Nosocomial infections in a newborn intensive-care unit. Results of forty-one months of surveillance

Pneumonia

Neonatal pneumonia may occur in isolation or as one component of a larger infectious process. Bacteria, viruses, fungi, and parasites are all potential causes of neonatal pneumonia, and may be transmitted vertically from the mother or acquired from the postnatal environment. The patient's age at the time of disease onset may help narrow the differential diagnosis, as different pathogens are associated with congenital, early-onset, and late-onset pneumonia. Supportive care and rationally selected antimicrobial therapy are the mainstays of treatment for neonatal pneumonia. The challenges involved in microbiological testing of the lower airways may prevent definitive identification of a causative organism. In this case, secondary data must guide selection of empiric therapy, and the response to treatment must be closely monitored.

Lifetime Modulation of the Pain System via Neuroimmune and Neuroendocrine Interactions

Chronic pain is a debilitating condition that still is challenging both clinicians and researchers. Despite intense research, it is still not clear why some individuals develop chronic pain while others do not or how to heal this disease. In this review, we argue for a multisystem approach to understand chronic pain. Pain is not only to be viewed simply as a result of aberrant neuronal activity but also as a result of adverse early-life experiences that impact an individual's endocrine, immune, and nervous systems and changes which in turn program the pain system. First, we give an overview of the ontogeny of the central nervous system, endocrine, and immune systems and their windows of vulnerability. Thereafter, we summarize human and animal findings from our laboratories and others that point to an important role of the endocrine and immune systems in modulating pain sensitivity. Taking "early-life history" into account, together with the past and current immunological and endocrine status of chronic pain patients, is a necessary step to understand chronic pain pathophysiology and assist clinicians in tailoring the best therapeutic approach.

Prevalence of Gram-negative bacteria in ventilator-associated pneumonia in neonatal intensive care units: a systematic review and meta-analysis protocol

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a common and potentially lethal problem among mechanically ventilated neonates in neonatal intensive care units (NICUs). The main pathogenic bacteria of VAP in NICUs are Gram-negative pathogens, which show a general decline in sensitivities to commonly used antibiotics, but their true prevalence is not known.

METHODS AND ANALYSIS

We aim to provide a systematic review of studies measuring the prevalence of Gram-negative bacteria in VAP in NICUs. We will search PubMed, SCOPUS, EMBASE and the ISI Web of Science, as well as the Google Scholar search engine with no restriction on language. Full copies of articles will be identified by a defined search strategy and will be considered for inclusion against predefined criteria. Study selection and data extraction will be performed by 2 independent reviewers. Statistical analysis will include the identification of data sources and documentation of estimates, as well as the application of the random-effects and fixed-effects meta-analysis models. This will allow us to aggregate prevalence estimates and account for between-study variability in calculating the overall pooled estimates and 95% CI for the prevalence of Gram-negative bacteria in VAP in NICUs. Heterogeneity will be evaluated using the I2 and χ2 statistical tests to determine the extent of variation in effect estimates due to heterogeneity rather than chance. Publication bias and data synthesis will be assessed by funnel plots and Begg's and Egger's tests using STATA software V.13. This systematic review protocol was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P) 2015 Statement.

ETHICS AND DISSEMINATION

No ethical issues are predicted. These findings will be published in a peer-reviewed journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

CRD42016036048.

[Five steps to decreasing nosocomial infections in large immature premature infants: A quasi-experimental study]

OBJECTIVES

An evaluation is made of the impact of a series of five interventions on the incidence of hospital-related infections in a level iii neonatal unit.

MATERIAL AND METHODS

Quasi-experimental, pre-post intervention study, which included preterm infants weighing 1,500g at birth or delivered at <32 weeks gestation, admitted in the 12 months before and after the measures were implemented (January 2014). The measures consisted of: optimising hand washing, following a protocol for insertion and handling of central intravenous catheters, encouraging breastfeeding; applying a protocol for rational antibiotic use, and establishing a surveillance system for multi-resistant bacteria. The primary endpoint was to assess the incidence of hospital-acquired infections before and after implementing the interventions.

RESULTS

Thirty-three matched patients were included in each period. There was an incidence of 8.7 and 2.7 hospital-related infections/1,000 hospital stay days in the pre- and post-intervention periods, respectively (P<.05). Additionally, patients in the treatment group showed a statistically-significant decrease in days on mechanical ventilation, use of blood products, and vasoactive drugs.

CONCLUSIONS

The strategy, based on implementing five specific measures in a unit with a high rate of hospital-related infections, proved effective in reducing their incidence. This reduction could contribute to lowering the use of mechanical ventilation, blood products, and vasoactive drugs.

Bacterial Sepsis in the Newborn Infant: Developmental Deficiencies in Neutrophils and the Role of Neutrophil Transfusion

Bacterial sepsis is an important cause of morbidity and mortality in newborns. Group B streptococci and Es cherichia coli are the primary causative organisms. New and theoretically more effective antibiotics have not im proved survival. Because the neonate has defects in the immune response, new forms of therapy may be able to improve outcome by correcting or circumventing those deficiencies. The neutrophil has a substantial role in antibacterial defense, yet neonatal neutrophil function is limited by impaired chemotaxis, phagocytosis, and in tracellular killing. The supply of neonatal neutrophils is restricted by a small neutrophil reserve, a delay in mobilization of neutrophils from the bone marrow re serve after bacterial invasion, a small granulocytopoietic progenitor cell reserve, and a limited ability to acceler ate proliferation of progenitor cells during bacterial in fection. Recent studies of neutrophil transfusions in in fected neonates suggest a beneficial effect at least in certain situations. Exchange transfusion with fresh whole blood may be an alternative to transfusion with neutro phils obtained by apheresis. The ultimate role of neutro phil transfusions as an adjunct therapy for neonatal sep sis remains to be determined.

