Neonatal nosocomial infections

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International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

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Neonatal nosocomial infections

  1. 1. NOSOCOMIAL INFECTIONS Eucharius Rößlin 1528 Rolf Schlößer University Hospital Goethe University Department of Neonatology
  2. 2. Neonatal nosocomial infections arouse public interest in Germany Bremen Siegen Berlin PassauHamburg Mainz
  3. 3. Two aspects of nosocomial infections in Neonatology • Infection control at the unit • Prevention and treatment of infections in the individual case
  4. 4. Nosocomial Infections as a increasing issue in NeonatologyDoyle LW et al.: J Paediatr Child Health 1999 Berrington JE et al.: J Pediatr 2012% 100100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 1988-1994 1995-2001 2002-2208 1983-90 1992-96 Respiratory failure Infection/NEC
  5. 5. 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
  6. 6. Decreasing EOS, Increasing LOS Van den Hoogen A et al. 2010
  7. 7. Late Onset Infections and late mortality of preterm infants 1598 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
  8. 8. Impact of sepsis on cognitive and motor functions in elderly Iwashyna, T. J. et al. JAMA 2010;304:1787-1794.
  9. 9. Morbidity of preterm infants from Adams-Chapman I Seminars Perinat 2012 nach Stoll et al. 2004
  10. 10. A nosocomial infection (is defined) as a localized or systemic condition 1) that results from adversereaction 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
  11. 11. Approximately 25% of VLBW have at least one nosocomial infection during their stay in hospital (Geffers et al. 2008)
  12. 12. 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
  13. 13. Changes in Neonatology – Family-centered care www.neonatology.org
  14. 14. Bacterial Contamination of toys in incubators Quelle Frosch-Shop.de 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 Davies MW et al. Pediatrics 2000
  15. 15. Harbarth S, et al.Outbreak of Enterobacter cloacae related tounderstaffing, overcrowding, andpoor hygiene practices. Infect Control Hosp Epidemiol. 1999
  16. 16. 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
  17. 17. 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
  18. 18. Device-associated infections – not only central venous but also peripheral venous catheter 100 µm Geffers C et al. J Hosp Infect. 2008 100 µm
  19. 19. 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
  20. 20. Spectrum of pathogens in nosocomial infections in NICU Study 1 Studie 1 Study 2 Studie 2 Study 3 Gram-neg Gram-pos FungiStudy 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)
  21. 21. Pathogen Specific MortalityOrganism Death Rate Death Rate 1 2All 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 2002 2) 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)
  22. 22. Problem of Multiresistent Agents• ESBL Extended-Spectrum-BetaLactamase• MRSA Methicillin-Resistant Staphylococcus aureus
  23. 23. „ESBL-Bacteria are probably both imported into, andspread within the NICU“ (Benenson S et al. Neonatology 2012) Dubois V et al.J Antimicrob Chemother 2010
  24. 24. Duration of ESBL-colonization after discharge from hospital
  25. 25. 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 %)
  26. 26. Transmission of MRSA Gray JW, Suviste J J Hosp Infect 2013
  27. 27. Human Cytomegalovirus (HCMV)• 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).
  28. 28. Importance of breast milk:Police escorted transport!
  29. 29. HCMV – short term consequences (Kurath et al. Clin Microbiol Inf 2010;16:1172-8). 29
  30. 30. HCMV – short term consequences Kurath et al. Clin Microbiol Inf 2010;16:1172-8 30
  31. 31. 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
  32. 32. Ranges for blood leukocyte count in preterm and term newborns, and in adults Sharma AA et al. Clinical Immunology 2012
  33. 33. Developmental changes occurring in the human immune system early in life Sharma AA et al. Clinical Immunology 2012
  34. 34. Classification of Nosocomial InfectionsInfection Comment PreventionPrimary endogen Body´s own pathogens become source of partial infection through changed immunologic conditionSecondary endogen Body´s own pathogens get into bloodstream or partial cavities through manipulation, devices, or instrumentationExogen Pathogens are transmitted through either Usually possible personal contact or the environment mod. Gastmeier P et al. Dtsch Med Wochenschr 2010;
  35. 35. 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
  36. 36. The „neonatal problem“ of extended length of stay in hospital Benenson S et al. Neonatology 2013
  37. 37. Management
  38. 38. Infection control• Hand desinfection• Gloves/aprons, gowns• Patient isolation• Cohorting Screening/Surveillance
  39. 39. Detection of nosocomial pathogens in hospital Bomers MK et al. BMJ 2012;345:e7396
  40. 40. 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).
  41. 41. Potential sources for nosocomial infections in NICU -A collection-Powdered milk Simmons et al. Infect Control Hosp Epidemiol 1989Glucose infusion Lalitha et al. J Hosp Infect 1999Breastpump Donowitz et Rev Infect Dis 1981IV infusion MMWR MMWR 1998Bathwater Vochem et al. EJM 2001Clinical thermometer Donkers et al. Ned Tijdschr Geneeskd 2001Transducer Bloodpressure Ransjo et al. Acta Anaestesiol Scand 1992Waterbath for FFP Muyldermanns et al. J Hosp Infect 1998Ventilator circuits Gray et al. J Hosp Infect 1999Air humidifiers Schlösser et al. Infection 1990Desinfection Reiss et al. Lancet 2000Almond oil Gras-Le Guen C J Perinatol. 2007
  42. 42. TreatmentTime is Life!
  43. 43. Immediate treatment of gram-negative sepsis is essentialOrganism Number of Time of Death in Relation to Blood Culture, Deaths n (%) Days 1–3 Days 4–7 >7 DaysGram-negative 93 66 (71%) 5 (5%) 22 (24%)Gram-positiveCONS 55 10 (18%) 4 (7%) 41 (75%)Other Gram- 46 19 (41%) 8 (17%) 19 (41%)positiveFungi 48 23 (48%) 12 (25%) 13 (27%) Stoll BJ et al.: Pediatrics 2002
  44. 44. Clinical signs of late onset sepsis in preterm infantsRespiratory Symptoms Circulatory symptomsApnoe/Bradykardie/cyanotic spells Capillary refill time > 2SIncreased respiratory support Pallor/grey skin TachykardiaIncreased oxygen requirementDyspnoeaGeneral Symptoms RiskfaktorsTemperature instabilty Gestational ageLethargy Birth weightHyperthermia Männl. GeschlechtFeeding intolerance CVC in last 24 hrsIrritabilitity Weight at episodeHypothermia Age at episode Ventilation Bekhof J et al. Eur J Pediatr 2012
  45. 45. Brierley J et al.: Crit Care Med. 2009 Feb;37(2):666-88
  46. 46. Prophylaxis of neonatal sepsis?Option RatingG-CSF No significant increase of infection- free survival at 4 weeks after treat- ment Kuhn P et al.: J Pediatr 2009IVIG 3% reduction of sepis episodes, but no reduction of mortality from sepsis OhlssonA, Lacy JB Cochrane Database Syst Rev 2004Fluconazole Most beneficial in NICUs with high incidence of invasive candidiasis Shane AL, Stoll BJ: Amer J Perinatol 2013Vancomycin Reduction of nosocomial sepsis and catheter related infection; risk of resistance Craft AP et al.: The Cochrane Library, Issue 3, 2002Probiotics Reduction of NEC, no effect on sepsis Mihatsch W A et al.:Clin Nutr 2012 ; 31 : 6 – 15
  47. 47. Thank you for your attention! Quelle Internet

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