Improving survival of vulnerable infants increases neonatal intensive care unit nosocomial infection rate

OBJECTIVE: To determine the factors associated with an increasing rate of nosocomial infections in infants with very low birth weights. METHODS: Retrospective review of clinical and nosocomial infection databases for all infants with birth weights of 1500 g or less admitted to an academic neonatal intensive care unit between January 1, 1991, and December 31, 1997 (N = 1184). Two study periods were compared: 1991-1995 and 1996-1997. RESULTS: Among the 1085 infants who survived beyond 48 hours, the proportion who developed nosocomial infections increased from 22% to 31% (P =.001) and the infection rate increased from 0.5 to 0.8 per 100 patient-days (P<.001) during the period from 1996 to 1997. In that same period, the median duration of indwelling vascular access increased from 10 to 16 days (P<.001), and the median duration of mechanical ventilation increased from 7 to 12 days (P<.001). Although the device-specific rate of bloodstream or respiratory infections did not change, the increase in infections was directly attributable to the increasing proportion of infants who required these devices. In both study periods, the peak incidence of initial infection occurred between 10 and 20 days of age. For the entire sample, proportional hazard models identified birth weight, duration of vascular access, and postnatal corticosteroid exposure as significant contributors to the risk of infection. CONCLUSIONS: The increasing number of technology-dependent infants was the primary determinant in the increase of nosocomial infections. Because these infections occur in a small proportion of infants, understanding the host factors that contribute to this vulnerability is necessary to decrease nosocomial infections in neonatal intensive care units.     

Nosocomial bacterial infections in very low birth weight infants

The occurrence of congenital and nosocomial bacterial septicaemia has been documented by identifying the number of positive blood cultures by reviewing the laboratory and clinical records of 394 very low birth weight infants who were consecutively admitted to a neonatal intensive care unit over a 40-month period. The incidence of congenital septicaemia was 6% and of nosocomial septicaemia 17%. The commonest causes of congenital infection wereStreptococcus agalactiae Staphylococcus epidermidis andEnterococcus faecalis (each in 18% of cases). The commonest cause of nosocomial infection wasS. epidermidis (51% of cases), except in infants of birth weight less than 750 g. Risk factors for nosocomial infection were extremely low birth weight, very preterm birth and prolonged ventilation. Nosocomial infection was associated with significantly lengthened hospital admission.     

新生儿危重病例评分与临床危险指数评分预测极低出生体重儿死亡风险的比较

目的探讨新生儿危重病例评分(NCIS)与新生儿临床危险指数(CRIB)评分对极低出生体重儿死亡风险评估的价值。方法对93例早产儿按不同胎龄、体重分组进行NCIS,其中42例胎龄<31周或出生体重<1.5kg者再进行CRIB评分,将两种评分结果进行比较。结果①胎龄越小、体重越轻,疾病危重评分分值越低,胎龄<31周或出生体重<1.5kg者明显低于≥31周或出生体重≥1.5kg者,其差异有显著性(P均<0.05雪;②死亡病例NCIS明显低于非死亡病例,CRIB评分明显高于非死亡病例,差异有显著性(P均<0.05雪;③NCIS与新生儿CRIB评分两者间呈负相关,r=-0.383,P<0.01。结论NCIS与CRIB评分均可较好地判断极低出生体重儿的疾病危重度,预测死亡风险,且两者相关性好。     

需要机械通气的极低出生体重儿院内病死率及病死风险因素的前瞻性研究

目的：描述危重极低出生体重儿（VLBWI）的临床特征、接受治疗状况及其转归,评估其病死风险相关因素,评价CRIB、SNAPPE-II评分系统预测我国早产儿病死风险的价值。方法：对2010年1月至2011年10月间新生儿重症监护室（NICU）收治的127例需要机械通气的VLBWI进行前瞻性数据收集。结果：纳入患儿平均胎龄为31±2 周,平均体重为1290±170 g,男女比例为1.23∶1,超低出生体重儿占6.3%。接受肺表面活性剂（PS）治疗者占 48.0%;接受气管插管机械通气的患儿占49.6%。总的院内病死率为41.7%。低出生体重、多胎分娩、剖宫产、低PaO2/FiO2比值是病死的独立风险因素,OR值分别为1.611、7.572、4.062、0.133,P<0.05。SNAPPE-II和CRIB评分系统可较好地预测病死转归,ROC曲线下面积分别为0.806、0.777。结论：VLBWI总的病死率仍处于较高水平;低出生体重、多胎分娩、剖宫产、低PaO2/FiO2比值是VLBWI病死的高危因素。应用新生儿危重评分系统可对研究对象疾病危重程度进行量化。     

