Urinary Infection in Two Selected Neonatal Populations

The urines from 204 infants admitted to a neonatal special care unit and from 25 infants whose mothers had bacteriuria in the last trimester of pregnancy were cultured and examined for white cells.A comparison of 39 bag collected urines with suprapubic specimens showed that growth in a bag collection was usually due to contamination, and that the presence of more than 10 WBC/cu.mm. in the suprapubic aspirate was not usually associated with a positive culture.Only 2 infants from a total of 70 studied in the special care unit had more than 100,000 organisms/ml. with more than 10 WBC/cu.mm. in the bladder urine. All urines, which were obtained from infants whose mothers had bacteriuria in the last trimester of pregnancy, were sterile. These results support the view that neonatal urinary infection is uncommon and that infants of this age is not justified.     

Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant

Chemical burns in extremely preterm infants have major implications in terms of morbidity and risk management. We report a case of extensive chemical burn in an extremely low birth weight (ELBW) infant caused by clear, colourless solution of 0.5% chlorhexidine in 70% alcohol mistaken for normal saline for skin cleansing during umbilical catheter insertion. This case reflects the on going problem faced by many neonatal intensive care units of similar coloured solutions with similar packages, but with varying degrees of toxic effects. CONCLUSION: The case highlights the importance of having a clear policy for skin cleansing in every neonatal unit and measures to avoid errors by vigilant checking of all medications including topical solutions.     

Neonatal sepsis and infection control policies in Australia

The pattern of neonatal bacterial infection, its management and the types of infection control policy were ascertained in 20 neonatal intensive care units (NICU) in Australia by questionnaire survey. Group B Streptococcus and Escherichia coli were the predominant organisms responsible for perinatally acquired infection for which the most common antibiotic combination used was Penicillin and Gentamicin. Staphylococcus epidermidis and aureus (majority Methicillin resistant) were the predominant organisms responsible for nosocomial infection for which the most common antibiotic combination used was Vancomycin and Cefotaxime. A Serratia epidemic was experienced in four NICU. Lumbar and suprapubic punctures were frequently done as part of the diagnostic workup in nosocomial infections but not with perinatally acquired infections. Haematological indices considered useful as a diagnosis aid varied between NICU and acute phase reactants were rarely relied upon for diagnosis or for monitoring treatment response. Granulocyte transfusion and intravenous immunoglobulins were infrequently used in therapy. No consensus was found on infection control policies. Eight NICU required routine gowning on entry, two restricted sibling visiting and four restricted visiting by relatives and friends. Although routine bacteriological surveillance on staff or equipment was uncommon, serial cultures were carried out in infants from the body surface in six NICU and from the endotracheal aspirate in 17 NICU. Antiseptics used with technical procedures included iodine, chlorhexidine and alcohol used singly or in combination. Skin and umbilical cord care also varied between NICU. The literature was reviewed to determine the effectiveness or otherwise of some of the existing policies in the prevention or management of neonatal infection to encourage consensus towards a more rational approach to neonatal infection in Australia.     

Preventing central-line-associated bloodstream infections in pediatric specialized care units: A case study of successful quality improvement

Central line associated bloodstream infections in pediatric intensive care units extend the intensive care unit length of stay and increase the cost of hospitalization. These infections, once thought to be an accepted complication of central vascular access, are now known to be preventable. Despite using hand hygiene, full barrier protection, and proper skin disinfection with 70% isopropyl alcohol/20% chlorhexidine gluconate for pediatric central venous catheter insertion, our catheter associated bloodstream infection rate remained high. We instituted a new practice involving scrubbing the catheter hub and performing dressing changes with 70% isopropyl alcohol/20% chlorhexidine gluconate in a combined pediatric intensive care and pediatric cardiac intensive care unit. We removed alternative products from the bedside thereby making it easier for the staff to follow procedure and reducing the need for training and monitoring. This change reduced our catheter associated bloodstream infection rate from 7.1 episodes per 1000 line days to 1.5 episodes per 1000 line days. We describe the barriers we encountered in instituting this practice change, evaluating the impact of the change with limited resources, and in eventually implementing the change in other units system-wide. The most commonly encountered obstacle to change was not a lack of resources, but the insistence by the medical staff that the incidence of these infections was a result of differences in patient populations and not differences in compliance with standardized procedure.     

