Control of an outbreak of a highly beta-lactam-resistant Enterobacter cloacae strain in a neonatal special care unit

Two successive outbreaks of colonization and infection with Enterobacter cloacae resistant to third generation cephalosporins (cephalosporin-resistant E. cloacae, CREC) and involving 15 infants occurred within 12 months in a neonatal special care unit. Isolates of clinical significance were obtained from four infants (urine 2 cases, blood, pleural drainage). According to epidemiological typing using computerized biochemical fingerprinting and pulsed-field gel electrophoresis (PFGE) the same CREC strain was found in both outbreaks. The origin of the strain and its reservoir between the two outbreaks remained unknown. Emphasizing strict barrier nursing of the infants had little or no impact on the presence and transmission of the strain in the unit. In contrast, replacing ampicillin plus cefotaxime as standard empiric therapy with penicillin G plus netilmicin plus consequent cohorting of newborns and staff promptly halted both the outbreaks. During a 5-y follow-up after the last episode, the choice of antibiotics for empirical treatment has varied, and no further outbreaks of CREC have been seen, with the exception of two sporadic cases.     

Bacterial changes in neonatal intensive care unit

Organisms routinely cultured from throat swabs and infectious agents of sepsis and/or meningitis were reviewed. During the last 12 years, Klebsiella pneumoniae and Escherichia coli have been replaced by Staphylococcus aureus and Pseudomonas aeruginosa as the predominant isolates from throat swabs after admission. These change in the etiologic pattern of infectious agents of sepsis and/or meningitis, i.e., K. pneumoniae, E. coli, S. aureus, P. aeruginosa and staphylococcus epidermidis, were in agreement with the organisms isolated from the throat swabs after admission. The S. aureus isolated from throat swabs after admission showed a decrease in the bacterial activity of cloxacillin, cephazolin and cefotaxime since 1978.     

NICU导管相关感染现状调查分析

目的 调查分析新生儿重症监护病房医疗装置导管相关感染的发生率、危险因素及病原蒲的分布特点.方法 收集2002年1月-2007年12月248例入住中山大学附属第一医院NICU,并接受气管插管及经外周置入中心静脉导管患儿的临床资料,分析导管装置相关感染发生的百分率和导管相关感染的感染率、病原菌种类和特点.结果 248例患儿中,侵入性操作相关感染141例次(56.9%);发生呼吸机相关肺炎感染染为66.9%或64.9/1000通气日,导管相关血源感染为7.7%或5.8/1000置管日.置管时间和多种侵入性操作是导管相关感染的独立危险因素.导管相关感染的病原菌以耐甲氧西林凝固酶阴性葡萄球菌为主(占29.4%),其次分别为肺炎克雷伯杆菌(14.7%,ESBL为主)、铜绿假单胞菌(8.6%)、金黄色葡萄球菌(8.0%)、阴沟肠杆菌(8.0%).结论 NICU导管相关感染尤其足呼吸机相关肺炎的感染率高,病原菌多为耐药菌,需采取有效的干预措施进一步降低院内感染的发生率.     

Enterobacter cloacae causing pneumatocele in a neonate

Pneumatocele formation, a cyst-like rarefaction that develops within the lung parenchyma, is an unusual complication of pneumonia in the neonate. It has been reported to occur with Staphlococcus aureus, Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae , and Pseudomonas aeruginosa infections. We describe a case of a premature neonate with pneumonia and subsequent pneumatocele formation caused by Enterobacter cloacae     

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.     

Enteral administration of hematopoietic growth factors in the neonatal intensive care unit

GI trophic factors have been identified that influence the prenatal and postnatal growth and development of the GI tract. Systemically as well as enterally administered growth factors can stimulate GI growth and maturation, suggesting that trophic factors in the serum of neonates can modulate GI growth via receptors on the serosal membranes of enterocytes. GI trophic factors can be synthesized endogenously or provided prenatally in amniotic fluid and postnatally in human milk.
GI trophic factors in human milk play an important role in regulating the adaptive functional changes that accompany the transition to postnatal enteral feedings. Although human milk growth factors are not essential for infant survival, the elevated risk of GI-related illnesses in formula-fed compared with human milk-fed infants suggests that bioactive compounds in human milk contribute to the protective effects of human milk feedings (13).
GI trophic factors have the potential to be used therapeutically to enhance GI maturation and repair following injury. These applications may be particularly useful in the premature or postsurgical infant. Several issues require further research, including: (i) the efficacy of oral versus systemic administration; (ii) characterization of the complex interactions among the various growth factors; (iii) the effect of exogenously administered growth factors on endogenous production of that factor, its receptor or other growth factors; (iv) the effect of growth factors upon tissues not directly associated with the GI tract; and (v) the determination of safe and effective limits. Significant advances in feeding strategies to reduce feeding intolerance in the neonate are likely to occur with the application of these principles in clinical neonatology.     