Statistical Analysis of Stratified 2X2 Tables

Previous papers in this series have discussed design and analysis issues for epidemiologic data that can be presented in a 2 × 2 table.‘” the primary focus was on methods for determining the extent of association between a dichotomous disease state and a dichotomous risk factor. methods appropriate for cross-sectional, prospective, and retrospective studies using matched or unmatched samples were described.

In order to study the association between disease status and a dichotomous risk factor, it is often necessary to take into account other variables that may influence either the disease status or the risk factor. For example, Hemming, Overall, and Britt studied the association between the occurrence of nosocomial infections (risk factor) and mortality (disease status) in a large cohort of infants in a newborn intensive care unit. these authors analyzed the data using methods for summarizing the results from a single 2 × 2 table. However, because very low birth weight is associated strongly with both the acquisition of nosocomial infection and mortality, it may be more appropriate to control or adjust for the effects of birthweight.

An Outbreak of Gentamicin-ResistantEnterobacter cloacaeInfections in a Pediatric Intensive Care Unit

The intensive care unit at Children's Medical Center in Dallas is a medical-surgical unit that cares for pediatric patients of all ages. In 1978 an outbreak of infections occurred that was caused by a gentamicin-resistant strain ofEnterobacter cloacae. Thirty of the 34 patients involved in the outbreak were neonates. Six patients developed bacteremia, five of them neonates. The neonates who became infected were significantly smaller (> 1500 g) and more premature (< 35 weeks) than control patients. Neonates with bacteremia had a significantly higher incidence of congenital anomalies. In a multi-specialty pediatric intensive care unit newborn infants were the group of patients at high risk for nosocomial infection.

Handwashing Program for the Prevention of Nosocomial Infections in a Neonatal Intensive Care Unit

Objective:

To evaluate the effects of a hand hygiene program on compliance with hand hygiene and the rate of nosocomial infections in a neonatal intensive care unit (NICU).

Design:

Open trial.

Setting:

A level-III NICU in a teaching hospital.

Participants:

Nurses, physicians, and other healthcare workers in the NICU.

Interventions:

A multimodal campaign for hand hygiene promotion was conducted beginning in September 1998. This program consisted of formal lectures, written instructions and posted reminders regarding hand hygiene and proper handwashing techniques, covert observation, financial incentives, and regular group feedback on compliance. Surveillance of handwashing compliance and nosocomial infections before and during the program was analyzed.

Results:

Overall compliance with hand hygiene improved from 43% at baseline to 80% during the promotion program. The rate of nosocomial infections decreased from 15.13 to 10.69 per 1,000 patient-days (P= .003) with improved handwashing compliance. In particular, respiratory tract infections decreased from 3.35 to 1.06 per 1,000 patient-days during the handwashing campaign (P= .002). Furthermore, the correlation between nosocomial infection of the respiratory tract and handwashing compliance also reached statistical significance (r= -0.385;P= .014).

Conclusions:

Improved compliance with handwashing was associated with a significant decrease in overall rates of nosocomial infection and respiratory infections in particular. Washing hands is a simple, economical, and effective method for preventing nosocomial infections in the NICU

Epidemiology of pathogens and drug resistance of ventilator-associated pneumonia in Chinese neonatal intensive care units: a meta-analysis

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common and serious problem in intensive care units. However, limited literature has been reviewed to synthesize the findings about the incidence, case fatality rate, pathogen distribution, and drug resistance of neonatal VAP in China.

METHODS

A search of electronic databases was undertaken to identify the incidence, case fatality rate, pathogen distribution, and drug resistance of neonatal VAP based on the inclusion and exclusion criteria. Meta-analysis was carried out using R3.0.2 software.

RESULTS

A total of 16,587 participants were included in our final analysis. The incidence and case fatality rates were 42.8% and 16.4%, respectively. Gram-negative bacteria were detected in 77.6% of cultures, followed by gram-positive bacteria (18.8%) and fungi (3.7%). Gram-negative bacteria were sensitive to meropenem, imipenem, and ciprofloxacin, with resistance rates of 1.5%-25.0%, 4.9%-29.0%, and 8.5%-24.7%, respectively. Gram-positive bacteria have resistance rates as high as 72.7%-99.1% to penicillin, 62.6%-90.9% to erythromycin, and 80.3%-91.9% to oxacillin.

CONCLUSIONS

The incidence and case fatality rates of neonatal VAP are high in China. VAP was mainly caused by gram-negative bacteria that were resistant to most common antibiotics. The future study of drug-resistance mechanisms should be intensified, and effective measures of hospital infection control should be considered to prevent the outbreak of drug-resistant strains.

Risk factors for ventilator-associated pneumonia in the neonatal intensive care unit: a meta-analysis of observational studies

Ventilator-associated pneumonia (VAP) is a common and serious problem among mechanically ventilated patients in intensive care units (ICU), especially for the newborn. However, limited literatures have been reviewed to synthesize the finding of previous papers to investigate the risk factors for VAP although it has been a serious complication of mechanical ventilation (MV) with a high morbidity and mortality in the newborn. We performed this meta-analysis to extend previous knowledge for developing VAP prevention strategies by identifying the potential risk factors related to VAP in the neonatal intensive care unit (NICU). The relevant literatures published up to July 2013 were searched in the databases of PubMed, Cochrane Central Register of Controlled Trials, Embase, and Web of Science. Three reviewers screened those literatures and extracted data according to the inclusion and exclusion criteria independently. A total of eight studies including 370 cases and 1,071 controls were identified. Ten risk factors were found to be related to neonatal VAP which were listed as follows in order by odds ratios (ORs): length of stay in NICU (OR 23.45), reintubation (OR 9.18), enteral feeding (OR 5.59), mechanical ventilation (OR 4.04), transfusion (OR 3.32), low birth weight (OR 3.16), premature infants (OR 2.66), parenteral nutrition (OR 2.30), bronchopulmonary dysplasia (OR 2.21), and tracheal intubation (OR 1.12).