The use of CRIB (clinical risk index for babies) score in auditing the performance of one neonatal intensive care unit

The CRIB (clinical risk index of babies) score was developed to overcome the disadvantages of birthweight-specific comparisons between neonatal units. The aims of this study were to assess the ability of CRIB score compared to birthweight and gestational age to predict hospital mortality in very low birthweight infants and to use CRIB score in auditing one unit's performance during a prolonged time period. The charts of 335 infants with birthweight ≤ 1500 g born between 1980 and 1995 were reviewed retrospectively. CRIB predicted hospital mortality significantly better than birthweight and gestation and performed equally well, whether the infants were treated with synthetic surfactant or not. When adjusting for CRIB score there was a significant improvement in the unit's performance, probably owing to the introduction of surfactant. As small samples tend to be associated with wide confidence intervals, use of CRIB is recommended in comparing risk adjusted mortality in a single unit over several years, as in this study, or between large groups of neonatal units over shorter periods.     

Early-onset bacterial infection in Brazilian neonates with respiratory distress: a hospital-based study

We investigated infants with respiratory distress within 4 days of birth whose mothers had not received antibiotic prophylaxis to evaluate the frequency and etiology of bacterial infection and associated risk factors. The study was conducted on 261 infants suffering respiratory distress admitted to a Brazilian neonatal intensive care unit, 94 per cent of whom were born prematurely. Gestational and delivery history; bacteriological cultures of blood, cerebrospinal fluid, tracheal aspirates and urine; complete and differential blood counts; a urinary group B streptococcal latex antigen test; and a chest radiograph were analysed. Indications of infection were found in 38.7 per cent and confirmed in 11.9 per cent of the neonates. Gram-positive (70.9 per cent) and gram-negative bacteria (29.1 per cent) were found in 31 cases of confirmed early bacteremia. Group B Streptococcus was the predominant causative agent (19.4 per cent) in infants exhibiting confirmed infection. Culture-proven infection was more frequent among infants delivered vaginally (adjusted OR = 2.53, p = 0.05) or born to mothers with signs of intra-amniotic infection (adjusted OR = 2.83, p = 0.04). Preventive measures against early bacterial infection in preterm infants from this population are strongly warranted.     

早产儿医院感染危险因素临床分析

目的探讨早产儿医院感染发病的危险因素。方法回顾性分析2009—2012年本院新生儿科收治的早产儿病例资料,选择生后24 h内入院、住院时间>48 h、除外产前细菌感染史的病例,按照是否发生医院感染分为感染组与非感染组,将胎龄<32周、出生体重<1500 g等13项因素视为可疑危险因素,应用卡方检验及多因素非条件逐步Logistic回归分析明确早产儿医院感染的独立危险因素。结果共纳入588例早产儿,感染组259例,非感染组329例,单因素分析结果显示,胎龄<32周,出生体重<1500 g,开奶日龄>5天、机械通气、经外周中心静脉置管、动脉置管、住院时间>2周、预防性应用抗生素8项因素与医院感染相关;进一步Logistic多因素回归分析显示,胎龄<32周(OR=1.731,95%CI 1.054~2.875)、出生体重<1500 g(OR=1.843,95%CI1.052~3.286)及住院时间大于2周(OR=6.445,95%CI 3.883~10.694)为早产儿医院感染的独立危险因素。结论早产儿胎龄越小、出生体重越低、住院时间越长,越易发生医院感染;预防早产儿医院感染的有效措施为加强产前保健,从根本上减少早产儿及低出生体重儿的出生。     

