as observed by fourth-year baccalaureate students in clinical settings. A descriptive qualitative approach was used to describe the findings from a Quality and Safety Education for Nurses–based assignment. Ninety-six individual student assignments were included in this analysis; the themes of infection prevention and control and medication management emerged. The theme of workload emerged as the reason why students believed nurses engaged in work-arounds. Further studies are needed to determine how work-arounds influence short- and long-term patient outcomes.

Treatment outcomes of infants with cyanotic congenital heart disease treated with synbiotics

OBJECTIVES

The goal was to investigate the effect of orally administered synbiotics on outcome of infants with cyanotic congenital heart disease (CCHD).

METHODS

A prospective, blinded, randomized controlled trial was conducted to evaluate the effect of synbiotics on outcome of infants with CCHD. The infants with CCHD were assigned randomly to 2 groups. Infants in the study group were given synbiotic (Bifidobacterium lactis plus inulin) added to breast milk or mixed feeding until discharge or death. Infants in the placebo group were fed with breast milk or mixed feeding. The outcome measurements were nosocomial sepsis, necrotizing enterocolitis (NEC; Bell stage ≥ 2), length of NICU stay, and death.

RESULTS

A total of 100 infants were enrolled in the trial: 50 in each arm. There were 9 cases of culture-proven sepsis (18%) in the placebo group and 2 cases (4%) in the synbiotic group (P = .03). Length of NICU stay did not differ between the groups (26 [14-36] vs 32 days [20-44], P = .07]. There were 5 cases of NEC (10%) in the placebo group and none in the synbiotic group (P = .03). The incidence of death was lower in synbiotic group (5 [10%] of 50 vs 14 [28.0%] of 50, respectively; P = .04).

CONCLUSIONS

Synbiotics administered enterally to infants with CCHD might reduce the incidence of nosocomial sepsis, NEC, and death.

Viral outbreaks in neonatal intensive care units: what we do not know

Background

Nosocomial infection is among the most important causes of morbidity, prolonged hospital stay, increased hospital costs, and mortality in neonates, particularly those born preterm. The vast majority of scientific articles dealing with nosocomial infections address bacterial or fungal infections, and viral agents are often disregarded. This analysis reviews the medical literature in an effort to establish the incidence, types of pathogens, and clinical features of noncongenital neonatal viral infections.

Methods

This analysis was performed using the worldwide database of health care–associated outbreaks (http://www.outbreak-database.com). Items analyzed included causative pathogens, types of infection, source of outbreaks, and measures taken to stop outbreaks.

Results

The outbreak database contained a total of 590 neonatal outbreaks, of which 64 were originated by viruses, 44 of which (68.75%) were reported from neonatal intensive care units (NICUs). The 5 most frequent viral agents were rotavirus (23.44%), respiratory syncytial virus (17.19%), enterovirus (15.63%), hepatitis A virus (10.94%), and adenovirus (9.38%).

Conclusion

Our analysis of the viral origins of nosocomial infections in NICUs can be a valuable tool in the investigation of neonatal infections. The mortality rates reported in this analysis demonstrate the significance of noncongenital viral infections in NICUs and the need for more effective outbreak prevention strategies.

Trends in incidence of neonatal sepsis and antibiotic susceptibility of causative agents in two neonatal intensive care units in tehran, I.R iran

BACKGROUND

Neonatal sepsis is a worldwide problem that presents a management challenge to care groups for neonates and infants. Early diagnosis and management can considerably decrease the risk of sepsis, and improve the outcome.

AIM

The aim of the present study was to determine the incidence, causative pathogens, and the antibiotic sensitivity pattern for neonatal sepsis in Iran.

MATERIALS AND METHODS

A historical cohort study was conducted on 84 patients with neonatal sepsis who were admitted to the neonatal intensive care unit (NICU) wards of Baqiyatallah and Najmieh University hospitals in Tehran, between 2003 and 2006. Clinical, demographic and laboratory data was collected from medical records.