CONCLUSION

We identified ten variables as independent risk factors for the development of VAP: length of stay in NICU, reintubation, enteral feeding, mechanical ventilation, transfusion, low birth weight, premature infants, parenteral nutrition, bronchopulmonary dysplasia, and tracheal intubation. Due to several limitations in the present study, further large and well-designed studies are needed to confirm the conclusion.

Antibiotic timing in neonates with suspected hospital-acquired infections

There exists general agreement within neonatology that antibiotics should be administered promptly to neonates with possible bacterial sepsis and meningitis. We initiated a series of quality improvement cycles designed to reduce delays in the initiation of antibiotic therapy to less than 2 hours when hospital-acquired infection (HAI) was suspected. All infants in this study were in neonatal intensive care (level II or III) who were started on antibiotics for a suspected HAI (defined as an infection that occurred 72 hours after admission to the NICU) were audited. Through a series of quality improvement cycles, we analyzed sources of delays in the initiation of antibiotic therapy from the time the order was written through administration. In subsequent cycles, we intervened to reduce delays through education, standardize the evaluation process, and develop an online ordering system that streamlined the workflow patterns in the nurseries and pharmacy. Using a prospective cohort design, we compared antibiotic delivery times after each process improvement cycle. Antibiotic delivery time was reduced from a median of 137.5 minutes to 75 minutes and variation of practice was reduced in terms of standard deviation and range (P < .001). The use of computerized physician order entry significantly improved the writing of STAT orders (P < .0001). A systematic analysis of workflow patterns and efficiencies, coupled with improvement cycles targeting delays and development of a computerized physician order entry system, allowed us to improve antibiotic delivery time in neonates with suspected HAI in an intensive care nursery system.

Management and outcome of positive urine cultures in a neonatal intensive care unit

OBJECTIVES

The aim of this study was to describe the management and outcome of positive urine cultures in a neonatal intensive care unit (NICU).

STUDY DESIGN

A chart review was completed of infants born October 1, 2004 to December 31, 2006 and admitted to the NICU at the Royal Alexandra Hospital, Edmonton, Alberta with any growth of bacteria or fungi in urine.

RESULTS

Positive urine cultures were obtained in 64 of 2936 admissions (2%) and were classified as contaminated urines (n=34), possible urinary tract infection (UTI) (n=14), definite UTI (n=10), and candidal UTI (n=6). Management was inconsistent. Two children required new assisted ventilation but no other complications occurred.

CONCLUSIONS

The diagnosis of UTI in NICU is hampered by use of urine collection methods that are subject to contamination. Outcome is generally excellent, but there is a great need for guidelines on management of positive urine cultures in the NICU.

Strategies to prevent ventilator-associated pneumonia in neonates

Ventilator-associated pneumonia (VAP) is one of the leading causes of preventable morbidity and mortality in neonatal intensive care units. This review examines the epidemiology and pathogenesis of VAP in neonates as well as the dilemmas faced by caregivers to diagnose and prevent VAP.

Diagnostic Imaging of Neonatal Pneumonia

Respiratory infections remain a significant and formidable threat to the health and well being of the neonate despite potent antibiotics, increasingly sophisticated laboratory detection methods and technologically advanced neonatal intensive care nurseries. Although the clinical and radiological definitions of pneumonia are variable throughout medical and governmental literature, quoted incidence rates for neonatal pneumonia range between 1.5–5.0 per 1,000 live births (Keyserling 1997; Webber et el 1990).

Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.

Nosocomial infection in a neonatal intensive care unit: a prospective study in Taiwan

BACKGROUND

We performed a prospective analysis to determine the prevalence of nosocomial infection and associated risk factors in our neonatal intensive care unit (NICU).

METHODS

Data were collected prospectively on underlying diagnoses, therapeutic interventions/treatments, infections, and outcomes at 9 am every day from November 2004 through October 2005. Prevalence of nosocomial infection and infection site definitions were according to the National Nosocomial Infections Surveillance system of the Centers for Disease Control and Prevention.

RESULTS

Among 528 infants enrolled, 60 (11.4%) had 97 nosocomial infections. The survival rate was 92%. The prevalence of nosocomial infections was 17.5%: bloodstream infection, 4.7%, clinical sepsis, 6.3%, pneumonia, 5.1%, urinary tract infections (UTIs), 0.7%, surgical site infection, 0.7%. Intervention-associated infection rate: central intravascular catheter-associated bloodstream infection, 13.7%, TPN-associated bloodstream infection, 15.8%, ventilator-associated pneumonia, 18.6%, surgical site infection 13.7%, urinary catheter-associated UTI, 17.3%. Cut-off values of onset of central intravascular catheter-associated bloodstream infection and ventilator-associated pneumonia were 6 days and 10 days after intervention, respectively. Patients with a birth weight <1000 g (relative risk, 11.8, 95% confidence interval, 7.66-18.18; P < .001) were at the greatest risk for nosocomial infection.

CONCLUSIONS

This study revealed the high prevalence of nosocomial infections in NICU patients, and the urgent need for a national surveillance and more effective prevention interventions.

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).

