The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates - results of nation-wide cohort study in Germany

Multidrug-resistant organisms may be associated with bed allocation and utilization efficiency in healthcare institutions, based on national monitoring data from China (2014-2020)

Analyzing the influence of the bed allocation and utilization efficiency in healthcare institutions on the isolation proportion of Multidrug-resistant organisms (MDROs) to provide data to support prevention and control of MDROs. In this study, the provincial panel data from 2014 to 2020 in China on health resource indicators, including the number of beds per 1,000 population, hospital bed utilization rate, and average hospital stay from 2014 to 2020 in China were used to analyze the relationship between bed allocation or utilization efficiency and MDROs by the panel data quantile regression model. It was shown that the number of beds per 1,000 population had a negative effect on the isolation proportion of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, vancomycin-resistant Enterococcus faecium, penicillin-resistant Streptococcus pneumoniae, methicillin-resistant coagulase-negative Staphylococcus, and cefotaxime or ceftriaxone resistant Escherichia coli (regression coefficient < 0, P < 0.05). The utilization rate of hospital bed had a positive effect on the isolation proportion of methicillin-resistant Staphylococcus aureus, methicillin-resistant coagulase-negative Staphylococcus, vancomycin-resistant Enterococcus faecium, penicillin-resistant Streptococcus pneumoniae, cefotaxime or ceftriaxone resistant Escherichia coli, carbapenem-resistant Escherichia coli, cefotaxime or ceftriaxone resistant Klebsiella pneumoniae, carbapenem-resistant Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii (regression coefficient > 0, P < 0.05). The average hospital stay had a positive effect on the isolation proportion for several antibiotic-resistant organisms, including methicillin-resistant Staphylococcus aureus, methicillin-resistant coagulase-negative Staphylococcus, vancomycin-resistant Enterococcus faecalis, vancomycin-resistant Enterococcus faecium, penicillin-resistant Streptococcus pneumoniae, cefotaxime or ceftriaxone resistant Escherichia coli, carbapenem-resistant Escherichia coli, quinolone-resistant Escherichia coli, cefotaxime or ceftriaxone resistant Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii (regression coefficient > 0, P < 0.05). Bed allocation and utilization efficiency in healthcare institutions may affect the isolation proportion of MDROs in varying degrees.

Determining the need for additional training among hospital infection-control workforce - results from a multicentric survey within the multiresistance network of southern Lower Saxony (MRNS), Germany

Infection-control nurses (ICN) and infection-control link physicians (ICLP) are both responsible for infection prevention practices in hospitals. However, their topic-specific education levels and extent of engagement in infection-control issues are diverse, creating potential needs for additional training. We aimed at determining the potential need for additional training in infection-control among ICN, ICLP and medical Chief Executive Officers (CEO) in hospitals of the Multiresistance Network of southern Lower Saxony (MRNS), via structured surveys (n=48; 55.1%). Our data suggest that the majority of ICN as well as ICLP have unmet needs for consultation and training on the topics of hospital hygiene and infection control. We observed a higher need for advice/additional information among ICLP than among ICN, e.g., concerning outbreaks (p=0.032), multidrug resistance (p=0.005) or antimicrobial stewardship (p=0.020). Therefore, future training programs might require targeting workforce-specific topics as part of their curricula. Furthermore, the improvement of the knowledge of ICN and ICLP for the implementation of infection control could contribute to improved prevention of the transmission of infectious diseases.

Prevention of Central-Line Associated Bloodstream Infections: 2021 Update

Despite a large volume of research in prevention, central line-associated bloodstream infections and catheter-related bloodstream infections continue to cause significant morbidity, mortality, and increased health care costs. Strategies in prevention, including decision about catheter placement, insertion bundles, adherence to standard of care guidelines, and technologic innovations, shown to decrease rates of catheter-related bloodstream infections and central line-associated bloodstream infections are described in this update. The coronavirus disease 2019 pandemic has resulted in increased health care-acquired infections, including central line-associated bloodstream infections.