早产儿医院感染目标性监测结果及危险因素分析

目的 分析早产儿医院感染现状、特征及相关危险因素。方法 温州市儿童医院新生儿科2011年1月至2012年12月开展医院感染目标性监测,将入住时间〉48 h的早产儿医院感染情况进行分析,并分析其高危因素。结果 研究期间共纳入早产儿563例,总住院日6310天,51例发生医院感染,共61例次,感染率9.1%,8.1例次/1000住院日。呼吸机相关性肺炎感染率17.2%,37.3例/1000呼吸机使用日;脐静脉、外周中心静脉置管血管相关性感染率12.5%,8.7例/1000导管日。早产儿医院感染病原菌主要为革兰阴性菌,占68.0%,其中肺炎克雷伯菌占24.0%,革兰阳性菌占20.0%,真菌占12.0%。多因素Logistic回归分析显示,胎龄小（OR=1.079,95%CI 1.025~1.136）、极低出生体重（OR=1.053,95%CI 1.038~1.069）、机械通气治疗（OR=4.850,95%CI 3.035~7.751）、胃肠外营养时间（OR=3.180,95%CI 2.058~4.915）、中心静脉置管（OR=4.509,95%CI 2.275~8.935）是早产儿发生医院感染的高危因素。结论 早产儿发生医院感染率较高,存在诸多医院感染易感因素,目标监测对采取防控措施有指导意义。     

Variations in central venous catheter-related infection risks among Canadian neonatal intensive care units

BACKGROUND: The objective of this study was to examine central venous catheter (CVC)-related nosocomial blood stream infection risks of umbilical venous, percutaneous and Broviac catheters, as well as variations in CVC use and CVC-related risk for nosocomial blood stream infection in the neonatal intensive care unit (NICU). METHODS: A cohort study was performed based on 19,507 infants admitted to 17 NICUs in the Canadian Neonatal Network from January, 1996, through October, 1997. Information on these subjects was prospectively collected by trained abstractors. Incidence of infection was measured as infection episodes per 1000 patient days. The risk ratio (RR) of CVC use for nosocomial blood stream infection was calculated as the infection rate during catheter days divided by the infection rate during noncatheter days. Using a Poisson regression model we examined the adjusted RR of CVC use for nosocomial blood stream infection, controlling for patient characteristics and illness severity at admission. Interinstitutional variations in CVC-related infection risks were examined by stratified analyses. RESULTS: CVC were used in 22.5% of patients. The incidence of nosocomial blood stream infection was 2.9 per 1000 noncatheter days, 7.2 per 1000 umbilical venous catheter days, 13.1 per 1000 percutaneous catheter days and 12.1 per 1000 Broviac catheter days. The RR for nosocomial blood stream infection, adjusted for differences in patient characteristics and admission illness severity, was 2.5 for umbilical venous catheter, 4.6 for percutaneous catheter and 4.3 for Broviac catheter (P < 0.05). There were significant (P < 0.05) risk-adjusted variations in CVC-related infection risks among NICUs. CONCLUSIONS: CVC use increased the risk of nosocomial blood stream infection. The risk of nosocomial blood stream infection in percutaneous and Broviac catheters was 70 to 80% higher than in umbilical venous catheters. There was significant variation in CVC-related infection risks among Canadian NICUs.     

Bacteraemia and antibiotic use in respiratory syncytial virus infections

Aims: To examine the frequency of and risk factors for bacteraemia in children hospitalised with respiratory syncytial virus (RSV) infection; and to determine current use of antibiotics in hospitalised children with RSV infection. Methods: Retrospective study of all children, aged 0–14 years, admitted to a tertiary children''s hospital with proven RSV infection over a four year period. Children with concurrent bacteraemia and RSV infection were identified, and risk factors examined for bacteraemia. The case notes of a randomly selected comparison sample of 100 of these RSV infected children were examined to assess antibiotic use and population incidence of risk factors for severe RSV infection. Results: A total of 1795 children had proven RSV infection, and blood cultures were sent on 861 (48%). Eleven (0.6%) of the 1795 RSV positive children had bacteraemia. RSV positive children had a significantly higher incidence of bacteraemia if they had nosocomial RSV infection (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the paediatric intensive care unit (2.9%). Forty five (45%) of the random comparison sample of RSV infected children received antibiotics. Conclusions: Bacteraemia is rare in RSV infection. Children with RSV infection are more likely to be bacteraemic, however, if they have nosocomial RSV infection, cyanotic congenital heart disease, or require intensive care unit admission.     