Significance of coagulase-negative staphylococci isolated from a single blood culture from neonates in intensive care

BACKGROUND: Coagulase-negative staphylococci (CoNS) are the most common pathogens of late-onset bacteraemia in neonatal intensive care units (NICUs). Discriminating true infection from contamination is difficult. METHODS: To evaluate the significance of a single blood culture yielding CoNS from only one blood culture obtained from NICU infants between July 1999 and November 2000, paired blood cultures were obtained simultaneously from two peripheral sites from infants hospitalised in two NICUs with clinically suspected late-onset sepsis, and a single blood culture was obtained peripherally from infants hospitalised in a third NICU. Demographic data, predisposing factors, clinical manifestations, laboratory data, management and outcome of infants with either paired or single blood cultures yielding CoNS were analysed and compared. RESULTS: Both blood cultures yielded CoNS during 26 episodes in 24 infants. A single blood culture which grew CoNS from one blood culture was identified during 24 episodes in 23 infants. Except for prior use of an umbilical venous catheter, there was no significant difference between the infants with CoNS isolated from a paired or a single blood culture in terms of demographic characteristics, predisposing factors, clinical manifestations, laboratory findings, management and outcome. CONCLUSION: There was no difference in the clinical features of CoNS infection between single and paired CoNS-positive blood cultures.     

Is urethral catheterization a successful alternative to suprapubic aspiration in neonates?

OBJECTIVE: To compare urine collection by urethral catheterization with suprapubic aspiration in a neonatal intensive care unit. METHODOLOGY: All urine collections were documented, the collection methods attempted recorded and success rates calculated. The incidence of contaminated specimens was determined. The infants ranged in weight from 570 g to 4180 g and in gestation from 24 to 44 weeks. RESULTS: Thirty-two out of 65 (49%) suprapubic aspirations were successful. Overall 33/42 (77%) of catheterizations were successful, 12/18 (67%) were successful when following an unsuccessful SPA. No SPA was contaminated compared to 7/22 (22%) of the catheter specimens. Urinary tract infection was present in 4/63 (6.3%) infants. There were no complications following catheterization. CONCLUSIONS: Urethral catheterization is a useful and safe alternative to suprapubic aspiration, but suprapubic aspiration remains the method of first choice.     

Endotracheal aspirate cultures in predicting sepsis in ventilated neonates

Nosocomial infections are the most common complications encountered in the neonatal intensive care unit (NICU). They are associated with high mortality and prolonged duration of hospitalization in the survivors, contributing to an increased cost of health care. In this article, we review the literature on the value of routine endotracheal aspirate cultures for the prediction of neonatal sepsis and provide guidelines to prevent nosocomial infections. Upon reviewing the literature it appears that the practice of routine cultures of endotracheal aspirate and cultures obtained from multiple body sites is an expensive proposition with low yield. The sensitivity of this test is at best 50% and all studies report a very low positive predictive value. The specificity of this test is 80%, hence its role is mainly limited to identifying infants who are at low risk for sepsis. As we do not have any reliable test for early diagnosis of neontal sepsis and also to dientify infants at high risk for sepsis, our main emphasis should be towards preventing nosocomial infections. Guidelines for reducing nosocomial infections are described.     

Renal candidiasis in neonates with candiduria

BACKGROUND: Candida species commonly cause urinary tract infection in infants admitted to neonatal intensive care units. The purpose of this study was to describe the natural history of renal candidiasis as evidenced by sonography in infants with candiduria. METHODS: The medical records of all infants who developed candiduria during their neonatal intensive care hospitalization between 1982 and 1993 were reviewed. Candiduria was defined as the isolation of Candida from (1) one or more specimens obtained by bladder catheterization or suprapubic aspiration, (2) one or more voided specimens and concurrent positive cultures from another sterile body site or (3) one or more voided specimens and changes on renal ultrasound consistent with renal candidiasis. Renal ultrasounds were retrospectively reviewed by one pediatric radiologist. Nonshadowing echogenic foci were considered evidence of renal fungus balls. RESULTS: Forty-one infants with candiduria were identified. Thirty-six infants underwent 1 or more renal imaging studies (ultrasonography, 35; computerized tomography, 1). The incidence of renal candidiasis in neonates with candiduria, defined as renal fungus balls or renal fungal abscess, was 42%. Of the 13 patients who had sonographic abnormalities suggestive of renal fungus balls, 7 had abnormalities on the first ultrasound obtained after the discovery of candiduria, whereas 6 patients developed abnormalities between 8 and 39 days later. CONCLUSIONS: Serial renal ultrasounds are required to reliably detect late appearing renal fungus balls in neonates with candiduria. Complications requiring surgical intervention, like urinary tract obstruction, were uncommon.     

