Neonatal nosocomial infections
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Transcript of Neonatal nosocomial infections
Rolf SchlößerUniversity HospitalGoethe University
Department of Neonatology
NOSOCOMIAL INFECTIONS
Eucharius Rößlin 1528
Bremen
Berlin
Hamburg
Passau
Siegen
Mainz
Neonatal nosocomial infections arouse public interest in Germany
• Infection control at the unit
• Prevention and treatment of infections in the individual case
Two aspects of nosocomial infectionsin Neonatology
0102030405060708090
100
1983-90 1992-96
Doyle LW et al.: J Paediatr Child Health 1999
%
Berrington JE et al.: J Pediatr 2012
0102030405060708090
100
1988-1994 1995-2001 2002-2208
Respiratory failure
Infection/NEC
Nosocomial Infections as a increasing issue in Neonatology
Major contributors to hospital mortality in very-low-birth-weight infants
-Data of the birth year 2010 cohort of the German Neonatal Network-
Stichtenoth G et al. Klin Päd.2012
Decreasing EOS, Increasing LOS
Van den Hoogen A et al. 2010
Late Onset Infections and late mortality of preterm infants1598 cases of death out of 7861 VLBW (<1500g) during 32 mts; 12 NICU (US)
Age at death (d) Number Number of death caused by infection
%
1-3 950 40 4,2
4-7 137 20 14,6
8-14 130 20 14,6
15-28 143 74 51,8
>29 220 88 40
Stoll BJ et al. J Pediatr. 1996
Iwashyna, T. J. et al. JAMA 2010;304:1787-1794.
Impact of sepsis on cognitive and motor functions in elderly
from Adams-Chapman I Seminars Perinat 2012 nach Stoll et al. 2004
Mo
rbid
ity
of
pre
term
infa
nts
A nosocomial infection (is defined) as a localized orsystemic condition 1) that results from adverse
reaction to the presence of an infectious agent(s) orits toxin(s) and 2) that was not present or incubating
at the time of admission to the hospital
Garner JS et al.: 1996
Approximately 25% of VLBW have at least one nosocomial infection during their stay in hospital (Geffers et al. 2008)
Risk Factors of LOS in Neonates
• Poor hygiene
• Invasive monitoring and invasive procedures
• Specific pathogens
• Specific immunologic situation of newborns
• Extended length of stay in hospital
Changes in Neonatology – Family-centered care
www.neonatology.org
Bacterial Contamination of toys in incubators
Davies MW et al. Pediatrics 2000
19 Infants
34 Toys
86 Swabs:
All toys were contaminated with bacteria during a 4 week period
8 Infants had infections
5 of them with the same pathogen on their toy
Quelle Frosch-Shop.de
Harbarth S, et al.
Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices.
Infect Control Hosp Epidemiol. 1999
Risk Factors for LOS in Neonates
• Poor hygiene
• Invasive monitoring and invasive procedures
• Specific pathogens
• Specific immunologic situation of newborns
• Extended length of stay in hospital
Pooled Means of the Distribution of CVC-AssociatedBloodstream Infection Rates in Hospitals That Report to the
NNIS System, January 1992 to June 2001
O´Grady NP et al. Pediatrics 2002
100 µm
100 µmGeffers C et al. J Hosp Infect. 2008
Device-associated infections – not only central venous but also
peripheral venous catheter
Risk Factors for LOS in Neonates
• Poor hygiene
• Invasive monitoring and invasive procedures
• Specific pathogens
• Specific immunologic situation of newborns
• Extended length of stay in hospital
Studie 2Studie 1
Spectrum of pathogens in nosocomial infections in NICU
Study 1: Nambiar S, Singh N; Pediatr Infect Dis J 2002Study 2: Robles Garcia MG et al.; Ann Esp Pediatr. 2002Study 3: Frankfurt experience during a 4 years period (71 positive blood cultures)
Study 1 Study 2 Study 3
Gram-neg Gram-pos Fungi
Pathogen Specific Mortality Organism Death Rate
1Death Rate
2
All Gram-positive 11.2 % 10.6%
All Gram-negative 36.2 % 21.3 %
All Fungal 31.8 % 28.8 %
1) Stoll BJ et al.: Pediatrics 20022) Smith PB et al. Early Human Develop 2012
• Enterobacter cloacae (10%; Chen2009)
• Acinetobacter spp. (30% Touati 2009/37,5% Al Jarousha 2009)
• Serratia marcescens (14%; Arslan 2009)
• Cronobacter (Enterobacter sakazakii)
(27%: Friedemann 2009)
Problem of Multiresistent Agents
• ESBLExtended-Spectrum-BetaLactamase
• MRSA
Methicillin-Resistant Staphylococcus aureus
„ESBL-Bacteria are probably both imported into, and spread within the NICU“ (Benenson S et al. Neonatology 2012)
Dubois V et al.J Antimicrob Chemother 2010
Duration of ESBL-colonization after discharge from hospital
Methicillin Resistant Staphylococcus aureus-MRSA-
LOS with Staphylococcus aureus is rare (3.7%)
LOS with MRSA is even rare (1 %)
But
Mortality for both is high (≈ 25 %)
Transmission of MRSA
Gray JW, Suviste J J Hosp Infect 2013
• HCMV-infected preterms are mainly asymptomatic (Hamprecht et al. Lancet 2001).
