Surveillance of infection in neonatal intensive care units

https://doi.org/10.1016/j.earlhumdev.2007.01.006Get rights and content

Abstract

Monitoring infection rates is increasingly regarded as an important contributor to safe and high quality health care, especially in intensive care settings. Early-onset neonatal sepsis rates are an important indicator of ante- and intra-partum care, especially as medicalisation of obstetric practice increases. However, surveillance of late-onset neonatal sepsis is required to monitor the quality of Neonatal Intensive Care Unit (NICU)-related care. Infection surveillance on NICUs presents a number of unique challenges, including defining infections, the preponderance of coagulase-negative staphylococci as both pathogens and commensals, and allowing for the influence of important risk factors. Ideally an infection surveillance programme should permit benchmarking of infection rates, and multi-centre programmes have been reported to decrease the incidence of healthcare-associated infections on NICUs. However, further research is required to identify the most clinically- and cost-effective means of surveying NICU-acquired infections before a national programme can be implemented. Until then, considerable value can be obtained from local infection surveillance.

Introduction

Infection rates are an indicator of quality and safety in all areas of health care [1]. Determining infection rates via a surveillance programme is the first step in both identifying problems and evaluating the impact of processes to decrease the frequency of healthcare-associated infection (HCAI) [2]. The ultimate aim of an infection surveillance programme must be to reduce the incidence of HCAI and the associated costs. Against this background infection surveillance has been advocated for many years as a key component of hospital infection control, and comprehensive infection surveillance programmes exist in several countries [1]. However, progress has been patchy in many countries, including the UK. This has been attributed to a lack of basic comparative information on infection rates, and a lack of evidence for the impact of different intervention strategies.

Infection rates in preterm neonates are high, they are associated with significant morbidity and mortality, and they lead to additional length of stay and costs. Studies have demonstrated considerable differences in infection rates between comparable units [3], [4], whilst intervention studies have shown that changes in practice can decrease infection rates and reduce antibiotic resistance [5]. All these observations suggest that Neonatal Intensive Care Units (NICUs) should be priority areas for infection surveillance. NICUs also already collect a considerable amount of demographic, epidemiological and clinical data that can provide denominator data to underpin infection surveillance schemes. Against this background it may seem surprising that infection surveillance on NICUs is not better established. However, there are significant obstacles to undertaking multi-centre infection surveillance. This article will review the epidemiology and aetiology of neonatal infections, and consider how this impacts on developing infection surveillance.

Section snippets

Microbial causes of infection

The microbial causes of neonatal infection are age-dependent (Table 1). In the first 24 h the picture is dominated by vertically-transmitted infections, with group B streptococci and Escherichia coli as the predominant pathogens [6]. Thereafter, there is a rapid transition to nosocomially-acquired pathogens [6]. Coagulase-negative staphylococci (CoNS) are the predominant nosocomial pathogens, and present a particular challenge for both clinical practice and infection surveillance in

Timing and origin of infection

Infections occurring on NICUs are classified according to time of onset. EONS is usually due to vertical transmission before or during birth, whereas LONS usually occurs via nosocomial transmission [6]. However, there is no clear agreement on where the cut-off between EONS and LONS should lie. Originally 7 days of age was used, probably because this is the age widely used to classify GBS infections as early-onset (and therefore of maternal origin) or late-onset (likely to be due to

Requirements of an infection surveillance system

Successful infection surveillance depends on a number of factors (Table 3) [2]. Some features of Neonatology facilitate infection surveillance. For example investigation of patients with suspected infection tends to be thorough and protocol-driven, whilst comprehensive demographic, epidemiological and clinical data are already collected in a relatively standardised way. Unfortunately however, as will be explored later in the article, simplicity is generally not a characteristic of infection

Options for infection surveillance in NICU

Infection surveillance can be undertaken at many different levels, ranging from independent surveillance by individual units, through local or regional consortia to inclusive national or international programmes. Multi-centre surveillance is important for benchmarking, and for monitoring trends of regional or national importance. Locally focussed surveillance can be used for various purposes, including observation of local trends, detection of outbreaks, antimicrobial resistance monitoring and

Conclusions

Considerable variation in infection rates between NICUs, suggests that multi-centre surveillance of LONS could significantly improve the quality and safety of neonatal care. Multi-centre infection surveillance has indeed been reported to reduce the incidence of HCAI on NICUs [5]. However, published studies have been conducted over relatively short time periods in units that are highly motivated. Any multi-centre infection surveillance programme requires significant investment to ensure that

Key guidelines

  • Priority should be given to developing multi-centre infection surveillance for NICUs, so that standardised infection rates can be used as a benchmark to drive improvements in the quality and safety of care.

