Enterobacter aerogenes outbreak in a neonatal intensive care unit

BACKGROUND: Enterobacter aerogenes, a Gram-negative bacterium, is an important, although infrequent, cause of nosocomial bacteremia in the hospitalized pediatric and neonatal population. Enterobacter aerogenes was isolated for the first time in our neonatal intensive care unit (NICU) from blood culture of a 5-day-old neonate; 12 more cases were discovered in the next 70 days. The present report summarizes the clinico-bacteriological spectrum and outcome of the affected neonates. Efforts made to find the source of infection and curb the outbreak are also presented. METHODS AND RESULTS: Thirteen newborns, including seven preterms, acquired E. aerogenes septicemia. Perinatal risk factors were present in all the neonates. The mean birthweight of affected infants was 1880 +/- 540 g. Symptoms appeared at a mean age of 3.5 +/- 1.5 days (range 3-8 days). The clinical presentation was indistinguishable from septicemia caused by other Gram-negative organisms. Complications encountered included sclerema, bleeding diathesis, meningitis and shock. The organism, isolated from blood in all and from the cerebrospinal fluid in two cases, was found to be resistant to all antibiotics in the first five cases, but turned sensitive to gentamicin, cefotaxime and amikacin during the latter half of the epidemic. The bacterium in the last case (no. 13) was again found to be resistant to all the antibiotics. Overall mortality was 46.2%; the mean interval between onset of symptoms and death being 2.3 +/- 1.8 days. The organism was traced to the rubber pipe attached to a foot-operated suction machine in the NICU. The neonatal unit was temporarily closed, fumigated and reopened with strict instructions to follow proper hand washing protocol and ensure cohort nursing of infected infants. CONCLUSIONS: Enterobacter aerogenes is capable of causing nosocomial outbreaks of septicemia in NICU. Low birthweight infants with associated perinatal risk factors appear to be predisposed. The sensitivity patterns of the isolates highlight the capability of E. aerogenes to acquire or lose resistance to antibiotics rapidly during treatment. A high mortality rate coupled with a short interval between onset of symptoms and death, suggested high virulence of the strain.     

An echovirus type 18 outbreak in a neonatal intensive care unit

We describe an outbreak of echovirus type 18 infection involving 20 neonatal intensive care unit (NICU) patients and the results of virological investigations are presented. RT-PCR demonstrated a widespread transmission of the virus in NICU patients during the outbreak. Separation care and additional infection control measures seemed to be effective in preventing further spread of the virus.     

Parainfluenza virus type 3 outbreak in a neonatal intensive care unit

Parainfluenza virus (PIV) is a respiratory pathogen in young children and is second only to the respiratory syncytial virus (RSV) as a cause of lower respiratory tract infection. PIV type 3 (PIV3) is the most severe. Herein we describe an outbreak of PIV3 in three infants in a neonatal intensive care unit. They were diagnosed on virus culture from pharyngeal swabs. We prevented the spread of the virus using standard infection control procedures and isolation of the symptomatic infants. One infant had severe chronic lung disease and was complicated with recurrent wheezing for a long time. Because RSV and PIV have many structural, pathogenic, epidemiologic, and clinical similarities, we speculate that PIV infection causes recurrent wheezing, as observed with RSV infection. Therefore, physicians must consider recurrent wheezing at the time of treatment of PIV infection early in life.     

Nosocomial hepatitis A infection in a paediatric intensive care unit.

Seven members of staff in a paediatric intensive care unit and two of their relatives developed hepatitis A over a period of five days. A 13 year old boy who was incontinent of faeces prior to his death, was presumed to be the source of infection. Two hundred and sixty seven other members of staff underwent serological testing and were given prophylactic pooled gamma globulin. Twenty three per cent were immune before exposure. Of people born in the United States, those at highest risk of developing the disease are physicians, dentists, nurses and those under the age of 40. Of those born outside the United States, being white and under the age of 30 are the two main risk factors. Data from a questionnaire sent to 19 nurses at risk (six cases, 13 controls) suggested that sharing food with patients or their families, drinking coffee, sharing cigarettes and eating in the nurses'' office in the intensive care unit were associated with an increased incidence of hepatitis. Nurses with three or four of these habits were at particular risk. The costs of screening and prophylaxis were US $64.72 per employee, while prophylaxis alone would have cost US $8.42 per employee. Assessing risk factors on the one hand and costs of prophylaxis on the other are important elements in the control of nosocomial infections.     

An outbreak of human rhinovirus species C infections in a neonatal intensive care unit

We describe an outbreak of human rhinovirus type C infection in 7 infants in our neonatal/pediatric intensive care unit. Five infants had clinically significant apneic episodes and 5 required increased oxygen or ventilatory support. Infants shed virus detectable by polymerase chain reaction for a median of 4 weeks.     

