Recurrent late-onset sepsis in the neonatal intensive care unit: incidence,clinical characteristics and risk factors

We aimed to characterize the incidence, clinical features, risk factors and outcomes of recurrent late-onset sepsis (LOS) in the neonatal intensive care unit (NICU). All neonates with LOS from the NICU of a tertiary-level teaching hospital in northern Taiwan between 2004 and 2011 were enrolled for analyses. A case-control study was performed to determine risk factors for recurrence. Of 713 neonates with LOS, 150 (21.0%) experienced recurrence and 48 (6.7%) had >1 recurrences; c. two-thirds of recurrent LOS occurred in infants with birth weight (BW) ≦ 1500 g or gestational age (GA) ≦ 30 weeks. The recurrent LOS episodes were significantly more severe and had a higher sepsis-attributable mortality rate than the first episodes. The overall in-hospital mortality rate was 30.7% for neonates with recurrent LOS and 7.8% for those with single LOS (odds ratio (OR), 5.22; 95% CI, 3.28–8.30). When both BW and GA were controlled, neonates with recurrent LOS had a significantly prolonged hospitalization compared with the controls (median 109 vs. 84 days, p <0.001). After multivariate logistic regression, longer duration of total parenteral nutrition (TPN; OR, 1.30; 95% CI, 1.10–1.52 for every 10-day increment), presence of congenital anomalies (OR, 2.64; 95% CI, 1.10–6.35) and neurological co-morbidities (OR, 4.14; 95% CI, 1.14–15.10) were identified as the independent risk factors for LOS recurrence. We concluded that c. one-fifth of neonates with LOS had recurrence, which significantly resulted in prolonged hospitalization and increased mortality. Longer TPN administration, presence of congenital anomalies and neurological co-morbidities are independently associated with recurrent LOS.     

Candidemia in neonatal intensive care unit

The present study was conducted over a period of 6 months to determine the Candida species causing candidemia in a neonatal intensive care unit and to analyse the risk factors associated with acquisition of significant fungemia. Speciation of the 19 isolated Candida spp was done by the standard techniques. Antimicrobial susceptibility of these isolates was determined by disc diffusion method against Amphotericin B, Fluconazole, Ketoconozole and 5-Flucytosine. Candida glabrata was the most common species involved (42.1%). Other species isolated were C. tropicalis (31.6%). Calbicans (21.1%) and C.parapsilosis (5.2%). All the isolates were sensitive to Amphotericin B. Resistance to other antigungal agents was seen only in C. globrata. Significant candidemia was seen in 14/19 (72.6%) of neonates. Risk factors found to be associated with significant candidemis in these neonates included intake of multiple broad-spectrum antibiotics (p<0.0001), use of total parenteral nutrition (p<0.045) and ventilators (p<0.0001).     

Clinical and microbiological characteristics of hospital infections in the neonatal intensive care unit

Neonates hospitalized in intensive care units, are exposed to a higher risk of infectious complications. The research involved 52 neonates hospitalized in the Neonatal Intensive Care Unit (NICU), Chair and Clinic of Obstetrics and Perinatology over a span of one year. The incidence of hospital infections as well as etiological factors were analyzed. Clinically manifested hospital infections were diagnosed in 38.5% of babies with very low or extremely low birth weight, in boys twice as often as in girls. Generalised invasive infections prevailed; in most cases they were caused by Gram-negative rods, mainly Klebsiella spp.     

Cholestasis in a neonatal intensive care unit

A retrospective study of 17 babies admitted to the neonatal intensive care unit of the Royal Maternity Hospital, Belfast, was undertaken to determine the causes and prognosis of conjugated hyperbilirubinaemia (direct fraction greater than 20% of total) over a five year period. Mean gestational age was 29 weeks and mean birth weight was 1,240g with a 2:1 male preponderance. All babies had a complicated clinical course involving prolonged periods of parenteral nutrition and many episodes of sepsis. Liver damage was not found to be a contributory factor to death in any baby who died before the age of one year. Bilirubin levels in the survivors had returned to normal within one year. No permanent pathological cause of cholestasis, such as biliary atresia, was ascribable to any of the cases, indicating that extensive investigation to exclude anatomical causes in this population is unlikely to prove rewarding.     

End of life in the neonatal intensive care unit

PURPOSE:

Death at the beginning of life is tragic but not uncommon in neonatal intensive care units. In Portugal, few studies have examined the circumstances surrounding the final moments of neonates. We evaluated the care given to neonates and their families in terminal situations and the changes that had occurred one decade later.

DESIGN AND METHODS:

We analyzed 256 charts in a retrospective chart review of neonatal deaths between two periods (1992-1995 and 2002-2005) in a level III neonatal intensive care unit.