Bacteraemia and antibiotic use in respiratory syncytial virus infections.

AIMS: To examine the frequency of and risk factors for bacteraemia in children hospitalised with respiratory syncytial virus (RSV) infection; and to determine current use of antibiotics in hospitalised children with RSV infection. METHODS: Retrospective study of all children, aged 0-14 years, admitted to a tertiary children's hospital with proven RSV infection over a four year period. Children with concurrent bacteraemia and RSV infection were identified, and risk factors examined for bacteraemia. The case notes of a randomly selected comparison sample of 100 of these RSV infected children were examined to assess antibiotic use and population incidence of risk factors for severe RSV infection. RESULTS: A total of 1795 children had proven RSV infection, and blood cultures were sent on 861 (48%). Eleven (0.6%) of the 1795 RSV positive children had bacteraemia. RSV positive children had a significantly higher incidence of bacteraemia if they had nosocomial RSV infection (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the paediatric intensive care unit (2.9%). Forty five (45%) of the random comparison sample of RSV infected children received antibiotics. CONCLUSIONS: Bacteraemia is rare in RSV infection. Children with RSV infection are more likely to be bacteraemic, however, if they have nosocomial RSV infection, cyanotic congenital heart disease, or require intensive care unit admission.     

Neonatal neutropenia associated with maternal hypertension poses a risk for nosocomial infection

One hundred and six neonates of 24–32 weeks gestation born to hypertensive mothers and 106 concurrent control infants of normotensive mothers were evaluated to determine the relationship between maternal hypertension and neonatal neutropenia and the risk of nosocomial infection developing in neutropenic infants.. Complete blood counts were performed on both cohorts and retrospectively evaluated. Neutropenia was diagnosed using published reference ranges for infants with birth weight ≤1500 g and >1500 g. Evidence of nosocomial infection based on a positive blood culture with supportive clinical signs of sepsis was documented. The incidence of neutropenia among infants of hypertensive mothers was not significantly different from that among infants of normotensive mothers (21% vs 24%), but the duration of neutropenia was significantly longer in the infants of hypertensive mothers (P = 0.0001). Nosocomial infection was more frequent in neutropenic than the non-neutropenic hypertensive mothers' infants (55% vs 12%, P = 0.0002). Conclusion Although there is no difference in the incidence of neonatal neutropenia between infants of hypertensive mothers and those of normotensive mothers, the former group has an increased risk of nosocomial infection in neutropenic infants of hypertensive mothers. This may be related to prolonged neutropenia which was found in these infants in the present study. Received: 24 August 1997 and in revised form: 30 March 1998 / Accepted: 1 April 1998     

Histologic chorioamnionitis and severity of illness in very low birth weight newborns.

