Risk-adjusted comparisons of bloodstream infection rates in neonatal intensive-care units

Factors associated with the risk of positive blood culture in neonatal foals presented to a referral center (2000-2014)

Background

Bloodstream infections (BSI) are common in sick foals and increase foal morbidity and mortality when they occur. Recognition of risk factors for BSI could be an important means to limit their occurrence, but studies on this topic are limited.

Objectives

Historical as well as maternal and foal physical examination findings will predict risk of BSI in neonatal foals.

Animals

Foals <14 days of age admitted to a referral equine hospital for care.

Methods

Retrospective case‐control study with univariate and multivariable logistic regression analysis.

Results

Four hundred twenty‐nine (143 cases and 286 controls) foals <14 days of age were studied. Risk of a foal having a BSI was increased in foals with umbilical disease (adjusted odds ratio [OR], 11.01; P = .02), hypoglycemia (adjusted OR, 13.51; P = .03), and the combined presence of umbilical disease and low hematocrit (adjusted OR, >999.99; P = .04). Factors not found to be risk factors for development of BSI included prematurity, hypothermia, abdominal disease, diarrhea, failure of passive transfer, and maternal uterine infection.

Conclusions and Clinical Importance

Several historical and physical examination findings increase the risk of foals being blood culture positive at presentation to the hospital. This knowledge may aid early identification of blood culture status, thus aiding in treatment decisions.

The association between shift patterns and the quality of hand antisepsis in a neonatal intensive care unit: An observational study

BACKGROUND

Healthcare-associated infections represent a major burden in neonatal intensive care units. Hand antisepsis is the most important tool for prevention, however, compliance among healthcare workers remains low.

OBJECTIVES

To prospectively evaluate the influence of different work shifts (extended working hours, night shifts) on the quality of healthcare workers' hand antisepsis.

DESIGN

Observational study.

SETTINGS

Two equivalent "Level III" neonatal intensive care units at the University Hospital Vienna, Austria.

PARTICIPANTS

Seventy healthcare workers, 46 nurses and 24 physicians.

METHODS

The Semmelweis Scanner, an innovative training device assessing the quality of hand antisepsis with an ultraviolet dye labelled alcohol-based hand rub, was employed to collect data on the hand surface coverage achieved during hand antisepsis of participants. It provides visual feedback of appropriately versus inappropriately disinfected areas of the hand and can also be used for the objective quantification of hand surface coverage with the hand rub. Measurements were performed before and after 12.5 h (h) day and night shifts (nurses), as well as before and after regular 8 h day shifts and extended 25 h shifts (physicians). To avoid any bias caused by residual ultraviolet marker, scans had to be separated by 24 h periods. Primary outcome was the hand surface coverage with the hand rub: Hand scans were categorized as "passed" if an appropriate quality of hand hygiene, defined as a minimum 97% coverage of hand surface, was achieved. A generalized mixed model was used to analyse the data accounting for repeated measurements.

RESULTS

Seventy healthcare workers performed a total of 485 scans. Nineteen scans had to be excluded, resulting in 466 scans for further analyses. A difference in the predicted probability of achieving appropriate hand antisepsis was found between the beginning and end of extended shifts: In physicians, adequate hand antisepsis was remarkably reduced after 25 h shifts (predicted probability 99.4% vs 78.8%), whereas there was no relevant difference between the beginning and end of 8 h day shifts (92.2% vs 97.3%). In nurses, a relevant difference was found between the beginning and end of 12.5 h day shifts (88.6% vs 73.6%). This difference was not found for 12.5 h night shifts. The most frequently missed area on the hands was the right dorsum.

CONCLUSION

The quality of hand antisepsis of healthcare workers in neonatal intensive care units may be associated with long working hours.

Cost-effectiveness of strategies preventing late-onset infection in preterm infants

OBJECTIVE

Developing a model to analyse the cost-effectiveness of interventions preventing late-onset infection (LOI) in preterm infants and applying it to the evaluation of anti-microbial impregnated peripherally inserted central catheters (AM-PICCs) compared with standard PICCs (S-PICCs).

DESIGN

Model-based cost-effectiveness analysis, using data from the Preventing infection using Antimicrobial Impregnated Long Lines (PREVAIL) randomised controlled trial linked to routine healthcare data, supplemented with published literature. The model assumes that LOI increases the risk of neurodevelopmental impairment (NDI).

SETTING

Neonatal intensive care units in the UK National Health Service (NHS).

PATIENTS

Infants born ≤32 weeks gestational age, requiring a 1 French gauge PICC.

INTERVENTIONS

AM-PICC and S-PICC.

MAIN OUTCOME MEASURES

Life expectancy, quality-adjusted life years (QALYs) and healthcare costs over the infants' expected lifetime.

RESULTS

Severe NDI reduces life expectancy by 14.79 (95% CI 4.43 to 26.68; undiscounted) years, 10.63 (95% CI 7.74 to 14.02; discounted) QALYs and costs £19 057 (95% CI £14 197; £24697; discounted) to the NHS. If LOI causes NDI, the maximum acquisition price of an intervention reducing LOI risk by 5% is £120. AM-PICCs increase costs (£54.85 (95% CI £25.95 to £89.12)) but have negligible impact on health outcomes (-0.01 (95% CI -0.09 to 0.04) QALYs), compared with S-PICCs. The NHS can invest up to £2.4 million in research to confirm that AM-PICCs are not cost-effective.