Antimicrobial-impregnated central venous catheters for preventing neonatal bloodstream infection: the PREVAIL RCT

BACKGROUND

Clinical trials show that antimicrobial-impregnated central venous catheters reduce catheter-related bloodstream infection in adults and children receiving intensive care, but there is insufficient evidence for use in newborn babies.

OBJECTIVES

The objectives were (1) to determine clinical effectiveness by conducting a randomised controlled trial comparing antimicrobial-impregnated peripherally inserted central venous catheters with standard peripherally inserted central venous catheters for reducing bloodstream or cerebrospinal fluid infections (referred to as bloodstream infections); (2) to conduct an economic evaluation of the costs, cost-effectiveness and value of conducting additional research; and (3) to conduct a generalisability analysis of trial findings to neonatal care in the NHS.

DESIGN

Three separate studies were undertaken, each addressing one of the three objectives. (1) This was a multicentre, open-label, pragmatic randomised controlled trial; (2) an analysis was undertaken of hospital care costs, lifetime cost-effectiveness and value of information from an NHS perspective; and (3) this was a retrospective cohort study of bloodstream infection rates in neonatal units in England.

SETTING

The randomised controlled trial was conducted in 18 neonatal intensive care units in England.

PARTICIPANTS

Participants were babies who required a peripherally inserted central venous catheter (of 1 French gauge in size).

INTERVENTIONS

The interventions were an antimicrobial-impregnated peripherally inserted central venous catheter (coated with rifampicin-miconazole) or a standard peripherally inserted central venous catheter, allocated randomly (1 : 1) using web randomisation.

MAIN OUTCOME MEASURE

Study 1 - time to first bloodstream infection, sampled between 24 hours after randomisation and 48 hours after peripherally inserted central venous catheter removal. Study 2 - cost-effectiveness of the antimicrobial-impregnated peripherally inserted central venous catheter compared with the standard peripherally inserted central venous catheters. Study 3 - risk-adjusted bloodstream rates in the trial compared with those in neonatal units in England. For study 3, the data used were as follows: (1) case report forms and linked death registrations; (2) case report forms and linked death registrations linked to administrative health records with 6-month follow-up; and (3) neonatal health records linked to infection surveillance data.

RESULTS

Study 1, clinical effectiveness - 861 babies were randomised (antimicrobial-impregnated peripherally inserted central venous catheter, n = 430; standard peripherally inserted central venous catheter, n = 431). Bloodstream infections occurred in 46 babies (10.7%) randomised to antimicrobial-impregnated peripherally inserted central venous catheters and in 44 (10.2%) babies randomised to standard peripherally inserted central venous catheters. No difference in time to bloodstream infection was detected (hazard ratio 1.11, 95% confidence interval 0.73 to 1.67; p = 0.63). Secondary outcomes of rifampicin resistance in positive blood/cerebrospinal fluid cultures, mortality, clinical outcomes at neonatal unit discharge and time to peripherally inserted central venous catheter removal were similar in both groups. Rifampicin resistance in positive peripherally inserted central venous catheter tip cultures was higher in the antimicrobial-impregnated peripherally inserted central venous catheter group (relative risk 3.51, 95% confidence interval 1.16 to 10.57; p = 0.02) than in the standard peripherally inserted central venous catheter group. Adverse events were similar in both groups. Study 2, economic evaluation - the mean cost of babies' hospital care was £83,473. Antimicrobial-impregnated peripherally inserted central venous catheters were not cost-effective. Given the increased price, compared with standard peripherally inserted central venous catheters, the minimum reduction in risk of bloodstream infection for antimicrobial-impregnated peripherally inserted central venous catheters to be cost-effective was 3% and 15% for babies born at 23-27 and 28-32 weeks' gestation, respectively. Study 3, generalisability analysis - risk-adjusted bloodstream infection rates per 1000 peripherally inserted central venous catheter days were similar among babies in the trial and in all neonatal units. Of all bloodstream infections in babies receiving intensive or high-dependency care in neonatal units, 46% occurred during peripherally inserted central venous catheter days.