Referrals to a regional neonatal intensive care unit.

Over a three year period 444 requests for the neonatal transfer of babies with acute medical problems were received at this regional neonatal medical unit. Despite an increase in available resources in the North Western Health Region the provision of intensive care remained inadequate with 38% of requests declined, and babies had to be referred elsewhere including to neighbouring health regions. The survival of those babies who had to remain at the hospital of birth (49%) was significantly lower than for those transferred to the regional centre (71%). Those babies declined admission had significantly lower gestational ages and birth weights than those accepted. For those babies with respiratory failure and birth weights of less than 1500 g within these two groups, however, there were no significant differences in birth weight, gestational age, or gender yet survival was significantly better for those transferred. Babies from multiple pregnancies caused particular problems if neonatal transfer was required.     

Visitation to a neonatal intensive care unit

Preterm newborns may experience extended periods of hospitalization which disrupt the normal early contact between the newborn and its family. Variations in the frequency of visits to 164 preterm neonates in a neonatal intensive care unit were examined in relation to infant and family status variables and compliance with follow-up appointments at 3 months postterm. The mean number of visitors decreased from day 2 to day 12 of hospitalization and then remained stable through day 21. There was a corresponding increase in the number of days with no visitors through day 12, and then stabilization. Neonates who had intraventricular hemorrhages, whose parents did not live together, and who were not firstborn had the most days with no visitors. While the mother was hospitalized herself, her condition was the only variable related to percentage of no-visitor days. The sicker the mother, the more likely the newborn had no visitors. The greater the number of days with no visitors, the poorer the likelihood that the infant was brought to a 3-month follow-up clinic appointment.     

Medical and economic impact of a respiratory syncytial virus outbreak in a neonatal intensive care unit

BACKGROUND: Respiratory syncytial virus (RSV) causes frequent nosocomial outbreaks in general pediatric wards but is less commonly reported in neonatal intensive care units (NICUs). We investigated an outbreak of RSV infection in a NICU and its impact on health care delivery, outcomes and costs. METHODS: Retrospective chart review was performed after an RSV outbreak occurred in the NICU. A case was defined as an infant with a nasopharyngeal aspirate positive for RSV by viral culture. Nucleotide sequencing of the isolates was done to determine relatedness. Hospital bills for all RSV culture-positive infants were reviewed. RESULTS: Nine infants (mean age, 34 days; mean birth weight, 1757 g; and mean estimated gestational age 31 weeks and 5 days) were infected with RSV subgroup B during this outbreak. By nucleotide sequencing, the isolates were identical. Clinical manifestations included cough, congestion, increased oxygen requirement, apnea and respiratory failure. The 5 infants requiring intubation had a significantly lower mean birth weight (1301 g versus 2328 g, P = 0.027), mean estimated gestational age (28 weeks and 5 days versus 35 weeks and 2 days, P = 0.014) and mean weight at onset of symptoms (2093 g versus 2989 g, P = 0.049) than the 4 nonintubated infants. More than 1.15 million dollars in hospital charges were attributable to the outbreak. All infants survived. CONCLUSION: Infants in a NICU who develop cough, congestion or apnea should be tested for RSV and other common respiratory viruses during the winter respiratory season. Even in a closed NICU, nosocomial outbreaks of these viruses can occur and have a major effect on healthcare delivery, costs and outcomes.     

Endocarditis in neonatal intensive care unit

Summary The clinical spectrum of infective endocarditis (IE) in infants is examined in four infants between 3 and 9 months of age. None of the patients had signs of IE; all four had an anatomically normal heart. Echocardiograms showed echodense vegetations in the left side of heart in three cases and in the right side in one. Three of the four patients recovered after the episode of endocarditis. Three of the four patients had necrotizing enterocolitis in the neonatal period. The important predisposing factor was the presence of indwelling central catheter for intravenous nutrition. Unlike previously reported cases, coagulase-negativeStaphylococci andEnterococci were important causative organisms in this high-risk nursery population.Presented in part at the APS/SPR Meeting in Anaheim, California, May 8, 1990.     

Sibling visiting in a neonatal intensive care unit

The effect of sibling visiting in a neonatal intensive care unit was studied. Sixteen siblings of 13 infants were randomly assigned to a visiting or nonvisiting group. Behavioral patterns were measured by questionnaires administered to the parents and by direct observation and interviews with the children. There were no significant changes in the behavior of the children following the birth of their sibling, and there was no significant difference between the behavior scores of the two groups 1 week after the experimental (or control) intervention. The visiting children did not show signs of fear or anxiety during the visit. These data suggest that sibling visiting to a neonatal intensive care unit is not likely to be harmful and might be beneficial to the siblings and their families.     