Outbreak of cephalosporin resistant Enterobacter cloacae infection in a neonatal intensive care unit.

Enterobacter cloacae resistant to third generation cephalosporins emerged rapidly during an outbreak of serious infections due to this organism in a neonatal intensive care unit where ampicillin and gentamicin were used as first line antibiotic treatment. Organisms resistant to cephalosporins were isolated from 12 infants, six of whom developed systemic infection. Two infants died. Isolates of E. cloacae from four of five infants treated with cefotaxime showed a loss of sensitivity to this antibiotic during treatment, but in the three infants who survived sensitive organisms were again isolated after treatment had stopped. Stopping treatment with the cephalosporins, closure of the unit to new admissions, and strict cohorting of colonised infants resulted in a prompt end to the outbreak. This outbreak suggests that the routine use of third generation cephalosporins for suspected sepsis may be inappropriate in the presence of a large reservoir of organisms with the potential for rapidly developing resistance. Routine bacteriological surveillance, however, might permit their use on a rotational basis.     

Clinical performance of the new glucometer in the nursery and neonatal intensive care unit

Background: Performance of point‐of‐care (POC) glucometers in newborns have been unsatisfactory in low glucose concentration range and the effects of different hematocrit levels on glucose measurements have also demonstrated in currently used POC glucometers. Methods: The aim of this study was to evaluate the performance of the new glucometer (Nova‐Statstrip^®; Nova Biomedical, Waltham, MA, USA) compared to the reference method. Venous blood specimens of neonates were collected and tested by the two glucometers. Standard reference was performed using the hexokinase method within 10 min of blood collection. Hematocrit and total serum bilirubin measurements were performed simultaneously. Results: One hundred and fifty‐one blood specimens were collected and measured by the reference method with plasma glucose concentrations ranging from 12 to 371 mg/dL. Twenty‐one specimens had plasma glucose concentrations <45 mg/dL. At plasma glucose concentrations less than 75 mg/dL, the Statstrip^® achieved 93% in the tests for discrepancy < 15 mg/dL. At a glucose concentration more than 75 mg/dL, 97% of the Statstrip^® readings were within 20% of the reference values. The mean difference (±2SD) of the Statstrip^® was 2.8 (?14.1, 19.7) mg/dL. At a hypoglycemic level (<45 mg/dL), it showed a sensitivity of 95.2%. No significant interference of hematocrit or total serum bilirubin was found on the mean bias of the Statstrip^®. Conclusion: The new glucometer (Nova‐Statstrip^®) could be used for point‐of‐care blood glucose measurement in neonates as it showed a narrow margin of error and had no hematocrit or bilirubin interference.     

Parental involvement in decision-making in the neonatal intensive care unit: a review of the international evidence

The aim of this review was to establish the current evidence base regarding parental involvement in decision-making in the NICU. The review question was set as ‘What is known about the process of parental participation in clinical decision-making in the NICU?’ The findings of this critical literature review illustrate the process of decision-making for parents in NICU. The available evidence base was minimal. The parental role in decision-making is variable with current literature suggesting that the informed parental role, allowing parents to make the ultimate decision, is increasingly desired. Despite this there is still a requirement for medical and shared decision-making for some families. Regardless of the role parents assume it is evident that there will always be an array of emotional complexities to follow. Most feelings and emotional responses reported by parents were negative. The literature suggests several reasons for these feelings. A lack of parental knowledge and experience in NICU leading to confusion as to whether the right decision has been made alongside parents having a heightened awareness of the potential for suffering and harm for their baby. There are the added pressures of time and the weight of responsibility. The burden appears to be unequally distributed between parents. Several studies illustrate the transfer of responsibility from the father to mothers.     

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.     

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.