• Up to 14 % of the nosocomial HCMV-infected preterms develop severe clinical, sepsis-like symptoms (Kurath et al. Clin Microbiol Inf 2010).
• One baby died (Hamele et al. Pediatr Infect Dis J 2010).
• Rate of transmission through breast milk is high. (Wakabayashi et al. Am J Perinatol 2012).
Human Cytomegalovirus (HCMV)
Importance of breast milk:
Police escorted transport!
29
(Kurath et al. Clin Microbiol Inf 2010;16:1172-8).
HCMV – short term consequences
30
Kurath et al. Clin Microbiol Inf 2010;16:1172-8
HCMV – short term consequences
Risk Factors for LOS in Neonates
• Poor hygiene
• Invasive monitoring and invasive procedures
• Specific pathogens
• Specific immunologic situation of newborns
• Extended length of stay in hospital
Ranges for blood leukocyte count in preterm and term newborns, and in adults
Sharma AA et al. Clinical Immunology 2012
Sharma AA et al. Clinical Immunology 2012
Developmental changes occurring in the human immune system early in life
Classification of Nosocomial Infections
Infection Comment Prevention
Primary endogen Body´s own pathogens become source of infection through changed immunologic condition
partial
Secondary endogen Body´s own pathogens get into bloodstream or cavities through manipulation, devices, or instrumentation
partial
Exogen Pathogens are transmitted through either personal contact or the environment
Usually possible
mod. Gastmeier P et al. Dtsch Med Wochenschr 2010;
Risk Factors for LOS in Neonates
• Poor hygiene
• Invasive monitoring and invasive procedures
• Specific pathogens
• Specific immunologic situation of newborns
• Extended length of stay in hospital
The „neonatal problem“ of extended length of stay in hospital
Benenson S et al. Neonatology 2013
Management
Infection control
• Hand desinfection• Gloves/aprons, gowns
• Patient isolation• Cohorting
Screening/Surveillance
Detection of nosocomial pathogens in hospital
Bomers MK et al. BMJ 2012;345:e7396
The purpose of Screening
• Knowledge of Pathogens in the own unit– Isolation of patients– Cohorting– Detection of source of infection
• In case of clinical sepsis knowledge of associated pathogen will help to choice antibiotics– Poor predictive value of pharyngeal colonization (Evans ME et al.:
JAMA 1988),
but– Concordance of gastrointestinal tract colonization with
subsequent sepsis (Smith A et al.: Pediatr Infect Dis 2010).
Potential sources for nosocomial infections in NICU-A collection-
Powdered milk Simmons et al. Infect Control Hosp Epidemiol 1989
Glucose infusion Lalitha et al. J Hosp Infect 1999
Breastpump Donowitz et Rev Infect Dis 1981
IV infusion MMWR MMWR 1998
Bathwater Vochem et al. EJM 2001
Clinical thermometer Donkers et al. Ned Tijdschr Geneeskd 2001
Transducer Bloodpressure Ransjo et al. Acta Anaestesiol Scand 1992
Waterbath for FFP Muyldermanns et al. J Hosp Infect 1998
Ventilator circuits Gray et al. J Hosp Infect 1999
Air humidifiers Schlösser et al. Infection 1990
Desinfection Reiss et al. Lancet 2000
Almond oil Gras-Le Guen C J Perinatol. 2007
Treatment
Time is Life!
Organism Number of Deaths
Time of Death in Relation to Blood Culture, n (%)
Days 1–3 Days 4–7 >7 Days
Gram-negative 93 66 (71%) 5 (5%) 22 (24%)
Gram-positive
CONS 55 10 (18%) 4 (7%) 41 (75%)
Other Gram-positive
46 19 (41%) 8 (17%) 19 (41%)
Fungi 48 23 (48%) 12 (25%) 13 (27%)
Stoll BJ et al.: Pediatrics 2002
Immediate treatment of gram-negative sepsis is essential
Clinical signs of late onset sepsis in preterm infants
Respiratory SymptomsApnoe/Bradykardie/cyanotic spells
Increased respiratory support
Increased oxygen requirement
Dyspnoea
Circulatory symptomsCapillary refill time > 2S
Pallor/grey skin
Tachykardia
General SymptomsTemperature instabilty
Lethargy
Hyperthermia
Feeding intolerance
Irritabilitity
Hypothermia
RiskfaktorsGestational age
Birth weight
Männl. Geschlecht
CVC in last 24 hrs
Weight at episode
Age at episode
Ventilation
Bekhof J et al. Eur J Pediatr 2012
Brierley J et al.: Crit Care Med. 2009 Feb;37(2):666-88
Prophylaxis of neonatal sepsis?
Option Rating
G-CSF No significant increase of infection-free survival at 4 weeks after treat-mentKuhn P et al.: J Pediatr 2009
IVIG 3% reduction of sepis episodes, but no reduction of mortality from sepsisOhlssonA, Lacy JB Cochrane Database Syst Rev 2004
Fluconazole Most beneficial in NICUs with high incidence of invasive candidiasisShane AL, Stoll BJ: Amer J Perinatol 2013
Vancomycin Reduction of nosocomial sepsis and catheter related infection; risk of resistance Craft AP et al.: The Cochrane Library, Issue 3, 2002
Probiotics Reduction of NEC, no effect on sepsisMihatsch W A et al.:Clin Nutr 2012 ; 31 : 6 – 15
Thank you for your attention!
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