RESULTS

Among all the comprised neonates, 44 patients were diagnosed with early-onset sepsis, 23 cases with late-onset sepsis and others with nosocomial sepsis. The most common isolated pathogen in all groups was Enterobacter, and was responsible for 31.4%, 47.8% and 41.2% of the episodes of sepsis, according to the sepsis type mentioned above, respectively. Susceptibility of common sepsis related pathogens to imipenem and gentamycin gradually reduced over the years between 2003 and 2006. Total mortality and morbidity rates due to neonatal sepsis were estimated at 27.4% and 89.3%, respectively. Mortality following sepsis was found more in boys (Odds Ratio (OR)=4.897, Conifdence Interval (CI)=95%, P=0.031), and those with low birth weight (OR=4.406, CI: 95%, P=0.011). Higher sepsis related co-morbidity was found in neonates following cesarean delivery (OR=6.280, CI: 95%, P=0.025).

CONCLUSION

It seems that the mortality rate in this study was lower than similar studies in Iran and other developing countries. This difference between the mortality rates of the centers in our study and others could be due to the high occurrence of Enterobacter infections in the latter and also high resistance of these pathogens to commonly used antibiotics such as β-lactams and aminoglycosides reported in other studies.

Reducing neonatal infections in south and south central Vietnam: the views of healthcare providers

BACKGROUND

Infection causes neonatal mortality in both high and low income countries. While simple interventions to prevent neonatal infection are available, they are often poorly understood and implemented by clinicians. A basic understanding of healthcare providers' perceptions of infection control provides a platform for improving current practices. Our aim was to explore the views of healthcare providers in provincial hospitals in south and south central Vietnam to inform the design of programmes to improve neonatal infection prevention and control.

METHODS

All fifty-four participants who attended a workshop on infection prevention and control were asked to complete an anonymous, written questionnaire identifying their priorities for improving neonatal infection prevention and control in provincial hospitals in south and south central Vietnam.

RESULTS

Hand washing, exclusive breastfeeding and safe disposal of medical waste were nominated by most participants as priorities for preventing neonatal infections. Education through instructional posters and written guidelines, family contact, kangaroo-mother-care, limitation of invasive procedures and screening for maternal GBS infection were advocated by a smaller proportion of participants.

CONCLUSIONS

The opinions of neonatal healthcare providers at the workshop accurately reflect some of the current international recommendations for infection prevention. However, other important recommendations were not commonly identified by participants and need to be reinforced. Our results will be used to design interventions to improve infection prevention in Vietnam, and may be relevant to other low-resource countries.

Probiotics and prebiotics: role in prevention of nosocomial sepsis in preterm infants

Nosocomial sepsis is associated with increased mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay. Prevention of sepsis especially in the preterm infants in the neonatal intensive care unit remains a major challenge. The gastrointestinal tract is an important source of potential pathogens causing nosocomial sepsis as the immature intestinal epithelium can permit translocation of bacteria and yeast. The intestinal tract and its microflora play an important role in the immunity. Altering the gut microflora has been extensively studied for immunomodulation in preterm infants. Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Probiotics have been used for prevention and treatment of various medical conditions in children and adults. Studies on probiotics in premature infants have focused on normalizing intestinal flora, improvement in feeding intolerance, prevention of necrotizing enterocolitis and sepsis. In this paper, we discuss the intestinal bacterial colonization pattern; the rational for probiotics and prebiotic therapy with special focus on the prevention of nosocomial sepsis in preterm infants.

Antibiotic use in newborns with transient tachypnea of the newborn

BACKGROUND

Initiation of empiric antibiotic treatment for possible early-onset sepsis is recommended for late preterm and term neonates with respiratory distress. There is no evidence base to this approach.

OBJECTIVES

To determine the incidence of adverse infectious events in neonates with transient tachypnea of the newborn (TTN) managed with a risk-factor-based restrictive antibiotic use policy.

METHODS

This is a single institution retrospective cohort study of neonates with primary diagnosis of TTN between 2004 and 2010. The relationship between antibiotic exposure and infectious outcomes during the neonatal hospitalization was evaluated. An infectious outcome was defined as pneumonia, bacteremia, clinical sepsis, or death. Analysis included t test, χ(2) test, and analysis of variance as appropriate.

