Hospital Infection Control

Neonates

What specific infection control measures are necessary for neonates?

Specific infection control measures for neonates largely center on unit-based strategies in the intensive care units providing care to patients of varying ages and weights, and thus at varying stages of immune system development. The neonate's skin immaturity and the neonate's environment of care (including life-supporting, invasive devices) are key features in its infection risk. Neonatal infection control measures must be comprehensive, and directed at any mechanism by which infection could be introduced into the premature host.

Infection control for the neonate must include focused attention to:

  • Blood-banking practices: For prevention of transmission of common pathogens from blood (e.g., Cytomegalovirus [CMV]) into non-infected neonates.

  • Infection control policies and surveillance to minimize transmissible diseases from staff caring for the neonate. The core of these procedures must include a unit-based and/or hospital wide focus on basic hand hygiene, with specific attention in the neonatal population to include those persons visiting/in contact with the neonate and those caring for the neonate.

  • Infection control policies and procedures to focus on the unique aspects of prevention in vulnerable neonatal populations, including:

    • Blood stream catheter-related infections (for both umbilical catheters and peripherally inserted central catheters). This should include application of available guidelines, which include neonatal-specific care recommendations.

There is little published information on prevention of ventilator-associated pneumonia or urinary tract infections in neonates. Most analysis focuses on prevention of catheter-related bloodstream infections.

What are the conclusions from clinical trials or meta-analyses regarding infection control in neonates that guide current practices and policies?

There are guidelines for umbilical catheter care, regarding basic established neonatal infection practices. These include:

  • Removing umbilical artery catheters (UAC) or umbilical venous catheters (UVC) if any sign of infection or thrombosis

  • Infusing heparin solutions through UAC's.

  • Maximal use of UAC 5 days

  • Maximal use of UVC 14 days

  • Antiseptic cleansing prior to UAC and/or UVC insertions

  • Avoidance of use of topical antibiotic creams or ointments at the UAC or UVC insertion sites

There are no clinical trials or meta-analyses available to guide other specific elements of infection control practice.

The most generalizable data are generated from on-line networks in which neonatal infection control measures may be compared among similar units, in order to attempt to analyze and improve infection control practices. There are also nationally published data on rates of catheter-related infections and pneumonia by birth weight category thus allowing units to compare their surveillance data. There are also well-established strategies for systematic risk reduction practices by neonatal immaturity and risk.

Review of available studies for infection control practices in neonatal units, confirms that collaboration of units with a focus on infection control, can lead to generally applicable interventions for others centers involved in neonatal care.

It is clear from neonatal infection control networks, and multi-unit analyses, that protocols for the following contribute to systems based practices which reduce nosocomial infections in the neonate. These include:

  • Hand washing for visitors/family

  • Hand washing for staff

  • Gown/glove protocols for family

  • Gown/glove protocols for staff

  • Peripherally inserted catheters: placement, monitoring, access, insertion site care

  • Intravenous catheter/hub access and care

  • Skin antisepsis prior to invasive procedures

What are the consequences of poor infection control in neonates?

As neonates are a developmentally and functionally immune-compromised group, particularly at younger gestational ages and lower birth weights, the consequences of poor infection control practices, can lead to short-term and long-term co-morbidities and neonatal mortality.

What other information supports the conclusions of studies regarding infection control in neonates (e.g., case control studies and case series)?

Numerous studies document that unit-based interventions lead to significant reductions in catheter-related bloodstream infections. While specific aspects of care (education of staff regarding infection control techniques, standardization of infection control practices) are universally applied, key conclusions are difficult to generalize from these types of studies.

Summary of current controversies regarding infection control in neonates.

Controversy exists regarding visitor and staff hand-washing procedures.

Controversy exists regarding optimal central venous catheter care:

  • Chlorhexidine solutions (2% in 70% isopropyl alcohol) may have effects on decrease catheter-related blood stream infections (CRBSI) rates, even with ongoing frequent catheter use in neonates. Iodine solutions, while effective at infection control, must be subsequently washed off the skin, as iodine absorption can have negative consequences due to neonatal immaturity, primarily related to integumentary (skin) barriers.

Even widely used practices lack recent or substantiated effectiveness.

  • Gowning of visitors and staff was recently reviewed without clear benefit noted across numerous studies encompassing 3,811 neonates.

What is the impact of infection control in neonates relative to infection control in other patient populations?

Neonates represent a more vulnerable population. They have limited immune and integumentary responses to infection, and thus prevention is perhaps more critical here than any other unit in the hospital, save some of the more immune-compromised hosts in transplant units.

How is infection prevention in neonates related to maternal risk of infection?

Some neonatal infection control practices require perinatal management of the mother, given particular maternal risks. There are developed protocols for prevention of disease in the infant from maternal infections with organisms such as Group B Streptococcus (GBS), herpes simplex virus (HSV), human immunodeficiency virus (HIV) and CMV which impact perinatal management of the mother in order to decrease risk to the neonate.

These protocols are not addressed here, as they are not part of neonatal infection control, but are managed perinatally and postnatally based on the individual neonate's risk.

Overview of all important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control in neonates.

There are no conclusive clinical trials, meta-analyses, case-control studies, case series or individual case reports regarding specific protocols for infection control. There are unit-specific variances, many of which have similar outcomes in reducing neonatal infections.

Controversies in detail.

  • While chlorhexidine is more effective than povidone-iodine at decreasing catheter hub colonization, application of chlorhexidine dressings to neonatal skin has a significant incidence of contact dermatitis, which can itself promote bloodstream infections or catheter infections in at-risk neonates.