OBJECTIVE: Estimating the risk of in-hospital mortality in the neonatal intensive care unit provides important information for health care providers, and several neonatal illness severity scores have been developed. Histologic chorioamnionitis (HCA) is a known cause of neonatal morbidity and mortality. To date, the relationship between HCA and neonatal illness severity scores has not been rigorously tested. In this study, the relationships among HCA, initial illness severity, and neonatal outcomes were analyzed in very low birth weight (VLBW) newborns admitted to the neonatal intensive care unit. DESIGN: Prospective. SETTING: Neonatal intensive care unit. PATIENTS: A total of 116 VLBW inborn infants (gestational age, 28.1 +/- 2.82 wks; birth weight, 1009 +/- 312 g) were categorized as HCA-positive (n = 67) and HCA-negative (n = 49). INTERVENTIONS: Placental histology was performed to identify HCA. Illness severity evaluation included several different neonatal illness severity scores-Clinical Risk Index for Babies (CRIB), CRIB-II, Score for Neonatal Acute Physiology-II (SNAP-II), and Score for Neonatal Acute Physiology Perinatal Extension-II (SNAPPE-II)-as well as the recording of severe morbidity and in-hospital mortality. MEASUREMENTS AND MAIN RESULTS: HCA-positive VLBW newborns showed significantly lower gestational age (p < .0001) and birth weight (p = .0010), together with higher CRIB, CRIB-II, SNAP-II, and SNAPPE-II scores at admission to the NICU (p 5 (odds ratio [OR], 21.37; 95% confidence interval [CI], 6.24-73.21); CRIB-II > 10 (OR, 56.17; 95% CI, 6.75-467.2); SNAP-II > 22 (OR, 43.05; 95% CI, 11.9-155.7), and SNAPPE-II > 42 (OR, 48.95; 95% CI, 10.18-235.4) (all p values <.0001). CONCLUSIONS: Our findings indicate that HCA is a major predictor of morbidity and mortality in VLBW newborns.     

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??Abstract??Objective??To explore the perinatal risk factors and clinical features of nosocomial neonatal sepsis in very-low-birth-weight??VLBW ??infants. Methods??Twenty-nine VLBW infants with nosocomial sepsis and 108 VLBW infants with non-sepsis born in hospital from January 2005 to June 2008 composed the study population. Their maternal?? perinatal??or postnatal variables were retrospectively analyzed. SPSS11.0 software was used to do statistical tests and multiple logistic regression. Results??Among 137 VLBW infants ??twenty-nine were nosocomial neonatal sepsis ??21.16% ??29/137??. The mortality rate was 13.79%??4/29????The incidence of nosocomial sepsis was increased with the gestational age and birth weight decreased. Gram-negative bacteria accounted for 70% of microbes?? Klebsiella pneumoniae and Escherichia coli were the most common bacterial pathogen causing nosocomial infection?? mainly extended spectrum betalactamase producing enterobacteriaceae ??ESBLs??. Birth weight≤1000g was the most impotant risk predictor of nosocomial neonatal sepsis??incidence of NBSIs was 75%??6/8????OR 7.56??4.35??14.24??. The risk factors were in the order of percutaneously inserted central catheter ??PICC???? anaemia??necrotizing enterocolitis??NEC?? and apnea . Conclusion??Nosocomial neonatal sepsis is a common problem and the main cause of late-onset death among very-low- birth-weight ??VLBW?? infants. This nosocomial infection should be lowered by active management.     

新生儿重症监护室医院内感染的调查

目的：对我院新生儿重症监护室（NICU）医院内感染（简称院感）进行前瞻性研究,分析其危险因素,以指导临床防治,降低NICU院感发生率。方法：2006年2月至2007年1月收入我院NICU住院时间48 h以上的患儿为研究对象,收集其相关资料,计算院感发生率,多因素回归分析调查其危险因素。结果：入选患儿共计1 159例,院感发生共计169例次,发生率为14.58％,日感染率为19.52‰,肺部感染率为7.94％,居首位,其中呼吸机相关性肺炎(VAP)发病率为每1 000个呼吸机使用日48.8;院感致病菌主要为鲍氏不动杆菌、肺炎克雷伯杆菌、凝固酶阴性葡萄球菌、绿脓杆菌。多因素回归分析显示低出生体重（OR 2.130, 95% CI 1.466~3.094 ）、机械通气（OR 7.038,95% CI 3.901~12.698）、胸腔闭式引流(OR 7.004, 95% CI 1.841~26.653 )及布洛芬治疗(OR 2.907, 95% CI 1.303~6.487)是NICU内院感发生的危险因素。结论：肺部感染是我院NICU 最常见的院感;革兰阴性细菌是院感常见病原菌;低出生体重、机械通气、胸腔闭式引流、布洛芬治疗是NICU内院感的独立危险因素。［中国当代儿科杂志,2010,12（2）：81-84］     

Outcomes of very low birth weight infants in a newborn tertiary center in Turkey, 1997-2000