RESULTS:

Our results show differences in the care of dying infants between the two periods. The analysis of the 2002-2005 cohort four years revealed more withholding and withdrawing of therapeutic activities and more effective pain and distress relief; however, on the final day of life, 95.7% of the infants received invasive ventilatory support, 76.3% received antibiotics, 58.1% received inotropics, and 25.8% received no opioid or sedative administration. The 2002-2005 cohort had more spiritual advisor solicitation, a higher number of relatives with permission to freely visit and more clinical meetings with neonatologists. Interventions by parents, healthcare providers and ethics committees during decision-making were not documented in any of the charts. Only eight written orders regarding therapeutic limitations and the adoption of palliative care were documented; seven (87.5%) were from the 2002-2005 cohort. Parental presence during death was more frequent in the latter four years (2002-2005 cohort), but only 21.5% of the parents wanted to be present at that moment.

CONCLUSION:

Despite an increase in the withholding and withdrawing of therapeutic activities and improvements in pain management and family support, many neonates still receive curative and aggressive practices at the end of life.     

Molecular tracking of Candida albicans in a neonatal intensive care unit: long-term colonizations versus catheter-related infections.

Nosocomial neonatal candidiasis is a major problem in infants requiring intensive therapy. The subjects of this retrospective study were nine preterm infants admitted to the neonatal intensive care unit of the Hospital Central de Asturias between March 1993 and August 1994. The infants were infected with or colonized by Candida albicans. Five patients developed C. albicans bloodstream infections. A total of 36 isolates (including isolates from catheters and parenteral nutrition) were examined for molecular relatedness by PCR fingerprinting and restriction fragment length polymorphism (RFLP) analysis. The core sequence of phage M13 was used as a single primer in the PCR-based fingerprinting procedure, and RFLP analysis was performed with C. albicans-specific DNA probe 27A. Both techniques were evaluated with a panel of eight C. albicans reference strains, and each technique showed eight different patterns. With the 36 isolates from neonates, each technique enabled us to identify by PCR and RFLP analysis seven and six different patterns, respectively. The combination of these two methods (composite DNA type) identified eight different profiles. A strain with one of these profiles was present in three patients and in their respective catheters. Patients infected with or colonized by this isolate profile were clustered in time. Among the other patients, each patient was infected over time and at multiple anatomic sites with a C. albicans strain with a distinct DNA type. We conclude that C. albicans was most commonly producing long-term colonizations, although horizontal transmission probably due to catheters also occurred.     

Nosocomial spread of a Staphylococcus hominis subsp. novobiosepticus strain causing sepsis in a neonatal intensive care unit

From 2002 to 2003, 32 isolates of Staphylococcus hominis subsp. novobiosepticus (SHN) were recovered from 21 patients, 18 of whom were neonates, with 13 considered to have late-onset SHN sepsis. All isolates from neonates had an indistinguishable pulsed-field gel electrophoresis pattern. Our data support SHN as an important nosocomial pathogen in neonates.     

Long persistence of methicillin-susceptible strains of Staphylococcus aureus causing sepsis in a neonatal intensive care unit

Molecular epidemiology of Staphylococcus aureus strains causing bacteremia in neonates during 2002 to 2005 revealed seven clones, with four MSSA clones responsible for 80% of the cases. Some clones persisted or reappeared throughout the study. Three bacteremic clones were found colonizing health care workers (HCWs), particularly clone C, which was harbored by at least 15% of HCWs.     

Healthcare-associated infections in a neonatal intensive care unit

Introduction

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

Material and methods

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

Results

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

Conclusions

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

Streptococcus faecium outbreak in a neonatal intensive care unit

An outbreak of bacteremia and meningitis in a neonatal intensive care unit is described. Seven cases occurred in premature infants with severe underlying diseases. An epidemiological investigation failed to document the reservoir of the epidemic strain but suggested that its transmission among the infants was via the hands of hospital personnel. All patients had nasogastric tubes and multiple intravascular devices, and the portal of entry may have been either the gastrointestinal tract or the sites of the intravascular devices. Conventional biotyping of isolates failed to differentiate between isolates from infected patients and isolates recovered from prevalence surveys and from the environment. However, rapid identification systems (API-20S [Analytab Products, Plainview, N.Y.] and the AutoMicrobic system [Vitek Systems, Inc., Hazelwood, Mo.]) were able to distinguish isolates recovered from infected patients and hands of hospital personnel from isolates recovered during prevalence and environmental surveys and 29 isolates from widespread geographical areas. This is the first known report of a nosocomial neonatal outbreak of bacteremia and meningitis due to Streptococcus faecium; it underscores the importance of identifying streptococci to species level.     

