Prevention and treatment of nosocomial sepsis in the NICU.

Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. It is associated with an increase in mortality, morbidity, and prolonged length of hospital stay. Thus, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to describe simple changes in process, which when implemented, can reduce nosocomial infection rates in neonates and improve outcomes.     

Hospital-acquired infections in the NICU: epidemiology for the new millennium

Nosocomial infections are an important cause of morbidity and mortality in the preterm neonate. Extrinsic and intrinsic risk factors make the preterm neonate particularly susceptible to infection. This review focuses on two major pathogens that cause nosocomial infection, Candida and methicillin-resistant Staphylococcus aureus. The difficult diagnosis of meningitis in the neonate also is discussed.     

Central line-associated bloodstream infections in the NICU: Successes and controversies in the quest for zero

Central line-associated bloodstream infections (CLABSI) are among the most common healthcare-acquired infections in the neonatal intensive care unit (NICU) population and are associated with an increased risk of morbidity and mortality, as well as increased healthcare costs, and duration of hospitalization. Over the past decade, numerous local, statewide, and national quality improvement initiatives have resulted in a significant reduction in CLABSI rates. The majority of successful initiatives have utilized similar strategies to implement and sustain their efforts, including education of NICU staff in the principles of quality improvement, creation and implementation of central line insertion and maintenance bundles and methods for assessing compliance, formation of dedicated central line insertion and maintenance teams, and utilization of reliable and effective methods for collecting, analyzing, and displaying data. Despite this progress, continued work toward discovery of better practices, such as the safest and most effective agent for cutaneous antisepsis or identification of optimal outcome and process measures, is required if further progress is to be made. Additionally, sustained progress in reducing the burden of neonatal infections may require a shift in focus away from CLABSI and toward the reporting, investigation, and prevention of all NICU-onset bacteremia.     

Risk factors affecting in-hospital mortality in patients with nosocomial infections.

BACKGROUND/PURPOSE: Nosocomial infection (NI)-associated death is an important issue for both patients and clinicians, and is of emerging importance in public health. This study investigated the factors associated with in-hospital deaths among patients with NI. METHODS: Between July 1, 2002 and June 30, 2003, a total of 1574 patients with NI at National Taiwan University Hospital were enrolled to investigate the factors associated with fatal outcome. Host factors, hospital services, surgical and medical interventions, microbial factors, infection sites, and the treatment and complications of NI were analyzed retrospectively. RESULTS: During the study period, 554 of the 1574 patients died (mortality rate, 28.3%). NI was directly involved in 80.5% of them (n = 446), and over two-thirds (67.9%) of deaths occurred within 2 weeks of NI onset. Sixteen variables were statistically implicated as independent factors significantly associated with mortality. Host factors included higher disease severity (p < 0.0001), liver cirrhosis (p < 0.0001), solid tumors (p < 0.0001), chronic lung disease (p = 0.003), and congestive heart failure (p = 0.005). Hospital and interventional factors included intensive care hospitalization (p = 0.002), longer hospitalization before NI onset (p = 0.004), hemodialysis (p = 0.0003), arterial-line insertion (p < 0.0001), urinary catheterization (p < 0.0001), and central venous catheterization (p = 0.001). Blood stream infections (p < 0.0001), NI due to Candida (p < 0.0001), and multiple (> or = 2) episodes of NI (p < 0.0001) were significant risk factors for death, as were occurrence of NI-associated septic shock (p < 0.0001) and disseminated intravascular coagulation (p < 0.0001). No significant associations of mortality with age, sex, species of bacteria, multi-antibiotic resistant bacteria, regimen for initial treatment, or multiple antibiotic therapy were evident. CONCLUSION: Measures that prevent the occurrence of NI, such as improving the immunity status of the host, removal of catheters as soon as possible, and implementing an infection control program, could reduce the risk of in-hospital deaths attributable to NI.     

Reducing nosocomial infections in neonatal intensive care

Background.?Nosocomial infection is a common problem in neonatal intensive care. A pilot quality improvement initiative focussing on hand hygiene and aimed at reducing nosocomial infection in very low birth weight (VLBW) infants was introduced in five Neonatal Intensive Care Units.