Neonatal Ureaplasma urealyticum colonization and chronic lung disease

We studied Ureaplasma urealyticum colonization in 93 intubated infants (gestational ages 23–40 weeks) in our neonatal intensive care unit by obtaining cultures from endotracheal aspirate and nasopharynx during their first week of life. Eighteen infants had positive cultures, giving a colonization rate of 19%. No infant more than 30 weeks' gestation had a positive culture. The infants with positive cultures had a significantly lower gestational age and birth weight ( p < 0.009 andp < 0.005), with a colonization rate of 33% in infants less than 1000 g. Among the infants with positive cultures, 10 of 17 developed chronic lung disease in contrast with 21 of 72 infants with negative cultures. The development of chronic lung disease and duration of oxygen requirement was strongly associated with immaturity but only weakly with Ureaplasma urealyticum.     

A randomized controlled trial of the impact of chlorhexidine skin cleansing on bacterial colonization of hospital-born infants in Nepal

BACKGROUND: Chlorhexidine skin cleansing might substantially reduce neonatal infection and mortality in developing countries. Few data exist on the impact of chlorhexidine cleansing on skin colonization of infants during the first day of life or on the absorption potential of chlorhexidine during newborn skin cleansing. METHODS: Hospital-born newborns in Kathmandu, Nepal were randomly allocated to full-body skin cleansing with 0.25%, 0.50%, or 1.00% chlorhexidine solution. Skin swabs were collected from the axilla, inguinal, and peri-umbilical areas before cleansing (baseline), and at 2 and 24 hours after treatment. Skin flora was quantified and organisms identified. In a subsample, heel prick blood was collected 24 hours after the cleansing and percutaneous absorption of chlorhexidine was assessed. RESULTS: Among 286 enrolled newborns, no adverse effects on skin were reported and body temperature was minimally reduced (mean reduction, 0.33 degrees C). In all groups, positive skin culture rates were significantly reduced at 2 hours but generally not at 24 hours; greater reductions were observed with higher concentrations of chlorhexidine. Effect at 24 hours was highest in the 1.00% group (37% lower positive skin culture rate). For 15 of 75 infants with heel pricks, chlorhexidine was detected at trace concentrations (<8 ng/mL, n = 14; 25.8 ng/mL, n = 1). CONCLUSIONS: Chlorhexidine skin cleansing seemed safe and reduced skin flora in newborns in a dose-dependent manner 2 hours after treatment. Greater residual effect at the highest concentration (1%) might provide broader benefit and may simplify combined maternal and neonatal regimens by matching the concentration used for vaginal cleansing during labor.     

The role of Candida surveillance cultures for identification of a preterm subpopulation at highest risk for invasive fungal infection

Candida surveillance cultures were obtained from 51 neonatal intensive care unit patients. Sixteen infants showing positive cultures developed subsequent Candida infection, whereas it did not occur for the 35 infants with negative cultures. Fifteen of 16 infants (<1000 g) had <27 weeks of gestational age. Antifungal treatment was started at the time colonization was detected; only 1 infant died of Candida infection.     