Our purpose was to determine mortality and morbidity rates and selected outcome variables for infants weighing less than 1500 g, who were admitted to the neonatal intensive care unit of our hospital from 1997 to 2000. The ultimate goal of the study was to define a model for developing a regional database. Information on all very low birth weight (VLBW) admissions to a tertiary level neonatal intensive care unit (NICU) in Ankara between January 1997 and December 2000 was prospectively collected by three neonatologists using a standard manual of operation and definitions. The data consisted of patient information including sociodemographic characteristics; antenatal history; mode of delivery; APGAR scores; need for resuscitation; admission illness severity (Clinical Risk Index for Babies-CRIB) and therapeutic intensity (Neonatal Therapeutic Intensity Scoring System-NTISS); selected NICU parameters and procedures such as respiratory support, surfactant therapy, and postnatal corticosteroid therapy; and selected patient outcomes such as intraventricular hemorrhage, septicemia, necrotizing enterecolitis, retinopathy of prematurity, and chronic lung disease. The number of VLBW admissions to the NICU was 133, with 51 (28.6%) referrals from other maternity centers. The mean birth weight and gestational age of the infants were 1175 +/- 252 g and 30.3 +/- 2.9 weeks, respectively. One hundred and seventeen of 133 cases (88.7%) received at least one antenatal care visit. The median CRIB and NTISS scores were 4.5 and 31, respectively. Antenatal steroids had been given to 74 (55.6%) infants. Surfactant treatment and respiratory support were given to 33 (24.8%) and 73 (54.8%) infants, respectively. Among selected outcomes, chronic lung disease (CLD), threshold retinopathy of prematurity (ROP), severe intraventricular hemorrhage (IVH > or = grade III), nosocomial infection and necrotizing enterocolitis (NEC) were encountered in 14 (12.6%), 9 (8.1%), 3 (2.2%), 34 (25.5%) and 35 (26.3%) of the infants, respectively. Overall survival rate was 83.5% (111/133); most of the deceased cases were under 750 g (12/22). It was prospectively shown that 111 (100%) of the surviving infants could be regularly followed in a newborn follow-up clinic to provide health maintenance, developmental assessment and support. Compared with reports from other developing countries, VLBW infants at our center had higher survival rates. Compared to developed countries, survival rate was lower, especially for extremely very low birth weight infants. There is interaction between birth weight and survival rate. Among selected neonatal outcomes, chronic lung disease, threshold retinopathy, severe intraventricular hemorrhage (IVH > or = grade III) and nosocomial infection rates at this center were comparable with some reports from developed nations.     

Effect of maternal hypertension on neonatal neutropenia and risk of nosocomial infection.

Neonatal neutropenia occurs in approximately 50% of newborns delivered by women with pregnancy-induced hypertension. It is thought to be transient, independent of birth weight and gestational age, and unassociated with significant risks, including infection. It recently was suggested that neonatal neutropenia occurs primarily in smaller, younger neonates, is related to the severity of pregnancy-induced hypertension, and importantly, may be associated with an increased risk for nosocomial infection. We examined these points in a large inborn population in consecutive years, performing retrospective (n = 110, 1989) and prospective (n = 151, 1990) studies in low birth weight (less than or equal to 2200 g) neonates delivered by women with pregnancy-induced hypertension. Overall, 40% to 50% of neonates studied developed neonatal neutropenia, and they were younger and smaller (P less than .01) than non-neutropenic neonates. In the prospective study, neutropenic neonates were more likely to have mothers with severe pregnancy-induced hypertension (P less than .001), and the incidence of neonatal neutropenia was primarily among neonates less than 30 weeks of gestation and less than 1500 g birth weight, approximately 80% vs 35% to 45% in older, larger neonates or infants (P less than .001). Although nosocomial infection occurred more frequently among the group of neutropenic neonates in the prospective study (P less than .02), the incidence was similar to that in matched non-neutropenic controls delivered of normotensive women. Thrombocytopenia (less than 100,000/mm3) was not more frequent in neutropenic neonates.(ABSTRACT TRUNCATED AT 250 WORDS)     