Methods.?Line associated laboratory confirmed bloodstream infection (LCBSI) and ventilator associated pneumonia (VAP) were chosen as main outcome measures.

Results.?In VLBW infants, the rate of line associated LCBSI per 1000 central venous catheter days fell by 24%. The rate of VAP per 1000 ventilator days in VLBW infants fell by 38%. Pre- and post-intervention questionnaires showed a statistically significant increase in use of alcohol-based gels and increased knowledge of hand hygiene.     

Microbiological investigations on genital infections: a nosocomial experience in Palermo

The new methods for in vitro fertilization and GIFT induced the authors to carry out a retrospective survey on microbiological investigations done on 820 patients (641 women and 179 men) affected with genital infections and 62 newborns hospitalized during the period 1980-1986 to the aim of studying the prevalence of the various microorganisms responsible for sexually transmitted diseases in our area. The biological material obtained from men gave positive results less frequently than that obtained from women (p less than 0.001) although the prevalence of "significant" microorganisms isolated from the same material was overlapping for both sexes (p greater than 0.5). Chlamydia trachomatis positive samples were rare in men (6.1%) as well as in women (4.2%); in one case C. trachomatis was contemporaneously observed in the auricular swab of a newborn and from the cervical swab of the mother. Herpes Simplex virus positive samples were observed in 4 (11.8%) out of 36 women only. This study confirms the usefulness of the microbiological investigation before undertaking attempts for in vitro fertilization.     

Life or death decisions in the NICU.

When, if ever, should we allow an extremely premature baby to die? The paper explains how that would be answered if we are guided by three reasonable assumptions. (1) The value a person's life has is primarily the value it has for that person, rather than a value it has in itself. (2) All competent persons have a right to decide for themselves whether their lives are to be prolonged. (3) Parents have a right to treat their children as they choose, so long as they neither abuse them nor neglect them.     

Reducing acquired infections in the NICU: observing and implementing meaningful differences in process between high and low acquired infection rate centers.

BACKGROUND: Acquired infection is one of the most prevalent sources of concern in neonatal intensive care units (NICUs). Center-to-center variation has been noted by both the National Nosocomial Infection Surveillance System and the Vermont Oxford Network suggesting that site of care influences outcomes including acquired infection. OBJECTIVE: To reduce the acquired infection rate by isolating and then implementing meaningful process differences between high and low infection rate centers. DESIGN/METHOD: A multistaged observation and intervention study. The primary outcome measure was defined as a positive blood culture, collected more than 3 days after birth. Hospital patient days along with infection episodes were collected for all NICU admissions in the network during the baseline and post-implementation periods. A detailed observation guide was used during site visits to high and low infection rate centers. The observations recorded in the guide allowed the team to isolate meaningful differences, which were shared with the network. Individual NICUs decided which of the meaningful differences, if any, to implement. To estimate the impact on costs, additional data were gathered in a case-matched series of infants in one demonstration site. RESULTS: In all, 15 meaningful differences were isolated and shared with the network. The network rate for acquired infection dropped from 3.8 to 2.9 episodes per 1000 patient days. In the demonstration site, the infection rate dropped from 7.4 to 4.0 per 1000 patient days. CONCLUSION: Isolation of process level differences between high and low performing centers followed by implementation of these meaningful differences may reduce acquired infections. Other targeted areas of care may benefit from this quality improvement methodology.     

Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh.

OBJECTIVE: The skin is a potential source for invasive infections in neonates from developing countries such as Bangladesh, where the level of environmental contamination is exceedingly high. A randomized controlled trial was conducted from 1998 to 2003 in the Special Care Nursery of a tertiary hospital in Bangladesh to test the effectiveness of topical emollient therapy in enhancing the skin barrier of preterm neonates less than 33 weeks of gestational age. In the initial months of the study, the infection and mortality rates were noted to be unacceptably high. Therefore, an infection control program was introduced early in the trial to reduce the rate of nosocomial infections. STUDY DESIGN: After a comprehensive review of neonatal care practices and equipment to identify sources of nosocomial infections, a simple but comprehensive infection control program was introduced that emphasized education of staff and caregivers about measures to decrease risk of contamination, particularly hand-washing, proper disposal of infectious waste, and strict asepsis during procedures, as well as prudent use of antibiotics. RESULTS: Infection control efforts resulted in declines in episodes of suspected sepsis (47%), cases of culture-proven (61%) sepsis, patients with a clinical diagnosis of sepsis (79%), and deaths with clinical (82%) or culture-proven sepsis (50%). CONCLUSION: The infection control program was shown to be a simple, low-cost, low-technology intervention to reduce substantially the incidence of septicemia and mortality in the nursery.     