LIMITATIONS

The trial was open label as antimicrobial-impregnated and standard peripherally inserted central venous catheters are different colours. There was insufficient power to determine differences in rifampicin resistance.

CONCLUSIONS

No evidence of benefit or harm was found of peripherally inserted central venous catheters impregnated with rifampicin-miconazole during neonatal care. Interventions with small effects on bloodstream infections could be cost-effective over a child's life course. Findings were generalisable to neonatal units in England. Future research should focus on other types of antimicrobial impregnation of peripherally inserted central venous catheters and alternative approaches for preventing bloodstream infections in neonatal care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81931394.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 57. See the NIHR Journals Library website for further project information.

Chlorhexidine locking device for central line infection prevention in ICU patients: protocol for an open-label pilot and feasibility randomized controlled trial

Background

Critically ill patients in the intensive care unit (ICU) are at risk for central line-associated bloodstream infection (CLABSI) with an incidence up to 6.9 per 1000 catheter days. CLABSI has a significant attributable mortality and increases in-hospital length of stay, readmissions, and costs. Chlorhexidine gluconate (CHG), a broad-spectrum biocide, has been shown to effectively reduce infections including CLABSI; however, few trials have utilized CHG for prevention of central line infections. Our preclinical work has demonstrated a device that diffuses CHG into the intravenous lock solution of central venous catheters and decreases bacterial growth on the catheter lumen. We designed a clinical trial to test the feasibility of using a CHG device in an ICU patient population.

Methods

The proposed pilot trial will be a single centre, open-label, two-arm, parallel group feasibility randomized controlled trial (RCT). Participants will have a central line in situ and will be enrolled within 72 h of admittance to 3 ICUs at a single academic hospital. Exclusion criteria will include suspected infection, chronic indwelling catheters, and CHG allergy. Informed consent will be obtained from eligible participants or their substitute decision maker prior to randomization. Participants will be randomized to receive either usual care or the CHG locking device. Blood cultures will be drawn from all participants every 48 h. The primary objective of this study will be to determine the feasibility of using this protocol to conduct a larger trial. Feasibility will be assessed through the following outcomes: (1) consent rate, (2) recruitment rate, (3) protocol adherence, and (4) comfort level with the device. The secondary objective of this study will be to establish the preliminary efficacy of the device.

Discussion

This study will be the first human RCT to investigate a CHG locking device for the prevention of central line infections. Findings from this trial will inform the feasibility of conducting a large RCT and provide preliminary data on the efficacy of a CHG locking device.

Trial registration

ClinicalTrials.gov, NCT03309137, registered on October 13, 2017.

Association of Nurse Staffing With Nosocomial Infections of Very Low-Birth-Weight Infants

Prior studies have reported inconsistent findings regarding the relationship between nurse staffing and nosocomial infections in very low-birth-weight (VLBW) infants. Little is known about whether similar associations occur in Korea. The purpose of this study was to identify the nurse staffing of neonatal intensive care units (NICUs) in Korea and to verify the association between nurse staffing and nosocomial infections among VLBW infants in NICUs. We selected 4654 VLBW infants admitted to 52 hospitals. Nosocomial infections were defined as incidence of bloodstream infection, urinary tract infection (UTI), or rotavirus infection. The average number of NICU patients per nurse was 4.51(minimum-maximum: 2.38-8.16). Hospitals with a higher number of patients per nurse exhibited a significant increased UTI rate (P = .005) and rotavirus infection rate (P = .025) in the univariate analysis. After adjusting for all patient and hospital characteristics, UTI significantly increased with increasing number of patients per nurse (odds ratio [OR] = 1.79; 95% confidence interval, 1.29-2.47), while bloodstream infection (OR = 0.93; 95% confidence interval, 0.79-1.09) and rotavirus infection (OR = 1.14; 95% confidence interval, 0.92-1.41) were not significant. These findings revealed that a nurse staffing in NICUs is an important factor for preventing UTI among VLBW infants.

Epidemiology and healthcare factors associated with neonatal enterococcal infections

OBJECTIVE

To investigate the epidemiology and healthcare factors associated with late-onset neonatal enterococcal infections.