Methicillin-resistant Staphylococcus caprae in a neonatal intensive care unit

Staphylococcus caprae, a hemolytic coagulase-negative staphylococcus that is infrequently associated with humans, was initially detected in specimens from six infants in our neonatal intensive care unit due to phenotypic characteristics common to methicillin-resistant Staphylococcus aureus. These isolates were subsequently identified as S. caprae by the Automated RiboPrinter microbial characterization system. This prompted an 8-month retrospective investigation in our neonatal intensive care unit. S. caprae was the cause of 6 of 18 episodes of coagulase-negative staphylococcal bacteremia, was the most common coagulase-negative staphylococcus recovered from the nares of 6 of 32 infants surveyed in a methicillin-resistant S. aureus surveillance program, and was isolated from 1 of 37 health care providers' hands. Of 13 neonatal intensive care unit isolates tested, all were methicillin resistant and positive for the mecA gene. All 21 isolates were found to be a single strain by Automated RiboPrinter and pulsed-field gel electrophoresis with ApaI or SmaI digestion; ApaI was more discriminating in analyzing epidemiologically unrelated strains than Automated RiboPrinter or electrophoresis with SmaI. These findings extend the importance of S. caprae, emphasize its similarities to methicillin-resistant S. aureus, and demonstrate its ability to persist in an intensive care unit setting.     

Epidemiologic trends in nosocomial bacteremia in a neonatal intensive care unit.

The primary goal of this study was to analyze the epidemiologic features of nosocomial bloodstream infection (NBSI) in a neonatal intensive care unit over a 7-year period. All neonatal patients with NBSI treated from January 1997 to December 2003 were retrospectively analyzed. 232 NBSI episodes were diagnosed in 208 patients. The average NBSI patient-day rates were 4.69 and 2.59 per 1000 patient-days in 1997-1999 and 2000-2003, respectively. The average NBSI rates were 5.00 and 1.50 per 1000 patient days in neonates <1500 g and > or =1500 g, respectively. The proportion of Gram-positive organisms increased from 24% in 1997-2001 to 41% in 2002-2003, whereas the proportion of Gram-negative isolates decreased from 65% in 1997-2001 to 47% in 2002-2003. The implementation of measures for the prevention of nosocomial infection was associated with the reduction of NBSI rates. Low birth weight was demonstrated to be a significant risk factor for NBSI. The fact that Gram-positive organisms were isolated in increasing frequency may impact on the appropriate selection of empiric antimicrobial therapy for NBSI in the neonatal intensive care unit.     

Molecular epidemiology of coagulase-negative staphylococci causing sepsis in a neonatal intensive care unit over an 11-year period

Coagulase-negative staphylococci (CoNS) are the major causative microorganisms in neonatal nosocomial sepsis. Previous studies have shown that CoNS sepsis in the neonatal intensive care unit (NICU) is caused by predominant molecular types that are widely distributed among both neonates and staff. Some of these molecular types may persist in the NICU for years. The purpose of the present study was to determine the dynamic behavior of CoNS strains causing sepsis over a prolonged period of time by determining the molecular types of all blood isolates from septicemic infants over a period of 11 years (1991 to 2001). The results show that neonatal CoNS sepsis is increasingly caused by a few predominant molecular clusters. The most striking finding was that in recent years one molecular cluster emerged as the predominant cause of neonatal CoNS sepsis, responsible for no less than 31% (20 of 65) of blood isolates in 2001. Antibiotic resistance, particularly beta-lactam resistance, is probably an important selective force considering the high mecA gene carriage of CoNS blood isolates (70 to 92%). We conclude that neonatal CoNS sepsis is increasingly caused by a limited number of predominant molecular CoNS types and that antibiotic resistance is probably a major selective force.     

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.     

Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit

BACKGROUND: Nosocomial infections due to Pseudomonas aeruginosa have been well described, but the environmental reservoir of the organism varies. We conducted an epidemiologic and molecular investigation of endemic P. aeruginosa infection among infants in a neonatal intensive care unit that was associated with carriage of the organisms on the hands of health care workers. METHODS: In August 1998, colonization or infection with P. aeruginosa was identified in six infants. Surveillance cultures for P. aeruginosa were obtained from the other 27 infants in the unit, and possible environmental reservoirs were also assessed. The hands of health care workers were inspected and cultured, and risk factors for P. aeruginosa colonization were evaluated. Isolates were analyzed for clonality by pulsed-field gel electrophoresis. RESULTS: Surveillance cultures showed that three additional infants were colonized with P. aeruginosa. Cultures of environmental specimens were negative, but cultures of the hands of 10 of 165 health care workers (6 percent) were positive for P. aeruginosa. Increasing age (P=0.05) and a history of the use of artificial fingernails or nail wraps (P=0.03) were both risk factors for colonization of the hands. From January 1997 to August 1998, 49 infants were infected or colonized with P. aeruginosa. Pulsed-field gel electrophoresis demonstrated that 17 of these infants and 1 health care worker who had onychomycosis had the same clone. Infants who were exposed to this health care worker in August 1998 were at greater risk of having this clone than infants who were not exposed to this health care worker (odds ratio, 41.2; 95 percent confidence interval, 1.8 to 940.0; P=0.006). CONCLUSIONS: An increased rate of infection and colonization with P. aeruginosa among infants in neonatal intensive care units should be investigated by assessing potential reservoirs, including environmental sources as well as patients and health care workers.