Short antibiotic prophylaxis for bacterial infections in a neonatal intensive care unit: a randomized controlled trial

We compared the effectiveness of a single dose and a three-day course of antibiotic prophylaxis in preventing bacterial infections in high-risk neonates. The study was a prospective, randomized controlled trial conducted in a 20-bed tertiary referral neonatal intensive care unit (NICU). A series of 130 neonates admitted consecutively to the NICU, fulfilling risk factors for infection, were assigned at random to receive intravenous antibiotic prophylaxis with ampicillin and netilmicin either in two daily doses for 72 h (three-day-administration group, 67 infants) or in a single bolus injection on admission (bolus group, 63 infants). Hospital-acquired infection, the main outcome measure, was defined as infection that developed at least 48 h after admission, and vertical infection (maternally transmitted) was considered to be present when clinical symptoms and abnormal laboratory findings became evident within 48 h of birth. Infections were considered as suspected when clinical and laboratory findings of infection were present, without positive cultures, and as confirmed when positive cultures were also present. No significant differences were found between the two groups of neonates studied in mean birth weight, gestational age or postnatal age on admission. The incidence of vertical infection was similar in the two groups (16/67, 23.9% vs. 14/63, 22.2%). Of the 130 newborns studied, 29 (22.3%) acquired at least one nosocomial infection during their NICU stay; total hospital-acquired infections, calculated as the incidence density of infection (the number of infective episodes divided by the number of days in the NICU), were less frequent among newborns who received the three-day course than the bolus (relative risk 0.69). This difference, although not statistically significant, depended on the different incidence density of confirmed nosocomial infections rather than on suspected infections (relative risk 0.59; 95% confidence interval 0.32-1.09; P=0.1). There were no significant differences between the two groups in overall mortality. A single bolus administration on admission is therefore likely to be as effective as a three-day course of antibiotic prophylaxis in preventing bacterial infection in high-risk infants admitted to an NICU.

Risk factors for Candida infections in a neonatal intensive care unit in Costa Rica

OBJECTIVE

To identify potential risk factors associated with Candida infections and compare these risk factors between patients who both died and survived.

STUDY DESIGN

A group of patients with positive Candida spp. blood cultures admitted to a neonatal intensive care unit (NICU) in Costa Rica between January 1994 and December 1998. Cases were identified through a computerized search of the microbiology laboratory's database on blood cultures.

RESULTS

One hundred and ten newborns were identified. Sixty-six patients (60%) were male; 46 (62%) were preterm infants. Thirty-seven (34%) patients died. Twenty (54%) of them died within three days of the candidemia diagnosis and 17 had disseminated Candida infection on autopsy. Candida albicans and Candida tropicalis were isolated in 90% and 10% of blood cultures, respectively. Mean +/- SD (range) number of days from admission to NICU to the initial positive blood culture were 13.5 +/- 8.5 (1-30) days. Most patients had at least two positive blood cultures (range 1-8). Median (range) days for the sterilization of blood culture were four (1-25) days. Significant differences in survival were identified in patients with axillary-inguinal lesions, apnea and seizures.

CONCLUSIONS

Invasive fungal infections are frequent in NICU. Future case-control prospective studies should be carried out to confirm the findings from this report.

Healthcare-associated infections among neonates in Brazil

OBJECTIVE

To describe the epidemiology of healthcare-associated infections (HAIs) among neonates.

DESIGN

Prospective surveillance of HAIs was conducted during 2 years. Infections beginning within 48 hours of birth were defined as HAIs of maternal origin. Death occurring during an active episode of HAI was considered related to HAI.

SETTING

Seven neonatal units located in three Brazilian cities.

PATIENTS

All admitted neonates were included and observed until discharge.

RESULTS

Twenty-two percent of 4,878 neonates had at least one HAI. The overall incidence density was 24.9 per 1,000 patient-days, and 28.1% of all HAIs were maternally acquired. HAI rates ranged from 12.3% in the group with a birth weight (BW) of more than 2,500 g to 51.9% in the group with a BW of 1,000 g or less. The main HAIs were bloodstream infection (BSI) and pneumonia. Coagulase-negative staphylococci, Enterobacter species, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens. Forty percent of all deaths were related to HAI. Central venous catheter (CVC)-associated BSIs per 1,000 CVC-days ranged from 17.3 (BW, 1,501 to 2,500 g; device utilization [DU], 0.11) to 34.9 (BW, < or = 1,000 g; DU, 34.92). Ventilator-associated pneumonia per 1,000 ventilator-days ranged from 7.0 (BW, < or = 1,000 g; DU, 0.34) to 9.2 (BW, 1,001 to 1,500 g; DU, 0.14).

CONCLUSIONS

The high proportion of HAIs of maternal origin highlights perinatal care issues in Brazil and the need to improve the diagnosis of neonatal HAIs. The very low BW group and device-associated infections should be priorities for prevention strategies in this population.

Postconception age and other risk factors associated with mortality following Gram-negative rod bacteremia

BACKGROUND

Neonatal nosocomial Gram-negative rod bacteremia (GNR-b) is considered ominous.

DESIGN

Multi-center cohort study of premature infants (N=6172) who had a blood culture after day of life 3 and whose birthweight was < or =1250 g.

RESULTS

A total of 437 neonates developed GNR-b; most commonly with Klebsiella (122/437; 28%), Enterobacter (97/437; 22%), Escherichia coli (90/437; 21%), Pseudomonas (63/437; 14%), and Serratia (49/437; 11%). Neonates infected with Pseudomonas were more likely to die (21/63; 33%) than infants infected with other GNR (50/374; 13%). In multivariable logistic regression, infection with Pseudomonas, mechanical ventilation, and race were associated with subsequent mortality. Postconception age (PCA) was most strongly associated with mortality. Using neonates with >34 weeks PCA at the time of the first blood culture as the reference category, mortality was higher in neonates <26 weeks PCA (odds ratio (OR)=9.21; 95% confidence interval (CI)=2.79, 30.44), and in neonates 26 to 28 weeks PCA (OR=3.94; 95% CI=1.29, 12.03).

CONCLUSIONS

Among premature infants, much of the mortality experienced in GNR-b is due to infection with Pseudomonas rather than enteric GNR. Race, the need for mechanical ventilation, and younger PCA when the blood culture was obtained were also strongly associated with mortality.

Mortality following blood culture in premature infants: increased with Gram-negative bacteremia and candidemia, but not Gram-positive bacteremia

OBJECTIVE

To describe survival following nosocomial bloodstream infections and quantify excess mortality associated with positive blood culture.

STUDY DESIGN

Multicenter cohort study of premature infants.

