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Back-to-basics approach advocated for preventing nosocomial infections
Good hand hygiene and educating staff about infection reduction strategies are integral to reducing nosocomial infections in the neonatal intensive care unit, according to a joint statement issued by the American Academy of Pediatrics’ Committee on Fetus and Newborn and Committee on Infectious Diseases.
Richard A. Polin, MD, and colleagues from both committees of the AAP said implementing “strategies that can influence the occurrence of health care-associated infections within the NICU requires a concerted team effort by all individuals who participate in the care of these infants.”
Committee members said adherence to hand hygiene recommendations is important, noting that “compliance with hand hygiene practices is less than optimal.” Educating staff and strategically placing infection control equipment can help with compliance, according to Polin and colleagues.
Besides hand hygiene, areas addressed included comprehensive information on preventing central-line bloodstream infection and health care-associated pneumonia. Infection reduction strategies, such as breast-feeding, and the use of topical emollients on preterm infants’ fragile skin to block pathogens from entering the bloodstream were also emphasized.
Both panels offered advice on antibiotic use and misuse, such as only using antibiotics when a bacterial infection is likely; stopping treatment if a bacterial infection has not been identified; using narrow-spectrum antibiotics; and using antibiotic for the appropriate amount of time.
“All too frequently, the health of a tiny infant whose life is being saved through the use of the best in 21st century technology is jeopardized by the smallest of acts — such as a care provider neglecting to wash his or her hands,” the researchers wrote. “Recognition of the importance of even the most basic care practices can result in behavior modification within the NICU and improve compliance with established infection control practices.”
In a related study by Polin and colleagues, preterm birth and its associated risk factors, such as low birth weight and insufficient pathogen protection from fragile skin and mucous membranes, were found to place this population at risk. Therefore, the AAP Committee on Fetus and Newborn and Committee on Infectious Diseases concluded that identifying causative agents and best treatment practices is key.
Polin and colleagues said the most common type of health care-associated infection within the NICU is a catheter-associated bloodstream infection.
“Within the first 30 days after birth, coagulase-negative Staphylococcus species, Staphylococcus aureus, Enterococcus species, and gram-negative enteric bacteria are the most common etiologic agents,” the researchers wrote. “After 30 days of age, coagulase negative Staphylococcus speciesremain the most common pathogens; however, fungi, particularly Candida species and Malassezia furfur have been noted with increasing frequency.”
Polin and colleagues said diagnosis of central line-associated infections of the bloodstream is difficult because “coagulase-negative staphylococci are skin commensals; therefore, interpretation of a blood culture result positive for this organism is difficult.”
The researchers also said nonspecific signs of sepsis in the infant make the diagnosis even more difficult. For this reason, the panel recommended a central-line and peripheral blood sample should be collected and examined, and treatment should include broad-spectrum antibiotics to cover gram-negative and gram-positive pathogens.
They said the best way to diagnose health care-associated pneumonia has yet to be found, mainly because upper respiratory colonization often distorts results the sample from the lower respiratory tract.
“When it is likely that a health care-associated bacterial pneumonia is present, a number of procedures can assist in establishing the etiologic agent,” the researchers wrote, specifically pointing to a Gram’s stain of a specimen obtained by suctioning through the endotracheal tube. “The presence of an abundance of polymorphonuclear neutrophils or a significant increase in polymorphonuclear neutrophils from a previous Gram stain of the same secretions, regardless of the presence of a predominant bacterial organism, is supportive evidence that pneumonia is present but also may represent tracheitis.”
Disclosure: Dr. Polin reports no relevant financial disclosures.
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