Eliminating obstetric fistula: progress in partnerships.

Obstetric fistula persists in the developing world due to poor access to obstetric care. It has been overlooked in the past, as the women suffering from fistula often live on the fringe of society due to their poverty and the stigma surrounding the condition. A global Campaign to End Fistula is bringing a variety of actors together to raise awareness and support to prevent fistula and provide comprehensive treatment for women living with fistula. This paper describes the strategies and progress of the campaign since it began in 2003.     

Epidemiology of nosocomial infections in selected neonatal intensive care units in Colombia, South America.

OBJECTIVE: The epidemiology of nosocomial infections (NI) in neonatal intensive care units in developing countries has been poorly studied. We conducted a prospective study in selected neonatal units in Colombia, SA, to describe the incidence rate, causative organisms, and interinstitutional differences. STUDY DESIGN: Data were collected prospectively from February 20 to August 30, 2001 from eight neonatal units. NI was defined as culture-proven infection diagnosed after 72 h of hospitalization, resulting in treatment with antibiotics for >3 days. Linear regression models were used to describe associations between institutional variables and NI rates. RESULTS: A total of 1504 infants were hospitalized for more than 72 h, and therefore, at risk for NI. Of all, 127 infections were reported among 80 patients (5.3%). The incidence density rate was 6.2 per 1000 patient-days. Bloodstream infections accounted for 78% of NIs. Gram-negative organisms predominated over gram-positive organisms (55 vs 38%) and were prevalent in infants < or =2000 g (54%). The most common pathogens were Staphylococcus epidermidis (26%) and Klebsiella pneumonia (12%). CONCLUSION: Gram-negative organisms predominate in Colombia among infants <2000 g. The emergence of gram-negative organisms and their associated risk factors requires further study.     

Unplanned Extubation in the NICU

Unplanned extubation (UE) in the neonatal intensive care unit (NICU) is a significant patient safety and quality control issue. I describe the implementation of a quality improvement program using multifactorial prevention strategies, including staff education, identification of neonates at risk for UE, extubation and weaning, standardization of procedures, and comprehensive documentation. Additional research on quality improvement with strategies for neonates may prove beneficial in reducing UE rates in neonates.     

12年早产儿院内感染的临床分析

目的　探讨早产儿发生院内感染的危险因素 ,为院内感染的监控和干预措施提供可靠的理论依据。　方法　对我科 1991年 1月～ 2 0 0 2年 12月共 12年期间住院的 94 8例早产儿及其院内感染病例进行回顾性研究总结。　结果　 94 8例早产儿中 114例发生 135次院内感染 ,发生率为9 0‰。发生院内感染者比未感染者的胎龄及出生体重均小 ,住院时间明显延长。早产儿发生院内感染的危险性相关因素为出生体重 (≤ 15 0 0g)、胎龄 (≤ 32周 )及呼吸机治疗 (P <0 .0 0 1)。以肺炎占首位 ,细菌检出率为 2 3.7% ,其中G 菌占 1/ 3,G-菌占 2 / 3。院内感染病死率为 9.6 5 %。　结论　充分了解和纠正早产儿发生院内感染的高危因素 ,强调洗手的重要性 ,合理应用抗生素 ,尽量减少侵袭性操作次数 ,缩短操作时间 ,加强消毒隔离制度和无菌原则 ,将明显减少院内感染发病率     

Risk factors for nosocomial infections in selected neonatal intensive care units in Colombia, South America.