RESULTS

745 neonates with TTN met inclusion criteria. None of the 494 antibiotic-naive infants, and 212 of the 251 antibiotic-exposed infants had identifiable risk factors for sepsis. No infectious outcomes occurred in infants who did not receive antibiotics. Eight neonates with TTN received full antibiotic treatment for early-onset sepsis. Each was appropriately identified for early receipt of antibiotics based on historical or clinical risk factors for early-onset sepsis.

CONCLUSIONS

This study suggests that empiric postnatal antibiotic treatment may not be warranted for late preterm and term infants with TTN in the absence of specific infectious risk factors.

Healthcare-associated infections in a neonatal intensive care unit

INTRODUCTION

Healthcare-associated infection is a common problem in patients from neonatal intensive care units and it is one of the leading causes of death in this group of patients. Healthcare-associated infections are associated with increases in mortality, morbidity, and prolonged length of hospital stay. The aim of the study was to assess the incidence, clinical presentation, mortality and aetiology of healthcare-associated infections in newborns in a neonatal intensive care unit between 2005 and 2010.

MATERIAL AND METHODS

The research involved documentation of 2610 neonates hospitalized in this period in the Neonatal Intensive Care Unit, Dr Jan Biziel University Hospital No. 2 in Bydgoszcz. The incidence, clinical presentation, mortality and causative factors of healthcare-associated infections were assessed.

RESULTS

The prevalence of healthcare-associated infections was 7.32%. The most frequent healthcare-associated infections were bloodstream infection (65.4%) and urinary tract infection (22.5%). The mortality rate was 2.1%. The most frequent pathogens were coagulase-negative staphylococci (36.1%) and Klebsiella pneumoniae (29.3%).

CONCLUSIONS

The rate of healthcare-associated bloodstream infections in the analysed department is low, taking into consideration the specificity of the department. There is a necessity to establish convenient definitions of various kinds of healthcare-associated infecions in neonates, especially those born preterm.

New possibilities of prevention of infection in the newborn

Severe infections represent the main cause of neonatal mortality and morbidity. Strategies of proven effectiveness in reducing the incidence of infection in neonatal intensive care units (NICUs) include hand hygiene practices and prevention of central venous catheter-related bloodstream infections. In recent years, new strategies have been developed to prevent infections in NICU including prevention of neonatal sepsis with lactoferrin, the use of heparin for the prevention of CRBSIs, the judicious use of antibiotics and chemoprophylaxis, prevention of invasive fungal infections with fluconazole, the use of specific anti-staphylococcal immunoglobulins, and the early identification of infants at higher risk of infection with the use of specific markers (mannose-binding lectin). This review will focus on these new strategies and on their role in clinical practice in order to further reduce the incidence of infection in NICU.

Use of cefoperazone/sulbactam in neonates

BACKGROUND

Neonates are at high risk for nosocomial infections due to multidrug-resistant pathogens. The use of β-lactamase inhibitors in combination with β-lactam antibiotics broadens the antimicrobial spectrum. Cefoperazone/sulbactam is used in children but there are limited data on its usage in neonates. The purpose of the present study was therefore to evaluate the use of cefoperazone/sulbactam in the treatment of neonatal infections caused by multidrug-resistant pathogens.

METHODS

The records of neonates who were hospitalized and who received cefoperazone/sulbactam were reviewed.

RESULTS

There were 90 infants who received cefoperazone/sulbactam. A pathogen could be isolated in 41 (45.6%) of the infants. In total, 17.1% of isolated pathogens were resistant to cefoperazone/sulbactam. Side-effects were seen in four of the infants. Two infants had cholestasis, one infant had neutropenia and one had superinfection with candida.

CONCLUSION

Cefoperazone/sulbactam can be used in the treatment of nosocomial infections caused by multidrug-resistant pathogens in neonates.

Coagulase-negative staphylococcal infections in the neonatal intensive care unit

BACKGROUND

Coagulase-negative staphylococci (CoNS) are the most commonly isolated pathogens in the neonatal intensive care unit (NICU). CoNS infections are associated with increased morbidity, including neurodevelopmental impairment.