Safety and effect of chlorhexidine skin cleansing on skin flora of neonates in Bangladesh

BACKGROUND: Chlorhexidine cleansing of newborn skin is a highly promising intervention for reducing neonatal mortality in developing countries, yet little is known of the mechanism of action. This study examined the impact of a single skin cleansing of hospitalized newborn infants in Bangladesh with baby wipes containing 0.25% chlorhexidine on both qualitative and quantitative skin flora. METHODS: Within 72 hours of birth, the skin of newborns admitted to Dhaka Shishu Hospital was wiped with baby wipes containing 0.25% chlorhexidine (n = 67) or placebo (n = 66) solution. Skin condition was assessed and skin swabs were taken from 3 sites (axillary, peri-umbilical, inguinal) at baseline and 2 hours, 24 hours, 3 days and 7 days after treatment. Skin flora was quantified and colonizing species were identified. FINDINGS: Skin cleansing with chlorhexidine had no adverse effects on skin condition, and resulted in minimal reduction (mean 0.5 degrees C) in body temperature. Positive skin culture rates 2 hours after skin cleansing were approximately 35%-55% lower than the baseline rates for placebo and chlorhexidine groups at all 3 sites. For the chlorhexidine group, positive skin culture rates remained significantly lower than the baseline rates for 24 hours to 3 days, whereas for the placebo group, beyond the first 2-hour follow-up, these values were not lower than baseline in any of the 3 sites. INTERPRETATION: Chlorhexidine skin treatment produced more extended skin cleansing effects than the placebo treatment. It is possible that the quantitative and qualitative reductions observed in the skin flora might contribute to reducing neonatal infections.     

Prevention and Control of Neonatal Pyoderma with Chlorhexidine

The extent of staphylococcal colonisation and neonatal pyoderma was studied in 5 220 infants in two large Swedish hospitals in 1979–1982. A method for routine cord care with 4 % chlorhexidine detergent solution was evaluated in one hospital. Nursery colonisation with Staph, aureus and streptococci decreased significantly. The method proved to be clinically efficient for prevention of pyoderma in the nursery as well as for controlling staphylococcal infection after discharge from hospital. The combined use of a quantitative sampling method and phage-typing showed that most post-discharge lesions were nursery-derived. In one of the hospitals, daily cord care with 70 % ethanol failed to prevent streptococcal and staphylococcal omphalitis in the nursery whereas daily cord care with chlorhexidine reduced the incidence of omphalitis from 21 to 1 %.     

Prevention and control of neonatal pyoderma with chlorhexidine

The extent of staphylococcal colonisation and neonatal pyoderma was studied in 5 220 infants in two large Swedish hospitals in 1979-1982. A method for routine cord care with 4% chlorhexidine detergent solution was evaluated in one hospital. Nursery colonisation with Staph. aureus and streptococci decreased significantly. The method proved to be clinically efficient for prevention of pyoderma in the nursery as well as for controlling staphylococcal infection after discharge from hospital. The combined use of a quantitative sampling method and phage-typing showed that most post-discharge lesions were nursery-derived. In one of the hospitals, daily cord care with 70% ethanol failed to prevent streptococcal and staphylococcal omphalitis in the nursery whereas daily cord care with chlorhexidine reduced the incidence of omphalitis from 21 to 1%.     

Lack of evidence of efficacy of cohorting nursing personnel in a neonatal intensive care unit to prevent contact spread of bacteria: an experimental study.

Nurse cohorting was investigated in a modern neonatal intensive care unit (NICU). During 99 days bacterial infection and colonization rates were determined in 100 infants experimentally assigned cohort or noncohorted care. Colonizing isolate identity was determined by plasmid profile analyses and biotyping in weekly surveillance cultures. Between Days 2 and 7, 3 infections occurred in cohorted infants but none in noncohorted ones. No secondary spread of infection or definitive colonization cluster occurred. The first colonization rate, at any site, was 0.53/patient-week in the noncohorted and 0.3 to 0.4 in the cohorted units (P greater than 0.05). Colonization ratios with species other than usual skin bacteria in the respiratory tract and with species other than Escherichia coli in the rectum were lower for noncohorted infants. Effective infection control practices in a modern NICU, including alcohol hand antisepsis, should obviate a need for cohorting.     