  • Local infection surveillance on NICUs plays an important role in the prevention and control of nosocomial infection, and in directing rational antimicrobial prescribing.

  • As a minimum all NICUs should undertake ongoing surveillance of microorganisms other than CoNS that are prevalent in their

Research directions

  • To ascertain the most effective determinants of standards of infection control on NICUs.

  • To investigate how data on infection rates can be presented in a standardised way that permits benchmarking of individual NICUs participating in a multi-centre surveillance programme.

  • To determine which interventions are most effective in reducing the incidence of LONS on NICUs.

  • To determine whether a multi-centre infection surveillance programme can deliver a reduction in the incidence of LONS that is

References (16)

There are more references available in the full text version of this article.

Cited by (42)

  • Risk factors for central venous catheter-related infections in a neonatal population – systematic review

    2018, Jornal de Pediatria
    Citation Excerpt :

    The Brazilian National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária [ANVISA]) Bulletin reports the incidence density of primary bloodstream infection in patients submitted to central venous catheter use in Brazilian neonatal intensive care units as ranging from 7.6 to 8.9/1000 CVC-day.13 The rate of neonatal mortality due to sepsis is as high as 68%,14 so surveillance measures are required to direct actions aimed at reducing the rates of healthcare-associated infections (HAIs), since they can provide data that allow comparisons and evaluation of the impact of the control measure, in addition to allowing comparisons with other healthcare services with the same characteristics.8,9 A study of adverse events associated with the use of central venous catheters in a neonatal unit in the state of Rio Grande do Sul, Brazil, observed a higher prevalence of mechanical obstruction in central peripherally-inserted central catheters (PICC) and a higher prevalence of catheter-associated infection (CAI) in the surgically-inserted catheters, with clinical sepsis being the most frequent (16%).15

  • Clinical usefulness of catheter-drawn blood samples and catheter tip cultures for the diagnosis of catheter-related bloodstream infections in neonatology: A systematic review

    2018, American Journal of Infection Control
    Citation Excerpt :

    CNS is the main microorganism isolated in health care-associated infections in NICUs. Although considered a commensal microorganism, CNS is the main etiologic agent of catheter-related sepsis in newborn infants, especially premature and low-birth-weight infants, with increased morbidity, costs, and length of hospitalization.30,51,54,58,59 In studies performed in a neonatal unit of Belo Horizonte, CNS was identified as the main microorganism responsible for the bloodstream infection episodes, ranging from 28%-32.8% of isolates in blood cultures.9,27

  • Rates of central line–associated bloodstream infection in tertiary care hospitals in 3 Arabian gulf countries: 6-year surveillance study

    2017, American Journal of Infection Control
    Citation Excerpt :

    Monitoring and comparing rates of health care–associated infections (HAIs) is increasingly regarded as a critical element of safe and high-quality health care.1

  • Risk factors of late-onset neonatal sepsis in Taiwan: A matched case-control study

    2016, Journal of Microbiology, Immunology and Infection
    Citation Excerpt :

    Neonatal bloodstream infections (BSIs) are an important complication among premature infants in neonatal intensive care units (NICU) all over the world.1

  • Health care-associated infection surveillance in a tertiary neonatal intensive care unit: A prospective clinical study after moving to a new building

    2016, American Journal of Infection Control
    Citation Excerpt :

    Infection rate is an important indicator of quality and safety in all areas of health care. Determining HAI rates via a surveillance program is the first step both in identifying problems and in evaluating the impact of processes to decrease the frequency of HAIs.9 Laboratory-based studies do not reflect actual results, because cultures are not positive in a significant number of infections.

View all citing articles on Scopus
View full text