OBJECTIVE

To describe the epidemiology of CoNS infections in the NICU. To determine mortality among infants with definite, probable, or possible CoNS infections.

METHODS

We performed a retrospective cohort study of all blood, urine, and cerebrospinal fluid cultures from samples obtained from infants aged <121 postnatal days.

SETTING

A total of 248 NICUs managed by the Pediatrix Medical Group from 1997 to 2009.

RESULTS

We identified 16,629 infants with 17,624 episodes of CoNS infection: 1,734 (10%) definite, 3,093 (17%) probable, and 12,797 (73%) possible infections. Infants with a lower gestational age and birth weight had a higher incidence of CoNS infection. When controlling for gestational age, birth weight, and 5-minute Apgar score, we found that infants with definite, probable, or possible CoNS infection had lower mortality (odds ratio [OR], 0.74 [95% confidence interval {CI}: 0.61, 0.89], 0.68 [95% CI, 0.59, 0.79], and 0.69 [95% CI, 0.63, 0.76], respectively) compared with infants who had negative culture results (P = .001). No significant difference in overall mortality was found in infants who had definite CoNS infection compared with those who had probable or possible CoNS infection (OR, 0.93 [95% CI, 0.75, 1.16] and 0.85 [95% CI, 0.70, 1.03], respectively).

CONCLUSIONS

CoNS infection was strongly related to lower gestational age and birth weight. Infants with clinical sepsis and culture-positive CoNS infection had lower mortality rates than infants with clinical sepsis and negative blood culture results. No difference in mortality between infants with a diagnosis of definite, probable, or possible CoNS infection was observed.

Emerging viral infections in neonatal intensive care unit

Nosocomial infections are the most important cause of morbidity and mortality among neonates and mostly in infants admitted to neonatal intensive care units (NICU). The total number of neonates who develop nosocomial infections per admission varies from 6.2 to 30%. The role of nosocomial virus infections is generally neglected in the actual epidemiologic scenario mostly due to the lack of data in the medical literature. Based on a worldwide database of health care-associated outbreaks (http://www.outbreak-database.com) we performed an analysis of the incidence, type of pathogens and clinical features of neonatal viral outbreaks especially those reported in NICUs. We also describe, as an example of emerging virus in NICU, a Norovirus outbreak along with clinical presentation that varies from mild to moderate clinical symptoms like vomiting, gastric remainder, diarrhoea, abdominal distension or severe presentation like necrotizing enterocolitis. and measures implemented for terminating the outbreak. In conclusion, our study analyses the viral origins of nosocomial infections in NICU and underline that the role of viral agents in neonatal nosocomial infections needs to be further investigated even in diseases traditionally considered of bacterial origin like necrotizing enterocolitis.

Risk factors associated with gut and nasopharyngeal colonization by common Gram-negative species and yeasts in neonatal intensive care units patients

AIM

To characterize dynamics of mucosal colonization of neonates by common aerobic Gram negative species and Candida spp. and to identify independent perinatal, neonatal, and environmental factors influencing the colonization process.

STUDY DESIGN

The nasopharyngeal (n=1145) and rectal (n=1242) swabs were collected on admission and thereafter twice a week in neonates with risk factors of early onset sepsis (n=276) admitted within the first 72 h of life. The association between colonization by different microbes and a total of 22 predefined risk factors was assessed using univariate and multiple logistic regression analyses.

RESULTS

Throughout the study about half of the patients had rectal (55.8%) or nasopharyngeal colonization (42.8%) with common Gram-negative microorganisms. Colonization dynamics and risk factors were in general similar for a given bacterial species in both mucosal sites; nonfermentative microbes more often found in nasopharyngeal swabs and Enterobacteriaceae in rectal swabs. All organisms except Escherichia coli were influenced by the duration of intensive care unit stay but other risk factors were species specific, perhaps reflecting their mode of acquisition. While colonization by E. coli and Candida albicans was associated with perinatal factors like term birth, vaginal delivery, and breast milk feeding; colonization by Klebsiella pneumoniae, Enteribacter cloacae, Acinetobacter spp. and non-albicans Candida spp. were mostly determined by hospital environment (treatment unit and period, artificial interventions and their duration) and gestation age ≤ 28 weeks.