DESIGN

Multicentre, multinational retrospective cohort study using prospectively collected infection data from a neonatal infection surveillance network between 2004 and 2016; this was supplemented with healthcare data from a questionnaire distributed to participating neonatal units.

SETTING

Sixty neonatal units across Europe (UK, Greece, Estonia) and Australia.

PATIENTS

Infants admitted to participating neonatal units who had a positive culture of blood, cerebrospinal fluid or urine after 48 hours of life.

RESULTS

In total, 414 episodes of invasive Enterococcus spp infection were reported in 388 infants (10.1% of a total 4083 episodes in 3602 infants). Enterococcus spp were the second most common cause of late-onset infection after coagulase-negative Staphylococcus spp and were strongly associated with necrotising enterocolitis (NEC) (adjusted OR 1.44, 95% CI 1.02 to 2.03, p=0.038), total parenteral nutrition (TPN) (adjusted OR 1.34, 95% CI 1.06 to 1.70, p=0.016), increasing postnatal age (per 1-week increase: adjusted OR 1.04, 95% CI 1.02 to 1.06, p<0.001) and decreasing birth weight (per 1 kg increase: adjusted OR 0.85, 95% CI 0.74 to 0.97, p=0.017). There was no evidence that inadequate nurse to patient staffing ratios in high-dependency units were associated with a higher risk of enterococcal infections.

CONCLUSIONS

Enterococcus spp were the second most frequent cause of late-onset infections. The association between enterococcal infections, NEC and TPN may inform empiric antimicrobial regimens in these contexts and provide insights into reducing these infections.

Practice variations and rates of late onset sepsis and necrotizing enterocolitis in very preterm born infants, a review

The burden of late onset sepsis (LOS) and necrotizing enterocolitis (NEC) remains high for newborns in low- and high-income countries. Very preterm born infants born below 32 weeks gestation are at highest risk because their immune system is not yet adapted to ex-utero life, providing intensive care frequently compromises their skin or mucosa and they require a long duration of hospital stay. An epidemiological overview is difficult to provide because there is no mutually accepted definition available for either LOS or NEC. LOS incidence proportions are generally reported based on identified blood culture pathogens. However, discordance in minimum day of onset and whether coagulase negative staphylococci or fungi should be included into the reported proportions lead to variation in reported incidences. Complicating the comparison are the absence of biomarkers, ancillary lab tests or prediction models with sufficiently high positive and/or negative predictive values. The only high negative predictive values result from negative blood culture results with negative lab results allowing to discontinue antibiotic treatment. Similar difficulties exist in reporting and diagnosing NEC. Although most publications base their proportions on a modified version of Bell's stage 2 or 3, comparisons are made difficult by the multifactorial nature of the disease reflecting several pathways to intestinal necrosis, the absence of a reliable biomarker and the unclear differentiation from spontaneous intestinal perforations. Comparable reports in very low birthweight infants range between 5% and 30% for LOS and 1.6% to 7.1% for NEC. Evidence based guidelines to support treatment are missing. Treatment for LOS remains largely empirical and focused mainly on antibiotics. In the absence of a clear diagnosis, even unspecific early warning signals need to be met with antibiotic treatment. Cessation after negative blood culture is difficult unless the child was asymptomatic from the beginning. As a result, antibiotics are the most commonly prescribed medications, but unnecessary exposure may result in increased risk for mortality, NEC, further infections and childhood obesity or asthma. Finding ways to limit antibiotic use are thus important and have shown a large potential for improvement of care and limitation of cost. Over recent decades, none of the attempts to establish novel therapies have succeeded. LOS and NEC proportions remained mostly stable. During the past 10 years however, publications emerged reporting a reduction, sometimes by almost 50%. Most concern units participating in a surveillance system using quality improvement strategies to prevent LOS or NEC (e.g., hand hygiene, evidence based "bundles", feeding onset, providing own mother's milk). We conclude that these approaches display a potential for wider spread reduction of LOS and NEC and for a subsequently more successful development of novel therapies as these often address the same pathways as the prevention strategies.