RESULTS

First blood culture was negative for 4648/5497 (78%) of the neonates--390/4648 (8%) died prior to discharge. Mortality prior to discharge was 19% in the 161 infants with Gram-negative rod (GNR) bacteremia, 8% in the 854 neonates with coagulase negative staphylococcus (CONS), 6% in the 169 infants infected with other Gram-positive bacteria (GP-o), and 26% in the 115 neonates with candidemia. The excess 7-day mortality was 0% for Gram-positive organisms and 83% for GNR bacteremia and candidemia. Using negative blood culture as referent, GNR [hazard ratio (HR)=2.61] and candidemia (HR=2.27) were associated with increased mortality; CONS (HR=1.08) and GP-o (HR=0.97) were not.

CONCLUSIONS

Nosocomial GNR bacteremia and candidemia were associated with increased mortality but Gram-positive bacteremia was not.

Ventilator-associated pneumonia in extremely preterm neonates in a neonatal intensive care unit: characteristics, risk factors, and outcomes

OBJECTIVE

To determine the rates, characteristics, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in extremely preterm neonates in a neonatal intensive care unit (NICU).

METHODS

A prospective cohort study was conducted at the St Louis Children's Hospital on all patients who had birth weight <or=2000 g and were admitted to the NICU for >or=48 hours from October 2000 to July 2001. Extremely preterm neonates were defined as neonates with estimated gestational age (EGA) <28 weeks. The primary outcome was the development of VAP. Secondary outcomes were death and NICU length of stay (LOS). Multiple logistic regression was performed to determine independent predictors for VAP and mortality.

RESULTS

A total of 229 patients were enrolled. Sixty-seven (29%) had EGA <28 weeks. Nineteen episodes of VAP occurred in 19 (28.3%) of 67 mechanically ventilated patients. VAP rates were 6.5 per 1000 ventilator days for patients with EGA <28 weeks and 4 per 1000 ventilator days for EGA >or=28 weeks. By multivariate analysis, bloodstream infection before VAP (adjusted odds ratio: 3.5; 95% confidence interval [CI]: 1.2-10.8) was an independent risk factor for VAP after adjustment for the duration of endotracheal intubation. Ventilator-associated pneumonia (adjusted odds ratio: 3.4; 95% CI: 1.2-12.3) was an independent predictor of mortality. A strong association between VAP and mortality was observed in neonates who stayed in the NICU >30 days (relative risk: 8.0; 95% CI: 1.9-35.0). Patients with VAP also had prolonged NICU LOS (median: 138 vs 82 days).

CONCLUSIONS

VAP occurred at high rates in extremely preterm neonates and was associated with increased mortality. Additional studies are needed to develop interventions to prevent VAP in NICU patients.

Effects of age and race on skin condition and bacterial counts on hands of neonatal ICU nurses

OBJECTIVE

The purpose of this study was to assess the relationship between demographic factors such as age and race and skin condition and bacterial counts on hands of nurses.

METHODS

Nurses (n = 111) working in 1 of 2 neonatal ICUs in New York City were surveyed regarding reported hand care practices and demographics, the condition of their hands was assessed by a trained observer and by themselves using validated instruments, and a hand culture was obtained.

RESULTS

There were no significant differences in any skin care practices by race, but nurses who wore powder-free gloves were significantly younger than those who did not (P =.004). There were no significant differences in bacterial counts on hands of black or white nurses (mean log colony-forming units 3.49 and 3.61 respectively, P =.63) and no significant correlation between age and microbial counts (r = 0.04, P =.72). In a logistic regression analysis, race, but not age, was a significant predictor of skin health. By both observer (P =.02) and self-assessment (P =.004) black nurses had healthier skin.

CONCLUSION

Physiochemical differences in skin associated with demographic factors such as age and race may be exacerbated among those in disciplines such as nursing, for whom the skin of the hands is continually stressed by occupational practices such as frequent hand hygiene. Such demographic factors need be considered when assessing skin condition and when advocating for appropriate strategies to maximize skin health. The recommendations of the new CDC Hand Hygiene Guideline for Healthcare Settings(23) regarding maintaining skin health and providing moisturizers and products that are milder to the skin are timely and should be followed.

Molecular epidemiology of systemic infection caused by Enterobacter cloacae in a high-risk neonatal intensive care unit

OBJECTIVE

To investigate the molecular epidemiology of systemic nosocomial infections caused by Enterobacter cloacae.

SETTING

Neonatal intensive care unit (NICU) of a tertiary-care university hospital.

PATIENTS

Forty-two high-risk neonates with systemic infections caused by E. cloacae.

METHODS

From 1995 to 1997, the variables associated with death in these patients were evaluated. The molecular epidemiology of the strains responsible for the systemic infections, and 14 unrelated strains, was studied using plasmid analysis and pulsed-field gel electrophoresis (PFGE).

RESULTS

The overall mortality rate for infection caused by E. cloacae was 34%, whereas the crude mortality rate during the study period was 8.12% (P < .001). Gestational age (preterm neonates) and birth weight (small for gestational age) were not associated with a higher risk of death. Insertion of a venous catheter by dissection of a peripheral vein was the only invasive procedure related to death (P = .016) in this study. A molecular analysis showed that three outbreaks, each occurring in a different year, were caused by strains with distinctive DNA profiles. Only one outbreak was identified by the infection control service, in the NICU. Plasmid analysis and PFGE showed similar ability to discriminate control strains from the E. cloacae strains isolated from the neonates.

CONCLUSIONS

Systemic infections caused by E. cloacae in our NICU were associated with a high mortality rate and occurred as small, unrecognized outbreaks. These results may not be generalizable because the data were from a single center.