CONCLUSIONS

The knowledge of risk factor profiles may permit the development of strategies to prevent heavy colonization and subsequent invasive disease in high risk infants.

Iatrogenic complications in the neonatal intensive care unit

With the introduction of novel technologies and approaches in neonatal care and the lack of appropriately designed and well-executed randomized clinical trials to investigate the impact of these interventions, iatrogenic complications have been increasingly seen in the neonatal intensive care unit. In addition, increased awareness and the introduction of more appropriate quality control measures have resulted in higher levels of suspicion about and increased recognition of complications associated with delivery of care. The incidence of complications also rises with the increased length of hospital stay and level of immaturity. Approximately half of the iatrogenic complications are related to medication errors. The other complications are due to nosocomial infections, insertion of invasive catheters, prolonged mechanical ventilation, administration of parenteral nutrition solution, skin damage and environmental complications. Adopting newer technologies and preventive measures might decrease these complications and improve outcomes. Quality improvement projects targeting areas for improvement are expected to build team spirit and further improve the outcomes. In addition, participation in national reporting systems will enhance education and provide an opportunity to compare outcomes with peer institutions.

The changing spectrum of neonatal infectious disease

To understand the changing spectrum of neonatal infectious disease, one must first be familiar with the history, the variety of organisms and the progression of change of neonatal infections over the years. As progressively more immature neonates are surviving, the spectrum of infectious disease has changed in response to current medical practice responsible for this success and to selective pressures on the microorganisms. The surviving very low birth weight infants are at a significant risk for contracting infections from this expanding repertoire of pathogens. Microorganisms once thought seemingly benign and nonpathogenic are now commonly accepted as pathogens and are among the most likely organisms to cause infections in this extremely vulnerable patient population. When considering the possible identity of infecting organisms and attempting to tailor specific therapies to decrease unwanted consequences, one must consider the level of maturity and the age of neonate, as well as the intensity of care necessary for a successful outcome. This brief review focuses primarily on the changing spectrum of bacterial and fungal infections and will not substantially address viral infections.

Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study

OBJECTIVES

The goals were to determine the incidence of iatrogenic events in NICUs and to determine whether awareness of iatrogenic events could influence their occurrence.

METHODS

We performed a prospective, observational, interventional, multicenter study including all consecutive infants hospitalized in 4 NICUs. In the first 3 months (observation period), the medical teams were unaware of the study; in the next 3 months (intervention period), they were made aware of daily ongoing monitoring of iatrogenic events by a designated "Iatrogenesis Advocate."

RESULTS

The numbers of infants admitted to the NICUs were comparable during the observation and intervention periods (328 and 369 infants, respectively). There was no difference between the 2 periods with respect to the number of infants of <1500 g, hospitalization days, or mean daily occupancy of the NICUs. Although the prevalence rates of iatrogenic events were comparable in the observation and intervention periods (18.0 and 18.2 infants with iatrogenic events per 100 hospitalized infants, respectively), the incidence rate decreased significantly during the intervention period (3.2 and 2.4 iatrogenic events per 100 hospitalization days of new admissions, respectively). Of all iatrogenic events, 7.9% were classified as life-threatening and 45.1% as harmful. There was no death related to an iatrogenic event. Eighty-three percent of iatrogenic events were considered preventable, of which 26.9% resulted from medical errors in ordering or delivery of medical care. Only 1.6% of all iatrogenic events were intercepted before reaching the infants, and only 47.0% of iatrogenic events were corrected. For younger and smaller infants, the rate of iatrogenic events was higher (57% at gestational ages of 24 to 27 weeks, compared with 3% at term) and the iatrogenic events were more severe and harmful. Increased length of stay was associated independently with more iatrogenic events.

CONCLUSIONS

Neonatal medical teams and parents should be aware of the burden of iatrogenesis, which occurs at a significant rate.

[Nosocomial Candida infections and thrombocytopenia in very low birth weight newborns]

OBJECTIVE

To analyze thrombocytopenia as an early marker of late-onset neonatal Candida sepsis and to determine whether there are significant differences in platelet count between neonates infected by different infectious agents.