Overcrowding in a neonatal intermediate care unit: impact on the incidence of multidrug-resistant gram-negative organisms

BACKGROUND

Overcrowding, reduced nurse to patient ratio, limited distance between incubators and absence of microbiological surveillance have been shown to promote spread of multidrug-resistant gram-negative organisms (MDRGN) in patients with birthweight < 1500 g. Patients > 1500 g treated on an intermediate care unit are unrepresented in recent literature. We therefore intended to present data obtained from a short-term overcrowded neonatal intermediate care unit (NIMCU) at a level III (international categorization) perinatal center at University Hospital Frankfurt, Germany.

METHODS

During a 25 day overcrowding (OV) and 28 day post-overcrowding period (POST-OV) on NIMCU, epidemiological data obtained from continuously hold microbiological surveillance were investigated and compared to the last 12 months of ward-regular bed occupancy preceding OV (PRAE-OV).

RESULTS

During OV, the number of patients simultaneously treated at the NIMCU increased from 18 to 22, resulting in a reduced bed-to-bed space. Nurse: patient ratio was 4:22 during OV compared to 3:18 during PRAE-OV. Cumulative incidence of MDRGN was 4.7% in OV and 2.4% POST-OV compared to 4.8% to PRAE-OV, respectively, without any significant variations. During OV and POST-OV, septic episodes due to MDRGN were not observed. In one case, potential nosocomial transmission of Enterobacter cloacae resistant to Piperacillin and 3rd/4th generation cephalosporins was observed.

CONCLUSIONS

Prevention of nosocomial spread of MDRGN in an overcrowded NIMCU is based on staff's diligent training and adequate staffing. Concise microbiological surveillance should be guaranteed to escort through overcrowding periods. In our setting, impact of bed-to-bed distance on MDRGN transmission seemed to be less strong.

Increased nurse workload is associated with bloodstream infections in very low birth weight infants

Neonatal sepsis is a major cause of morbidity and mortality in very low birth weight infants (VLBWI). Nurse workload considerably affects infection rates in intensive care units. However, data concerning the impact of staff workload on bloodstream infections (BSI) in VLBWI are scarce. The aim of the study was to examine the association between nurse workload and BSI in VLBWI. VLBWI admitted to our neonatal intensive care unit during 2016–2017 were retrospectively analysed. Association between nurse workload, determined by a standardized nursing score, and the BSI occurrence was investigated. A higher nurse workload was significantly associated with higher occurrence of BSI (p = 0.0139) in VLBWI. An assumed workload of 120% or higher, representing the need for additional nurses in our NICU setting, is associated with an elevated risk for BSI in this vulnerable population OR 2.32 (95% CI: 1.42–3.8, p = 0.0005). In conclusion, nurse understaffing is associated with a higher risk for BSI in VLBWI.

Preventive bundles to reduce catheter-associated bloodstream infections in neonatal intensive care

This systematic survey includes a total of 27 studies published between 2002 and 2016 on the benefit of preventive bundles for the prevention of central-line associated bloodstream infections (CLABSI) in neonatal intensive care. These studies are mainly cohort studies or studies analyzing an interrupted time series before and after intervention. The studies showed heterogeneity in terms of endpoint definitions (CLABSI), details of the implemented measures, and evidence of a publication bias favoring the use of of preventive bundles. The cumulative analysis showed a statistically and clinically significant benefit of preventive bundles to avoid CLABSI in neonatal intensive care.

Outbreaks in the neonatal ICU: a review of the literature

PURPOSE OF REVIEW

Neonates in the neonatal ICU (NICU) are uniquely vulnerable to colonization and infection with pathogens such as multidrug resistant Gram-negative bacteria, which in turn are associated with increased infection-related morbidities and higher case-fatality rates. We reviewed the English, French, and German language literature published between 2015 and 2017, for reports of NICU outbreaks.