Risk factors for nosocomial infections in a neonatal intensive-care unit

The clinical records a years cohort of 280 newborn infants consecutively hospitalized for 48 h or more in our neonatal intensive-care unit (NICU) were reviewed. Information on the infants' conditions during the first 12h of life, and on the procedures used in the NICU, were collected. Statistical significance was tested by univariate analysis with the chi(2) test and by multivariate logistic regression analysis with the software program SPSS (Version 10). Over the one-year period reviewed, 90 hospital-acquired infections (HAIs) were contracted; 55 (19.6%) of infants had at least one infection during their stay. The overall in-hospital mortality was 7.1%, and mortality was higher in infants in whom at least one infection developed than in non-infected infants (12.7 vs. 5.8% P=0.13). Very low birthweight infants (VLBW<1,501 g) who had more severe clinical conditions on admission [clinical risk index for babies (CRIB) score >/=5] had an almost two-fold higher risk of contracting a HAI. In the multivariate regression analysis, the onset of a HAI was strongly associated with a low gestational age and the presence of an intravascular catheter. HAIs frequently complicate hospitalization in NICUs and are associated with increased mortality. Our findings also suggest that CRIB could be predictive for the risk of infection in VLBW infants.

Expanding the infection control team: development of the infection control liaison position for the neonatal intensive care unit

Neonatal survival has risen progressively during the past 30 years. As the limits of viability continue to decline, the challenges of providing care to infants at the lowest extremes of gestational age and birth weight continually increase. Nosocomial infections in this very fragile population can be devastating. The complexity of care of these premature infants requires specialized knowledge of the neonate, infectious disease processes, and methods to reduce infection risks in the neonatal intensive care unit. The role of infection control liaison has been established in our institution as an adjunct to meeting this challenge by providing a line of communication between staff, neonatologists, and the infection control team. This article describes the role of the infection control liaison and its overall impact on the infection control program in an 87-bed level II, III, and IV neonatal intensive care unit from 1995 to 1999.

Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation

OBJECTIVE

To study the effect of subglottic secretions drainage on the incidence of ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation.

DESIGN

A randomized clinical trial.

SETTING

A 12-bed general ICU.

PATIENTS

One hundred fifty patients with an expected duration of mechanical ventilation > 72 h were enrolled in the study.

INTERVENTION

Patients were randomly assigned to receive either an endotracheal tube for intermittent subglottic secretions drainage or a standard endotracheal tube.

OUTCOME MEASUREMENTS

Incidence of VAP, duration of mechanical ventilation, length of ICU stay, length of hospital stay, and mortality.

RESULTS

Seventy-five patients were randomized to subglottic secretion drainage, and 75 patients were randomized to the control group. The two groups were similar at the time of randomization with respect to demographic characteristics and severity of illness. VAP was seen in 3 patients (4%) receiving suction secretion drainage and in 12 patients (16%) in the control group (relative risk, 0.22; 95% confidence interval, 0.06 to 0.81; p = 0.014). The other outcome measures were not significantly different between the two groups.

CONCLUSION

Intermittent subglottic secretion drainage reduces the incidence of VAP in patients receiving mechanical ventilation.

Nosocomial infections in a neonatal intensive care unit: incidence and risk factors

BACKGROUND

Nosocomial infections (NIs) have become a matter of major concern in neonatal intensive care units (NICUs). The objectives of this study were to determine the incidence rate and the most frequent sites of infection in a Brazilian NICU from January 1999 to March 2000 and to study the risk factors for NIs.

METHODS

A cohort study was carried out in which 225 neonates who remained at least 24 hours in the NICU were followed-up; neonates with NIs were identified, and the presence of risk factors was studied. Results were submitted to chi(2) distribution.

RESULTS

The incidence rate and the incidence density rate were 50.7% and 62 infections per 1000 patient-days, respectively. In order of frequency, the sites of infection were: pneumonia (40.3%), primary bloodstream (16.7%), skin and soft tissue (14.9%), and meningitis (9.6%). The following risk factors were associated with NIs (P <.05): birth weight, gestational age, mechanical ventilation, total parenteral nutrition, umbilical catheter, use of antibiotics, and intubation in the delivery room.

CONCLUSION

Risk factors were similar to those reported by other authors. However, incidence rates of infections in our NICU were much higher, possibly because of different methodologies and the adopted criteria for the classification of NIs.

Use of pulsed-field gel electrophoresis to investigate an outbreak of Serratia marcescens infection in a neonatal intensive care unit

Serratia marcescens is a well-recognized hospital-acquired pathogen, which has been associated with a number of specific outbreaks, particularly in critically ill neonates. We used pulsed-field gel electrophoresis (PEGE) typing to analyse an outbreak in a neonatal intensive care unit (NICU). We included samples from nine patients, three handwashes and ten environmental isolates from an outbreak (February to August 1999) in addition to four patient isolates from different wards of our hospital during the same time period. The clinical presentations of the outbreak included bacteraemia (four cases), pneumonia (three cases), umbilical wound infection (one case) and conjunctivitis (one case). Nine outbreak isolates exhibited an identical PFGE fingerprint, while the epidemiologically unrelated strains demonstrated distinct patterns. Epidemiological investigation failed to reveal a common source of the outbreak, although the epidemic S. marcescens strain was isolated from hand-washes and doors of incubators. We concluded that cross-transmission via transient contamination of hands was the major route for this outbreak. Strict handwashing practices, the cohorting and isolation of colonized and infected patients, and the regular dis-infection of incubators are crucial steps for preventing the transmission of S. marcescens in an NICU. This PFGE method is highly discriminatory for the thorough epidemiological investigation of an outbreak of S. marcescens.

[Risk factors associated with nosocomial bacteremia in low birth weight neonates. Grady Memorial Hospital, Atlanta]

BACKGROUND

Nosocomial bloodstream infections occur frequently in Neonatal Intensive Care Units and are associated with recognized and unrecognized risk factors. Little has been published regarding risk factors for bloodstream infections in low birth weight neonates.