Connatal tuberculosis in an extremely low birth weight infant: case report and management of exposure to tuberculosis in a neonatal intensive care unit

A case of connatal tuberculosis in an extremely low birth weight infant is reported. The patient was a female with a birth weight of 973 g born in the 27th week of pregnancy. She developed respiratory distress and signs of infection immediately after birth, which did not respond to mechanical ventilation, antibiotics, and corticosteroid therapy. Connatal tuberculosis was confirmed at 48 days of age by isolation of Mycobacterium tuberculosis from the infant's tracheal aspirate and the mother's menstrual discharge. The infant died of respiratory failure at 90 days of age. Mantoux tuberculin skin tests (TST) were performed on 99 infants, 144 medical staff members, and two family members. TST conversion occurred in three medical staff members, and preventive therapy with isoniazid was initiated. Eight exposed infants had normal chest X-rays and negative gastric aspirates for acid-fast bacilli and all received preventive isoniazid therapy. No case of tuberculosis developed during the 2-year follow-up period. Conclusion Connatal tuberculosis should be considered in neonatal respiratory infection resistant to antibiotics. Prevention of transmission of tuberculosis on the neonatal intensive care unit by chemoprophylaxis is important. Received: 14 March 2000 / Accepted: 13 September 2000     

Percutaneous central venous catheter colonization with Malassezia furfur: incidence and clinical significance

Malassezia furfur colonization of central venous catheters has been implicated in the pathogenesis of systemic infections with this lipid-dependent yeast. To determine the incidence of catheter colonization in our neonatal intensive care unit (NICU), 25 consecutively removed percutaneous central venous catheters were examined by rinsing the lumen with saline and plating the rinse fluid on Sabouraud dextrose agar overlaid with olive oil. M furfur grew from the lumina of eight catheters (32%). Surveillance skin cultures were performed in the NICU on two occasions to determine the prevalence of skin colonization with M furfur. M furfur was found on the skin of 64% of the infants. In contrast, only 3% (1/33) of healthy, nonhospitalized infants 2 to 8 weeks of age had skin colonized with M furfur. During the 5-month study period, two NICU infants had evidence of systemic infection with M furfur. We conclude that M furfur frequently colonizes both the skin and percutaneous central venous catheters in NICU infants. Further studies are needed to determine the relationship between skin colonization and catheter colonization, and the factors contributing to systemic disease with this organism.     

Prevention of nosocomial infections in the neonatal intensive care unit

Nosocomial infections are responsible for significant morbidity and late mortality among neonatal intensive care unit patients. The number of neonatal patients at risk for acquiring nosocomial infections is increasing because of the improved survival of very low birthweight infants and their need for invasive monitoring and supportive care. Effective strategies to prevent nosocomial infection must include continuous monitoring and surveillance of infection rates and distribution of pathogens; strategic nursery design and staffing; emphasis on handwashing compliance; minimizing central venous catheter use and contamination, and prudent use of antimicrobial agents. Educational programs and feedback to nursery personnel improve compliance with infection control programs.     

Outbreaks of influenza A virus infection in neonatal intensive care units

BACKGROUND: Outbreaks of nosocomial influenza virus infections have been described rarely during childhood and even less so in the neonatal period. METHODS: We report 30 neonates admitted to 2 neonatal intensive care units with nosocomial influenza A virus infection, which occurred in 2 outbreaks during 1999. Risk factors for infection were evaluated, and control measures were adopted. Virus was detected by indirect immunofluorescence antibody screen. Any infant with nasopharyngeal aspirate positive for influenza A virus was considered infected. RESULTS: Of 95 infants screened 30 were positive for influenza A virus (31.5%). Mean birth weight was 1622 g, and mean gestational age was 31 weeks in the infected group. In the noninfected group mean birth weight was 2594 g and mean gestational age was 36.4 weeks. Low birth weight, short gestational age, twin pregnancy and mechanical ventilation were identified as risk factors for infection. Clinical symptoms were seen in 22, and 8 were asymptomatic. Clinical features were predominantly respiratory and digestive. The outcome was favorable in all cases. CONCLUSIONS: Infection by influenza virus has to be considered as a possible cause of nosocomial infection in the neonatal period. Control measures and prevention are important.     

Early and late neonatal septicaemia.

Between 1979 and 1982 we reviewed 1000 consecutive admissions to the neonatal intensive care unit of this hospital. Sixty five infants had positive blood cultures. Mortality was 70% among 17 infants who had septicaemia in the first 48 hours of life and for whom appropriate treatment may have been too late because of difficulties of early diagnosis. In the remaining 48 infants mortality was 12%, septicaemia occurred later, and was associated with Staphylococcus epidermidis (56%) and with the presence of an intravascular catheter (50%).