RECENT FINDINGS

A total of 39 outbreaks in NICUs were reported with Gram-negative bacteria (n = 21; 54%) causing most, and extended spectrum beta-lactamase-producing organisms being the most frequent resistance mechanism reported (n = 5). Five viral outbreaks were reported (respiratory syncytial virus = 3). A significant proportion of outbreaks (33%) did not identify a source. Whole genome sequencing was used more (n = 6 reports). The most common described infection prevention and control interventions included staff and parent education on hand hygiene, patient isolation, additional contact precautions, including discontinuation of 'kangaroo care', and cohorting. Reporting and publication bias are likely common.

SUMMARY

NICUs must be vigilant in identifying outbreaks, conduct comprehensive investigations, and implement targeted infection prevention and control strategies. Molecular epidemiology capacities are an essential element in outbreak investigation. More studies are needed to determine the added value of active colonization screening and their impact on outbreak development.

Central line-associated bloodstream infections in Australian ICUs: evaluating modifiable and non-modifiable risks in Victorian healthcare facilities

Central line-associated bloodstream infections (CLABSIs) in intensive care units (ICUs) result in poor clinical outcomes and increased costs. Although frequently regarded as preventable, infection risk may be influenced by non-modifiable factors. The objectives of this study were to evaluate organisational factors associated with CLABSI in Victorian ICUs to determine the nature and relative contribution of modifiable and non-modifiable risk factors. Data captured by the Australian and New Zealand Intensive Care Society regarding ICU-admitted patients and resources were linked to CLABSI surveillance data collated by the Victorian Healthcare Associated Infection Surveillance System between 1 January 2010 and 31 December 2013. Accepted CLABSI surveillance methods were applied and hospital/patient characteristics were classified as 'modifiable' and 'non-modifiable', enabling longitudinal Poisson regression modelling of CLABSI risk. In total, 26 ICUs were studied. Annual CLABSI rates were 1·72, 1·37, 1·00 and 0·93/1000 CVC days for 2010-2013. Of non-modifiable factors, the number of non-invasively ventilated patients standardised to total ICU bed days was found to be independently associated with infection (RR 1·07; 95% CI 1·01-1·13; P = 0·030). Modelling of modifiable risk factors demonstrated the existence of a policy for mandatory ultrasound guidance for central venous catheter (CVC) localisation (RR 0·51; 95% CI 0·37-0·70; P < 0·001) and increased number of sessional specialist full-time equivalents (RR 0·52; 95% CI 0·29-0·93; P = 0·027) to be independently associated with protection against infection. Modifiable factors associated with reduced CLABSI risk include ultrasound guidance for CVC localisation and increased availability of sessional medical specialists.

Prevention of Vascular Catheter-Related Bloodstream Infections

Catheter-related bloodstream infections (CRBSI) are responsible for significant morbidity, mortality, and excess health care costs. It is increasingly evident that many CRBSI can be prevented with current knowledge and techniques. Preventive measures can be broadly grouped into clinical practice-based interventions and technologic innovations. Clinical practice-based interventions require changes in human behavior and can be subdivided into interventions before and at the time of insertion and postinsertion. Despite recent successes with prevention of CRBSI, pertinent questions regarding pathogenesis and prevention remain unanswered and work on improved surveillance, devices less prone to infection, and more effective prevention techniques are needed.

Pathogen-specific mortality in very low birth weight infants with primary bloodstream infection

Objective

Mortality in very low birth weight infants following microbiology confirmed primary bloodstream infections varies with the type of causative pathogen. Given evidence from other studies that infections with gram negative bacteria and fungi cause a higher case fatality risk. We tried to confirm this in a nation-wide multi-center trial.

Methods

A cohort of 55,465 very low birth weight infants from 242 neonatal departments participating in the German national neonatal infection surveillance system NEO-KISS was used to investigate differences in the case fatality risk of microbiology confirmed primary bloodstream infections according to individual pathogens. Cox proportional hazard regression analyses were performed with the outcomes death and time from microbiology confirmed primary bloodstream infections. The results were adjusted to the recorded risk factors and hospital and department characteristics.