MATERIAL AND METHODS

We retrospectively reviewed the medical charts of 42 neonates with late-onset sepsis with positive blood culture in our neonatology service between January 1, 2003 and December 31, 2004. Only the first episode of sepsis in any single patient was included. The principal parameter examined was the incidence of thrombocytopenia according to the microorganisms causing the sepsis (Gram-positive bacteria, Gram negative bacteria and fungi). The statistical analysis was performed using SPSS version 11.5. The data are expressed as mean+/-standard deviation. The chi-squared test was used to compare qualitative variables. For quantitative variables, the Kolmogorov-Smirnov was used; ANOVA was used for parametric variables and the Kruskal-Wallis test for non-parametric variables. A value of p<0.5 was considered significant.

RESULTS

Late-onset sepsis was diagnosed in 42 (2.3%) of 1,757 newborn admissions. Gestational age at birth was 31+/-4.9 weeks (24-41.5 weeks) with a mean birth weight of 1,618+/-911 g (750-4,070 g). There were 34 boys (81%) and eight girls (19%). When patients infected with the three groups of microorganisms were compared, no significant differences were found except for birth weight, days of stay in the neonatal intensive care unit, thoracotomy, days of mechanical ventilation, antibiotic therapy before sepsis, and thrombocytopenia. Gram-positive sepsis was found in 47.6%, Gram-negative sepsis in 33 % and fungal sepsis in 19%. The only cause of fungal sepsis was Candida, mainly C. glabrata (50%), followed by C. albicans (37.5%) and C. parapsilosis (12.5%). The most reliable marker of Candida sepsis was thrombocytopenia, which was found in 17.7% of the episodes of late-onset sepsis. The incidence of thrombocytopenia was significantly higher in Candida sepsis than in bacterial sepsis (100% vs 5.9%) (p<0.001). Only two patients with bacterial sepsis had thrombocytopenia and both cases were caused by Gram-negative bacteria.

CONCLUSION

Thrombocytopenia is a highly specific marker of neonatal Candida sepsis. Analysis of platelet counts is a simple laboratory test that helps to guide diagnosis and the use of early empirical therapy.

Bacillus licheniformis septicemia in a very-low-birth-weight neonate: a case report

Nosocomial infections in neonatal intensive care units are a preoccupying issue. Bacillus sp. can be pathogenic in immuno-compromised hosts, including premature infants. Central catheters and mechanical ventilation are potential sources of infection. We report for the first time a case of Bacillus licheniformis bacteremia in a premature infant. Recovery necessitated treatment with vancomycin and cefotaxime in combination with removal of the central catheter.

Nosocomial infection in small for gestational age newborns with birth weight <1500 g: a multicentre analysis

OBJECTIVE

To investigate whether preterm newborns who are small for gestational age are at increased risk of nosocomial infections and necrotising enterocolitis.

DESIGN, SETTING AND SUBJECTS

The German national surveillance system for nosocomial infection in very low birthweight infants uses the US Centers for Disease Control and Prevention criteria. 2918 newborns (24-28 weeks), born between 2000 and 2004, were selected after application of predefined inclusion criteria to ensure similar proportions of small and appropriate weight for gestational age newborns across gestational age groups.

MAIN OUTCOME MEASURES

The outcome criterion was at least one episode of nosocomial sepsis, pneumonia or necrotising enterocolitis. Adjusted odds ratios and corresponding 95% CIs were calculated based on general estimating equation models.

RESULTS

The study population consisted of 13% (n = 392) small and 87% (n = 2526) appropriate weight for gestational age infants. 33% (n = 950) of the infants experienced at least one episode of sepsis: 42% (n = 163) of small and 31% (n = 787) of appropriate weight for gestational age newborns (adjusted OR 1.41, 95% CI 1.05 to 1.89). Pneumonia was diagnosed in 6% (n = 171) of infants: 8.4% (n = 33) of small and 5.5% (n = 138) of appropriate weight for gestational age newborns (adjusted OR 1.57, 95% CI 1.19 to 5.57). Necrotising enterocolitis was documented in 5.2% (n = 152) of infants: 7.1% (n = 28) of small and 4.9% of (n = 124) appropriate weight for gestational age newborns (adjusted OR 1.20, 95% confidence interval 0.75 to 1.94).