  • While silver-based catheter dressings show trends toward decreased catheter related bloodstream infections, there remain concerns about systemic absorption of silver with long-term use in neonates. There, however, appears to be minimal skin irritation associated with these dressings.

  • Chlorhexidine-based line care protocols are generally successful, but are often combined with unit-based multi-disciplinary infection control processes.

  • Antibiotic lock solutions to prevent catheter related bloodstream infections are not routinely used, although this may be effective at prevention of infections.

  • Nursing education strategies form a basis for any infection control strategy in neonates; however, while multiple educational strategies are proven effective (20 to 40% reductions in catheter-related bloodstream infections), the specific contributors are often unclear.

  • Removal of toys in the neonatal environment, while investigated, has not shown significant reductions in neonatal infections, although toys have been shown to be colonized with potentially pathogenic bacteria.

What national and international guidelines exist related to infection control in neonates?

None.

Routine hospital catheter related bloodstream infection guidelines often do not address neonatal populations, and do not address those neonates most at risk.

Best practice guidelines, while providing useful frameworks for neonatal infection control, are limited by the experiences of a few large participating centers. Their cumulative cooperative experiences, nevertheless, provide vital frameworks for the design and implementation of neonatal infection control programs.

What other consensus group statements exist and what do key leaders advise?

Most units utilize apply general infection control practices to the neonatal population including:

  • Specific hand-washing requirements of visitors,

  • Exclusion of children/siblings who are concurrently ill

  • Specific staff requirements for hand-washing during care of individual neonates

  • Unit isolation policies for isolation of neonates with specific infectious diseases (Methicillin resistant Staphylococcus aureus)

  • Unit protocols for use of patient-care equipment including respiratory/gastrointestinal equipment, enteral and parenteral feeding supplies, diagnostic supplies used in neonatal daily care

  • Unit protocols for insertion, access and maintenance of central vascular catheters

  • Initiatives which focus on education of nursing staff on principles and practice of the implemented infection control practices

Specific data regarding impact on the neonate, as reviewed above, is often lacking or multifactorial.

References

O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph A, Rupp ME, Saint S and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections, 2011.

Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, Dudeck MA, Pollock DA, Horan TC. National healthcare safety network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009;37(10):783-805. PUBMED:20004811.

Newby J. Nosocomial infection in neonates:inevitable or preventable? J Perinat Neonatal Nurs 2008;22(3):221-7. PUBMED:18708874.

Kane E, Bretz G. Reduction in coagulase-negative staphylococcus infection in the NICU using evidence-based research. Neonatal Netw 2011;30(3):165-74. PUBMED:21576051.

Kilbride HW, Wirtschafter DD, Powers RJ, Sheehan MB. Implementation of evidence-based potentially better practices to decrease nosocomial infections. Pediatrics 2003;111:e519-33. PUBMED:12671172.

Cooley K, Grady S. Minimizing catheter-related bloodstream infections: one unit's approach. Adv Neonatal Care 2009;9(5):209-26. PUBMED:19823131.

Bizzarro MJ, Sabo B, Noonan M, Bonfiglio MP, Northrup V, Diefenback K. A quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2010;31:241-8. PUBMED:20102278.

Sannoh S, Clones B, Munoz J, Montecalvo M, Parvez B. A multimodal approach to central venous catheter hub care can decrease catheter related bloodstream infection. Am J Infection Control 2010;38(6):424-9. PUBMED:20137829.

Webster J, Pritchard, MA. Gowning by attendants and visitors in a newborn nursery for prevention of neonatal morbidity and mortality.Cochrane Database Syst Rev 2003;(3):CD003670. PUBMED:12917980.

Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris MC, Naples M, Pellegrini J, Buck RK, McAuliffe TL, Goldmann DA, Maki DG. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001;107(6):1431-6. PUBMED:11389271.

Khattak AZ, Ross R, Ngo T, Shoemaker CT. A randomized controlled evaluation of absorption of silver with the use of silver alginate (Algidex) patches in very low birth weight (VLBW) infants with central lines. Journal of Perinatology 2010;30:337-42. PUBMED:19940856.

Hill ML, Baldwin L, Slaughter JC, Walsh WF, Weitkamp JH. A silger-alginate coated dressing to reduce peripherally inserted central catheter (PICC) infections in NICU patients: a pilot randomized controlled trial. Journal of Perinatology 2010; 30:469-73. PUBMED:20010613.

Curry S, Honeycutt, M, Goins G, Gilliam C. Catheter-associated bloodstream infections in the NICU:getting to zero. Neonatal Netw 2009;28:151-5. PUBMED:19451076.

Smith MJ. Catheter-related bloodstream infections in children. Am J Infect Control 2008;36:S173.e1-3. PUBMED:19084151

Semelsberger CF. Educational interventions to reduce the rate of catheter related bloodstream infections in the NICU: a review of the research literature.Neonatal Netw 2009;28:391-5. PUBMED:19892637.

Hanrahan KS, Lofgren M. Evidence-based practice:examining the risk of toys in the microenvironment of infants in the neonatal intensive care unit. Adv Neonatal Care 2004;4(4):184-201. PUBMED:15368211.

Davies MW, Mehr S, Garland ST, Morley CJ. Bacterial colonization of toys in neonatal intensive cots. Pediatrics 2000;106(2):E18. PUBMED:10920174.

Kilbride HW, Powers R, Wirtschafter DD, Sheehan MB, Charsha DS, Lecort m, Finer N, Goldman DA. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia. Pediatrics 2003;111:e504-18. PUBMED:12671161.

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