OBJECTIVE

To investigate risk factors for bloodstream infection in neonates < 1,500 g admitted at a Neonatal Intensive Care Unit.

METHODS

A prospective study was undertaken in low birth weight neonates (< 1,500g) during a 22 months period. Bivariant, and logistic regresion (stepwise procedure) analysis was used to determine the significance association of bloodstream infection and perinatal and nosocomial risk factors.

RESULTS

A total of 72 patiens with nosocomial bacteriemia and 147 non bacteriemic patients were studied. Independent risk factors associated with bloodstream infection were birth weight, persistence of umbilical catheter > 7 days and persistence of peripheral arterial catheter > 1 day.

CONCLUSIONS

The uses of umbilical catheter > 7 days, peripheral arterial catheter > 1 day and birth weight < 1,500 g were significant determinants of nosocomial bloodstream infection risk. Because of the importance of invasive procedures as a source of nosocomial bloodstream infections, the lines duration needs to be reviewed with the aim of reducing the incidence of blood stream infection.

Molecular typing demonstrating transmission of gram-negative rods in a neonatal intensive care unit in the absence of a recognized epidemic

Molecular typing techniques have been used in outbreak investigations. In this study, molecular typing techniques were used to track the spread of gram-negative rods (GNRs) in a neonatal intensive care unit (NICU) in the absence of an outbreak. Stool or rectal swab cultures for GNRs were obtained from all infants on admission, weekly, and on discharge. GNRs were tested for gentamicin susceptibility and were typed by contour-clamped homogeneous electric field electrophoresis. Transmission of identical strains of GNRs among infants was noted. Shared strains were more gentamicin resistant compared with unique strains (53% vs. 10%; P=.0001). Infants first colonized when they were >1 week of age had more total days of antibiotic treatment and had a higher rate of acquiring a shared and gentamicin-resistant strain, compared with infants colonized earlier. Antibiotic use increases colonization of infants in the NICU with resistant and shared strains of GNRs.

Meropenem in neonatal severe infections due to multiresistant gram-negative bacteria

Recently, new broad spectrum carbapenem has been investigated on a world-wide scale for the treatment of moderate to severe infections. In the neonatal intensive care units the extensive use of third generation cephalosporins for therapy of neonatal sepsis may lead to rapid emergence of multiresistant gram-negative organisms. We report the use of meropenem in 35 infants with severe infections due to Acinetobacter baumanii and Klebsiella pneumoniae. All gram negative bacteria were resistant to ampicillin, amoxicillin, ticarcilin, cefazoline, cefotaxime, ceftazidime, ceftriaxone and aminoglycosides. Eighty two percent of the cases (29/35) were born prematurely. Assisted ventilation was needed in 85.7% (30/35). All infants deteriorated during their conventional treatment and were changed to meropenem monotherapy. Six percent (2/35) died. The incidence of drug-related adverse events (mostly a slight increase in liver enzymes) was 8.5%. No adverse effects such as diarrhea, vomiting, rash, glossitis, oral or diaper area moniliasis, thrombocytosis, thrombocytopenia, eosinophilia and seizures were observed. At the end of therapy, overall satisfactory clinical and bacterial response was obtained in 33/35 (94.3%) of the newborns treated with meropenem. Clinical and bacterial response rates for meropenem were 100% for sepsis and 87.5% for nosocomial pneumonia. This report suggests that meropenem may be a useful antimicrobial agent in neonatal infections caused by multiresistant gram negative bacilli. Further studies are needed to confirm these results: Meropenem, newborn, sepsis and nosocomial infection.

Molecular epidemiology of Staphylococcus epidermidis in a neonatal intensive care unit over a three-year period

Coagulase-negative staphylococci, especially Staphylococcus epidermidis, are increasingly important nosocomial pathogens, particularly in critically ill neonates. A 3-year prospective surveillance of nosocomial infections in a neonatal intensive care unit (NICU) was performed by traditional epidemiologic methods as well as molecular typing of microorganisms. The aims of the study were (i) to quantify the impact of S. epidermidis on NICU-acquired infections, (ii) to establish if these infections are caused by endemic clones or by incidentally occurring bacterial strains of this ubiquitous species, (iii) to evaluate the use of different methods for the epidemiologic typing of the isolates, and (iv) to characterize the occurrence and the spread of staphylococci with decreased glycopeptide susceptibility. Results confirmed that S. epidermidis is one of the leading causes of NICU-acquired infections and that the reduced glycopeptide susceptibility, if investigated by appropriate detection methods such as population analysis, is more common than is currently realized. Typing of isolates, which can be performed effectively through molecular techniques such as pulsed-field gel electrophoresis but not through antibiograms, showed that many of these infections are due to clonal dissemination and, thus, are potentially preventable by strict adherence to recommended infection control practices and the implementation of programs aimed toward the reduction of the unnecessary use of antibiotics. These strategies are also likely to have a significant impact on the frequency of the reduced susceptibility of staphylococci to glycopeptides, since this phenomenon appears to be determined either by more resistant clones transmitted from patient to patient or, to a lesser extent, by strains that become more resistant as a result of antibiotic pressure.

Detection of pathogen transmission in neonatal nurseries using DNA markers as surrogate indicators

OBJECTIVE

Nosocomial infections are a major problem confronting neonatal intensive care units (NICUs). This study was conducted to determine if DNA markers designed from the cauliflower mosaic virus (CaMV 35S DNA) can serve as surrogate indicators of nosocomial pathogen transmission in NICUs.

METHODS

Regions of cauliflower CaMV 35S promoter DNA were designed to serve as surrogate markers of microbial transmission pathways. Each of 6 pods within the NICU under study houses 8 newborn infants. DNA marker was placed on the telephone handle in only 1 of the 6 NICU pods (study pod). Bedside caregivers were blinded as to when placebo or marker were placed in the pod. Thirty-two samples were collected from predetermined sites within each pod at 0, 4, 8, 24, and 48 hours and 7 days after DNA placement. Similar sites were sampled in each of the 6 pods. Additional samples were collected concurrently from areas of the NICU segregated from direct patient care. Polymerase chain reactions were performed on collected samples, and products were analyzed by agarose gel electrophoresis.