CONCLUSIONS

The model quantifies health losses and additional healthcare costs caused by NDI and LOI during neonatal care. Given these consequences, interventions preventing LOI, even by a small extent, can be cost-effective. AM-PICCs, being less effective and more costly than S-PICC, are not likely to be cost-effective.

TRIAL REGISTRATION NUMBER

NCT03260517.

Prevention of Late Onset Sepsis and Central-line Associated Blood Stream Infection in Preterm Infants

AIM

Late onset sepsis (LOS) and central-line associated blood stream infection (CLA-BSI) contribute toward the mortality and morbidity in prematurely born infants. The aim of this study is to investigate the effects of hospital-wide and unit-based interventions on LOS and CLA-BSI in infants born at <32 weeks gestation.

METHODS

Intensive care, high dependency days and catheter days were obtained from the unit database and blood culture results from a microbiology laboratory database. Poisson regression was used to evaluate the effects of interventions on LOS and CLA-BSI.

RESULTS

Quarterly rates of LOS reduced from 26.1 to 2.9 per 1000 intensive care, high dependency days and CLA-BSI from 31.6 to 4.3 per 1000 catheter days between 2007 and 2012. Appointment of a hospital specialist vascular device nurse, a change in the mode of administration of vancomycin, standardization of the hospital skin and hub disinfection policy and the introduction of a venous infusion phlebitis scoring system were associated with a reduction of LOS to 55% (95% confidence interval: 40-74%) and CLA-BSI 45% (95% confidence interval: 33-61%) of pre-intervention levels. The standardization of the neonatal unit policy for skin disinfection and a move to a new building were associated with reductions of LOS to 64% (47-87%) and 54% (34-88%), respectively, and aseptic no touch technique for infusion access with CLA-BSI to 53% (37-75%) of pre-intervention levels.

CONCLUSION

A multifaceted approach involving changes in antimicrobial and skin disinfection policy, training for aseptic no touch technique and surveillance resulted in sustained reduction in LOS and CLA-BSI rates.

Bloodstream infections: epidemiology and resistance

Bloodstream infections in the neonatal intensive care unit (NICU) are associated with many adverse outcomes in infants, including increased length of stay and cost, poor neurodevelopmental outcomes, and death. Attention to the insertion and maintenance of central lines, along with careful review of when the catheters can be safely discontinued, can minimize central-line-associated bloodstream infections rates. Good antibiotic stewardship can further decrease the incidence of bloodstream infections, minimize the emergence of drug-resistant organisms or Candida as pathogens in the NICU, and safeguard the use of currently available antibiotics for future infants.

Risk factors associated with laboratory-confirmed bloodstream infections in a tertiary neonatal intensive care unit

BACKGROUND

Bloodstream infections (BSI) remain a leading cause of morbidity and mortality among infants admitted to neonatal intensive care units (NICUs). At the time of evaluation for suspected BSI, presenting signs may be nonspecific. We sought to determine the clinical signs and risk factors associated with laboratory-confirmed BSI among infants evaluated for late-onset sepsis in a tertiary NICU.

METHODS

This prospective cohort study included infants >3 days of age admitted to a level 4 NICU from July 2006 to October 2009 for whom a blood culture was drawn for suspected sepsis. Clinicians documented presenting signs at the time of culture. Laboratory-confirmed BSI was defined as per the National Healthcare Safety Network. Multivariate analyses were performed using a logistic regression random effects model.

RESULTS

Six-hundred and eighty eligible episodes of suspected BSI were recorded in 409 infants. Enteral contrast within the preceding 48 hours was the most significant risk factor for laboratory-confirmed BSI [Odds Ratio: 9.58 (95% confidence interval: 2.03-45.19)] followed by presence of a central venous catheter. Apnea and hypotension were the most strongly associated presenting signs.

CONCLUSION

Among infants evaluated in a tertiary NICU, recent exposure to enteral contrast was associated with increased odds of developing BSI. Apnea and hypotension were the most strongly associated clinical signs of infection.

A systematic review of strategies for reporting of neonatal hospital-acquired bloodstream infections

OBJECTIVE

To examine the reporting of hospital-acquired bloodstream infection (HABSI) and central line-associated BSI (CLABSI) rates in neonatal intensive care units (NICUs).

DESIGN

Systematic review of evidence published after 2000 reporting HABSI cumulative incidence, crude HABSI and/or CLABSI rate and total patient-days and/or central line-days for single NICU.

SETTING

Inpatient.

PATIENTS

Neonates admitted to NICU.

MAIN OUTCOME MEASURES

To consider the reporting of and relationship between cumulative incidence of BSI and HABSI and/or CLABSI rates.

RESULTS

18 studies fulfilled inclusion criteria. There was a wide variability in reporting of HABSI indicators and risk-adjustment strategies with reported crude HABSI and/or CLABSI rates showing an approximately sevenfold variation between centres. Information about NICU size and level of care was not always available. Many studies provided insufficient information about case mix, such as surgical care provision and prematurity. The proportion of total patient-days that were central venous catheters (CVC)-days ranged from 11.7% to 85.4%. Only six studies reported HABSI and CLABSI incidence. Comparing HABSI and CLABSI ranking, we found a relationship between rates.

CONCLUSIONS

We found significant variability in HABSI rate reporting. Although there appears to be an association between CLABSI and HABSI rates, non-CVC-related BSIs are likely to be highly relevant in some NICUs. If confirmed, and given CLABSI rates are more challenging to collect, it may be more appropriate to use HABSI rates for monitoring NICU healthcare-associated infection (HAI) in some settings. A European network of NICUs using a standardised methodology is required to determine the feasibility and reliability of different risk-adjusted measured of HAI rates.