The clinical risk index of babies (CRIB) score in India

OBJECTIVE: To assess the usefulness of clinical risk index of babies (CRIB score) in predicting neonatal mortality in extremely preterm neonates, compared to birth weight and gestation. METHODS: 97 preterm neonates with gestational age less than 31 weeks or birth weight less than or equal to 1500 g were enrolled for the prospective longitudinal study. Relevant neonatal data was recorded. Blood gas analysis results and the maximum and the minimum FiO2 required by babies in first 12 hours of life were noted. Mortality was taken as death while the baby was in nursery. The prediction of mortality by birth weight, gestational age and CRIB score was done using the Logistic model, and expressed as area under the ROC curve. RESULTS: The area under the ROC curve for birth weight, gestational age and CRIB score was almost the same, the areas being 0.829, 0.819 and 0.823 respectively. Hence CRIB score did not fare better than birth weight and gestational age in predicting neonatal mortality. CONCLUSION: The CRIB score did not improve on the ability of birth weight and gestational age to predict neonatal mortality in the study.     

In-hospital mortality of newborn infants born before 33 weeks of gestation depends on the initial level of neonatal care: the EPIPAGE study

AIM: To determine the relation between the level of initial neonatal care and in-hospital mortality of infants born before 33 wk of gestation in the era of surfactant therapy. METHODS: A 1 y prospective population-based survey was conducted in the north of France, as part of the EPIPAGE (Epidemiologie des Petits Ages Gestationnels) survey. Perinatal data were recorded for 585 very premature newborns transferred to a neonatal intensive care unit in 1997. The relation between the level of the neonatal unit that provided care for the first consecutive 48 h and in-hospital mortality was assessed by multivariate logistic regression, and adjusted for perinatal data and initial disease severity, estimated by the Clinical Risk Index for Babies (CRIB). RESULTS: The average gestational age (mean +/- SD) was 31.6 +/- 0.62 wk in level I, 30.7 +/- 0.21 in level II, 29.9 +/- 0.13 in non-teaching level III, and 29.0 +/- 0.15 in the level III teaching unit (p < 0.0001). The mean in-hospital mortality rate was 8.4% and did not differ by level of care (p(trend) = 0.17). After adjustment for perinatal data and CRIB, however, with the teaching unit as the reference, the risk of death was significantly higher in level I-II units [adjusted odds ratio (ORa) = 7.9, 95% confidence interval (95% CI) 2.2-29.1], but not in the non-teaching level III units (ORa = 0.8, 95% CI 0.3-2.1). CONCLUSION: In-hospital mortality in non-teaching level III units was similar to that in a teaching unit, but significantly higher in level I-level II units. Neonatal care of newborns delivered before 33 wk of gestation should initially occur in level III units.     

Illness severity measured by CRIB score: a product of changes in perinatal care?

AIM—To determine the perinatal factors associated with initial illness severity (measured by the CRIB (clinical risk index for babies) score) and its relation to survival to discharge.
METHODS—A retrospective study was made of intensive care nursing records on 380 inborn babies, of less than 31 weeks gestation or 1501 g birthweight, admitted to one unit between 1984-6 and 1991-4.
RESULTS—Between the two time periods mean initial illness severity score increased significantly from 2.8 to 3.9. This was the result of an increase in the maximum appropriate inspired oxygen concentration in the first 12 hours. Risk adjusted survival did not improve over time after accounting for gestation but was significantly greater after accounting for CRIB score. Illness severity score was also significantly inversely associated with gestation and 1 and 5 minute Apgar scores, using multiple regression analysis. Between the two time periods there was also a 92% increase in the admission rate of babies under 31 weeks gestation, higher median 1 and 5 minute Apgar scores (6 vs 5 and 9 vs 8, respectively), more multiple births, and more caesarean section deliveries.
CONCLUSIONS—The increase in illness severity score and admission rate may reflect changes in obstetric practice. The increase in illness severity score may also reflect changes in early neonatal care. However, after adjusting for CRIB score, risk adjusted mortality fell significantly, suggesting that neonatal care 12 hours from birth onwards had improved with time.