RESULTS

One thousand three hundred samples of the environment and hands of personnel were collected and analyzed. Within the study pod, 58% of sites tested positive for the DNA marker throughout all time points; positive sites peaked at 8 hours (78%) and declined to 23% positive at 7 days. The other 5 pods had a mean of 18% of sites positive throughout the 7 days and exhibited a similar decline throughout time. The most consistently positive sites within all pods were the blood gas analyzers, computer mice, telephone handles, medical charts, ventilator knobs, door handles, radiant warmer control buttons, patient monitors, and personnel hands. In areas outside the pods, the nurse's station, resident physician charting area, changing room, and staff break room had a mean of 50% positive sites throughout all time points.

CONCLUSIONS

DNA markers proved useful as safe, surrogate indicators of microorganism transmission within and outside pods in the NICU. We speculate that utilization of these techniques in the hospital environment will provide important information about transmission of pathogens in the NICU, assist in developing and enforcing cleaning procedures, and permit testing of educational intervention programs targeting a decrease in nosocomial infections.nosocomial infection, neonatal intensive care, DNA marker, polymerase chain reaction, infection control.

Randomised controlled study of clinical outcome following trophic feeding

AIMS

To determine the effect of trophic feeding on clinical outcome in ill preterm infants.

METHODS

A randomised, controlled, prospective study of 100 preterm infants, weighing less than 1750 g at birth and requiring ventilatory support and parenteral nutrition, was performed. Group TF (48 infants) received trophic feeding from day 3 (0.5-1 ml/h) along with parenteral nutrition until ventilatory support finished. Group C (52 infants) received parenteral nutrition alone. "Nutritive" milk feeding was then introduced to both groups. Clinical outcomes measured included total energy intake and growth over the first six postnatal weeks, sepsis incidence, liver function, milk tolerance, duration of respiratory support, duration of hospital stay and complication incidence.

RESULTS

Groups were well matched for birthweight, gestation and CRIB scores. Infants in group TF had significantly greater energy intake, mean difference 41.4 (95% confidence interval 9, 73.7) kcal/kg p=0.02; weight gain, 130 (CI 1, 250) g p = 0.02; head circumference gain, mean difference 0.7 (CI 0.1, 1.3) cm, p = 0.04; fewer episodes of culture confirmed sepsis, mean difference -0.7 (-1.3, -0.2) episodes, p = 0.04; less parenteral nutrition, mean difference -11.5 (CI -20, -3) days, p = 0. 03; tolerated full milk feeds (165 ml/kg/day) earlier, mean difference -11.2 (CI -19, -3) days, p = 0.03; reduced requirement for supplemental oxygen, mean difference -22.4 (CI-41.5, -3.3) days, p = 0.02; and were discharged home earlier, mean difference -22.1 (CI -42.1, -2.2) days, p = 0.04. There was no significant difference in the relative risk of any complication.

CONCLUSIONS

Trophic feeding improves clinical outcome in ill preterm infants requiring parenteral nutrition.

Molecular epidemiology as an effective tool in the surveillance of infections in the neonatal intensive care unit

OBJECTIVES

nosocomial infections result in considerable morbidity and mortality in Neonatal Intensive Care Units (NICUs). The aim of this study was to investigate the usefulness of the molecular epidemiology approach in the surveillance and control of infections in the NICU.

METHODS

a 1-year prospective surveillance of nosocomial infections in a NICU was performed using traditional epidemiological methods as well as molecular typing of micro-organisms.

RESULTS

the nosocomial infection rate among the 343 newborns was 24.8%. The risk of infection was associated with low birth weight, prolonged length of stay, empiric antibiotic treatment and nasopharyngeal colonization. Four pathogens (Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE) and methicillin-sensitive Staphylococcus aureus (MSSA) were responsible for more than 80% of the infections. Extended-spectrum beta-lactamase-producing (ESBL) K. pneumoniae and MRSA infections constituted outbreaks caused by a single clone, whereas MRSE and MSSA infections did not represent outbreaks but rather a series of sporadic infections caused by different strains.

CONCLUSIONS

molecular epidemiology techniques are powerful tools that can elucidate modes of spread and reservoirs of infection in the NICU and identify effective measures to control epidemic or endemic situations.

Constant rate infusion of vancomycin in premature neonates: a new dosage schedule

AIMS

Since vancomycin's bactericidal action has been shown to be time-dependent, a constant rate infusion over 24 h might result in a better bactericidal efficacy. The purpose of this study was to define a new dosage schedule in prematures.

METHODS

Two vancomycin 24 h constant rate infusion schedules were tested in two groups of neonates. Postconceptional age (PCA) was 27 to 41 weeks in group 1 (n=24) and 28 to 51.5 weeks in group 2 (n=29). Group 1 neonates received continuous infusion of 10 to 30 mgkg(-1) day(-1), adjusted for PCA and weight. Group 2 was designed to take into account the significant relationship observed in group 1 between vancomycin clearance standardized on weight and PCA and consisted of a constant loading dose of 7 mg kg(-1) followed by continuous infusion of 10 to 40 mg kg(-1) day(-1) adjusted for PCA and weight.

RESULTS

Mean vancomycin serum concentration at steady state was 11+/-3.1 mg1(-1) in group 1 and 15.4+/-6.2 mg1(-1) in group 2. Fifty-six percent of group 1 values vs 88% of group 2 values were between 10 and 30 mg at steady state (P<0.01). Both regimens were well tolerated.

CONCLUSIONS

A loading dose of vancomycin followed by constant rate infusion of the appropriate dose adjusted for PCA and weight might improve vancomycin concentrations in neonates.