CONCLUSIONS

Growth-retarded preterm infants seem to be at increased risk of nosocomial infection, irrespective of the responsible pathogen. Future immunological research should elucidate potential causal associations.

Infants at risk: when nurse fatigue jeopardizes quality care

Although most research on medical error has been conducted on adult inpatient units, the few studies conducted in pediatric settings suggest that errors occur more frequently in neonatal intensive care units (NICUs) than in other inpatient units. The effects of fatigue, due to long work hours, working at night, and insufficient sleep, are often underestimated. This article reviews basic information about fatigue and sleep and includes examples drawn from data provided by 6 NICU nurses who participated in a recent study to highlight the relationship between fatigue and error. These case studies reinforce the concept that NICU nurses need to be alert enough to provide safe care for their patients, as well as alert enough to detect and correct the errors made by others. Employing good sleep habits, minimizing shift rotations and excessive work hours, and using strategic naps can reduce the adverse effects of fatigue that could potentially put patients, especially the most vulnerable ones, at risk.

Hospital-acquired neonatal infections in developing countries

Hospital-born babies in developing countries are at increased risk of neonatal infections because of poor intrapartum and postnatal infection-control practices. We reviewed data from developing countries on rates of neonatal infections among hospital-born babies, range of pathogens, antimicrobial resistance, and infection-control interventions. Reported rates of neonatal infections were 3-20 times higher than those reported for hospital-born babies in industrialised countries. Klebsiella pneumoniae, other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp), and Staphylococcus aureus were the major pathogens among 11,471 bloodstream isolates reported. These infections can often present soon after birth. About 70% would not be covered by an empiric regimen of ampicillin and gentamicin, and many might be untreatable in resource-constrained environments. The associated morbidity, mortality, costs, and adverse effect on future health-seeking behaviour by communities pose barriers to improvement of neonatal outcomes in developing countries. Low-cost, "bundled" interventions using systems quality improvement approaches for improved infection control are possible, but should be supported by evidence in developing country settings.

Pathogen-specific early mortality in very low birth weight infants with late-onset sepsis: a national survey

BACKGROUND

Late-onset sepsis (LOS) is an important cause of mortality among very low birth weight (VLBW) infants, and deaths occurring within 3 days after the onset of sepsis can probably be ascribed to sepsis. We examined the association of sepsis due to specific pathogens with the risk for early mortality after the onset of LOS, adjusted for perinatal and neonatal risk factors.

METHODS

From 1995 through 2001, information about 10,215 infants was gathered and deposited in the Israel National VLBW Infant Database. The study population was composed of 2644 infants, of which each had >or=1 events of LOS (totalling 3462 events). Logistic regression models were used to calculate the crude and adjusted risk for early mortality.

RESULTS

Early mortality was associated with 179 LOS events (5.2% of 3,462); the range of pathogens associated with these events included coagulase-negative staphylococci (CoNS), which were the cause of 1.8% of LOS events associated with early mortality, and Pseudomonas species, which were the cause of 22.6% of such events. Early mortality after LOS, adjusted for neonatal risk factors, was significantly associated with sepsis due to certain pathogens: Pseudomonas species (odds ratio [OR], 12.3); Klebsiella species (OR, 6.3); Serratia species (OR, 6.2); Escherichia species (OR, 4.3); Enterobacter species (OR, 4.1); and Candida species (OR, 3.2), compared with sepsis due to CoNS . In addition, lower gestational age, lower chronological age, small size for gestational age, and grade 3-4 intraventricular hemorrhage, each had an independent association with early mortality.

CONCLUSIONS

Klebsiella sepsis and Pseudomonas sepsis were associated with a 6.3-fold and 12.3-fold increased risk of early mortality, respectively, and accounted for 41.9% of all early deaths associated with LOS. Considering the aggressive nature of sepsis caused by these pathogens, empiric antibiotic therapy active against these organisms is worth consideration for VLBW infants with presumed LOS.