Morbidity from acquired cytomegalovirus infection in a neonatal intensive care unit

In a prospective study of transfused neonates, 32 of 262 infants were viruric at greater than 20 days of life. Of 212 neonates whose early status was known, postnatally acquired infection was proven in 21, two of whom were seronegative at birth and were thought to have transfusion-acquired cytomegalovirus (CMV). Maternal transmission of CMV is important in this population as there was 91% seropositivity for CMV at birth among the 21 babies who acquired CMV compared with 55% positivity among 150 babies who did not shed CMV (P less than 0.01). Significantly increased morbidity (increased length of stay in hospital, increased use of antibiotics, and longer duration of antibiotic administration) was found in babies with acquired CMV compared with matched controls who did not become viruric. Significant morbidity and mortality was not restricted to the two seronegative babies with transfusion-acquired CMV. The cost of providing CMV antibody negative blood for this neonatal unit would be less than the cost of providing the extended hospital care needed by the two babies with transfusion-acquired CMV found during this 3 year study.     

Morbidity from acquired cytomegalovirus infection in a neonatal intensive care unit

Abstract In a prospective study of transfused neonates, 32 of 262 infants were viruric at greater than 20 days of life. Of 212 neonates whose early status was known, postnatally acquired infection was proven in 21, two of whom were seronegative at birth and were thought to have transfusion-acquired cytomegalovirus (CMV). Maternal transmission of CMV is important in this population as there was 91% seropositivity for CMV at birth among the 21 babies who acquired CMV compared with 55% positivity among 150 babies who did not shed CMV ( P < 0.01). Significantly increased morbidity (increased length of stay in hospital, increased use of antibiotics, and longer duration of antibiotic administration) was found in babies with acquired CMV compared with matched controls who did not become viruric. Significant morbidity and mortality was not restricted to the two seronegative babies with transfusion-acquired CMV. The cost of providing CMV antibody negative blood for this neonatal unit would be less than the cost of providing the extended hospital care needed by the two babies with transfusion-acquired CMV found during this 3 year study.     

Neurological assessment in infants discharged from a neonatal intensive care unit

BackgroundLongitudinal motor assessment in infants at different neurodevelopmental risk has not been previously evaluated using structured assessments.AimTo verify if the Hammersmith Infant Neurological Examination (HINE) is a good tool to predict the neuromotor outcome in infants discharged from a level II–III Neonatal Intensive Care Unit (NICU)MethodsIn this cohort analysis, 1541 infants discharged from our NICU between January of 2002 and the April 2006 were enrolled and assessed using the HINE at 3, 6, 9, 12 months. At two years, these infants were further assessed, and grouped into infants with normal outcome (1150), with mild disability (321) and with cerebral palsy (70),ResultsCorrelation analysis of Spearman showed a significant (p < 0.0001) and moderate (r² = −0.55 to −0.73) negative correlation between HINE scores (3, 6, 9, 12 months) and neurological outcome at two years. Cut-off scores for each assessment' age were provided as predictive value for cerebral palsy.DiscussionThis study mainly showed that HINE, as soon as the first months of life, helps in the process of prediction of neurological outcome at two years of age in a heterogeneous population of infants discharged from an NICU.     

Contamination of a milk bank pasteuriser causing a Pseudomonas aeruginosa outbreak in a neonatal intensive care unit

An environmental investigation and a cohort study were carried out to analyse an outbreak of infection caused by a serotype O10 Pseudomonas aeruginosa in a neonatal intensive care unit. Thirty one cases of infection were recorded, including four lethal ones. The outbreak was stopped by eradicating the environmental sources: a contaminated milk bank pasteuriser and bottle warmer.     

Palliative care in the neonatal intensive care unit

With increasing facilities for antenatal diagnosis, lowering gestation for intiation of intensive care, palliative care in the perinatal period is increasingly recognized as a specialist area. There have been standards and pathways developed in the UK that provides guidance to health professionals. Providing holistic perinatal palliative care depends on close multiprofessional working between the neonatal team and the palliative care professionals who are being integrated into the core neonatal services. Even though most neonates will continue to receive end of life care within the NICU, there are increasing number of families who choose to have end of life care either at home or a hospice. There is a need to develop services across the regions to provide equitable access to excellent clinical care as well as ongoing support to families following loss of a neonate. This short article explores the issues raised in the provision of palliative care in the perinatal period and offers practical guidance for paediatricians in this emerging area.