OBJECTIVE: This study was designed to identify risk factors for nosocomial infections among infants admitted into eight neonatal intensive care units in Colombia. Knowledge of modifiable risk factors could be used to guide the design of interventions to prevent the problem. STUDY DESIGN: Data were collected prospectively from eight neonatal units. Nosocomial infection was defined as culture-proven infection diagnosed after 72 hours of hospitalization, resulting in treatment with antibiotics for >3 days. Associations were expressed as odds ratios. Logistic regression was used to adjust for potential confounders. RESULTS: From a total of 1504 eligible infants, 80 were treated for 127 episodes of nosocomial infection. Logistic regression analysis identified the combined exposure to postnatal steroids and H2-blockers, and use of oral gastric tubes for enteral nutrition as risk factors significantly associated with nosocomial infection. CONCLUSION: Nosocomial infections in Colombian neonatal intensive care units were associated with modifiable risk factors including use of postnatal steroids and H2-blockers.     

Anesthesia and analgesia in the NICU

Painful procedures in the neonatal intensive care unit are common, undertreated, and lead to adverse consequences. A stepwise approach to treatment should include pain recognition, assessment, and treatment, starting with nonpharmacologic and progressing to pharmacologic methods for increasing pain. The most common nonpharmacologic techniques include nonnutritive sucking with and without sucrose, kangaroo care, swaddling, and massage therapy. Drugs used to treat neonatal pain include the opiates, benzodiazepines, barbiturates, ketamine, propofol, acetaminophen, and local and topical anesthetics. The indications, advantages, and disadvantages of the commonly used analgesic drugs are discussed. Guidance and references for drugs and dosing for specific neonatal procedures are provided.     

Evidence-based methylxanthine use in the NICU

The introduction of methylxanthines, especially caffeine, for the treatment of apnea of prematurity has been one of the most important and effective therapies in the neonatal intensive care unit (NICU) to date. Several trials have demonstrated its effectiveness in most NICU infants. It remains a cost-effective intervention with minimal short- and long-term risks when used appropriately. Caffeine also seems to be effective for reducing the risk of bronchopulmonary dysplasia and patent ductus arteriosus, and for decreasing the need for reintubation. For the infant with apnea, currently there does not seem to be any more effective treatment, and caffeine is also more effective and safer than any other methylxanthine.     

Approaches to end-of-life decision-making in the NICU: insights from Dostoevsky's The Grand Inquisitor.

For many parents stopping life-sustaining medical treatment on their dying infant is psychologically impossible. Dostoevsky's insights into human behavior, particularly the fact that individuals do not want the anxiety and guilt associated with responsibility for making difficult decisions, might change the way physicians approach parents for permission to withdraw life-prolonging medical interventions on dying infants.     

Impact of nosocomial infections on medical costs, hospital stay, and outcome in hospitalized patients.

BACKGROUND AND PURPOSE: Nosocomial infections have been shown to be associated with increased attributable mortality, length of hospital stay, and health care costs in studies mainly conducted in western populations. However, the health care system in Taiwan differs from the typical situation in western countries, with longer hospitalization times and lower daily costs. The purpose of this study was to understand the economic and clinical impacts of nosocomial infections in Taiwan. METHODS: Between June 1, 2001 and December 31, 2001, every hospitalized patient (age >/= 16 years) with nosocomial infections (case group) and matched control patients without nosocomial infections of the same age, gender, underlying medical illness, clinical diagnosis at admission and disease severity (control group) were recruited. Demographic characteristics, length of hospitalization, costs and final outcomes of both groups were collected for analysis. RESULTS: A total of 482 patient-pairs with median age of 68 years were studied. The median length of hospital stay was 40 days for the case group and 22 days for the control group (p < 0.0001). The median hospital cost for the case group was 363,425 New Taiwan Dollars (NTD) and 165,965 NTD for the control group (p < 0.0001). The median additional hospital stay for patients with nosocomial infection was 15 days, which amounted to 127,354 NTD. The extra hospital costs were not only associated with accommodation but also fees for materials, and costs relating to pharmacy, laboratory tests and diet. Patients with nosocomial infections were more likely to have shock, organ failure and death (all p < 0.0001). Additional hospital stay and costs were not related to various infection sites and bacterial pathogens causing nosocomial infections; however, medical costs attributable to nosocomial fungal infection were higher than that of bacterial infections. CONCLUSIONS: Nosocomial infections have a significant impact on the length of hospital stay and medical care cost. Extra costs of nosocomial infections resulted not only from prolongation of hospital stay, but also other medical costs. Infection control for preventing nosocomial infections may play an important role in reducing medical costs, hospital stay, and mortality in hospitalized patients.