Results

A total of 4 094 very low birth weight infants with microbiology confirmed primary bloodstream infections were included in the analysis. The crude case fatality risk was 5.7%. The Cox proportional hazard regression analysis with adjustment for available risk factors revealed that microbiology confirmed primary bloodstream infections caused by Klebsiella spp. (HR 3.17 CI95 1.69–5.95), Enterobacter spp. (HR 3.42 CI95 1.86–6.27), Escherichia coli (HR 3.32 CI95 1.84–6.00) and Serratia spp. (HR 3.30 CI95 1.44–7.57) were associated with significantly higher case fatality risk compared to Staphylococcus aureus. After adjusting, case fatality risk of Candida albicans causing microbiology confirmed primary bloodstream infections was not higher than that of S. aureus.

Conclusion

In very low birth weight infants, bloodstream infections caused by gram negative pathogens have an increased case fatality risk compared to bloodstream infections caused by gram positive pathogens. This should be considered for prevention and therapy. Further research should address the specific risk factors for case fatality of C. albicans bloodstream infections.

The Implementation of an Evidence-Based Bundle for Bloodstream Infections in Neonatal Intensive Care Units in Germany: A Controlled Intervention Study to Improve Patient Safety

OBJECTIVE

To improve the patient safety of very-low-birthweight infants in neonatal departments in Germany.

DESIGN

Multicenter cohort study with a baseline (24 months), an intervention (12 months), and a postinterventional follow-up period (12 months) and time series analysis.

STUDY POPULATION

Very-low-birthweight patients from 32 neonatal departments in Germany.

METHODS

Neonatal departments showing a standardized infection ratio of bloodstream infection 10% higher than the expected number (standardized infection ratio ≥1.1) were invited to participate in the study. To reduce the occurrence of primary bloodstream infections, evidence-based bundles to improve catheter maintenance routines, insertion practice, and hand-hygiene compliance were implemented in the participating infirmaries.

RESULTS

Thirty-four departments participated in the study and 32 reported data. In total, 6,222 very-low-birthweight infants with 231,868 patient-days and 1,405 cases of bloodstream infections were analyzed. In the baseline period the pooled mean bloodstream infection rate was 6.63 (95% CI, 6.17–7.12) per 1,000 patient-days. The bloodstream infection rate decreased in the intervention period to 5.68 (relative risk, 0.86 [95% CI, 0.76–0.97]) and in the 1-year follow-up period to 5.31 per 1,000 patient-days (relative risk, 0.80 [95% CI, 0.70–0.92]). The multivariable time series analysis of monthly aggregated data showed a significant change in the slope for the frequency of bloodstream infections from the start to the end of the intervention (change in slope incidence rate ratio, 0.97; P=.001).

CONCLUSION

The implementation of an intervention bundle is feasible and can reduce bloodstream infections in neonatal departments.

Infect Control Hosp Epidemiol 2016;37:798–804

Update on infection control challenges in special pediatric populations

PURPOSE OF REVIEW

Compared with adults, neonatal and pediatric populations are especially vulnerable patients who have specific diagnostic and therapeutic differences; therefore, the standard infection control practices designed for adults are sometimes not effective or need modifications to work. This review focuses on the recent literature addressing the challenges and successes in preventing healthcare-associated infections (HAIs) in children.

RECENT FINDINGS

Improving the implementation of pediatric versions of preventive bundles focusing on proper catheter insertion and maintenance, mainly as a part of a larger multimodal strategy, is effective in reducing the central-line-associated bloodstream infections in neonatal and pediatric populations including oncology patients. Appropriate feeding, antimicrobial stewardship, and infection control measures should be combined in reducing necrotizing enterocolitis in preterm neonates. Implementing a multimodal bundle strategy adapted for pediatric population is successful in preventing ventilator-associated pneumonia. Appropriate use of antimicrobial prophylaxis remains the cornerstone for preventing surgical-site infections irrespective of age, with few additional effective adjuvant preventive practices in specific pediatric patients.

SUMMARY

Several evidence-based practices are effective in reducing the incidence and the impact of HAIs in children; however, proper implementation remains a challenge. Additionally, several adult preventive practices are still unestablished in children and need further thorough examination.

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.

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.