NICU Infections

Vol. 20 •Issue 1 • Page 8
NICU Infections

Techniques to Protect Sick Infants Sometimes Overlooked

When you go into the hospital, you are supposed to get better. Things such as nosocomial infections—now called health care acquired infections or hospital associated infections—are not supposed to happen. They especially are not supposed to happen to a baby. Call me crazy, but being born is not reckoned to kill you.

Sadly, the incidence of hospital associated infections in neonatal units is on the rise. Data suggest that as many as 33 percent of neonates develop life-threatening infections. But these estimates may be low. We know that some 30 percent of very low weight preemies are prescribed broad spectrum antibiotics. It is impossible to determine from the published data whether these medications are given for pre-existing or for acquired infections.

What is certain is that neonatal infections have been associated with increased morbidity and mortality, increased costs and certainly with longer lengths of stay in a neonatal intensive care unit (NICU).

Babies most at risk for developing an infection are preemies or babies with very low birth weights, with neutropenia associated with a hypertensive mother, with exposure to a prolonged rupture of membranes, with existing disease or infections or with low baseline serum immunoglobulin G concentrations. Male babies in general tend to be sicker or get sicker more easily than females. Male babies seem to be especially susceptible to bacterial sepsis and meningitis.

Regardless of the baby’s sex, when infections do occur, gram-positive bacteria account for 55.4 percent of them and gram-negative bacteria account for 31.2 percent. The most common pathogens are Staphylococci, Escherichia coli, Klebsiella and Candida albicans, a yeast infection.

Tell-Tale Signs

Babies cannot tell us when they are not feeling well. Instead, they began to show symptoms. They develop apnea, hypoxia, increased pulmonary secretions, feeding intolerance, heart rate and/or rhythm changes and guaiac-positive stools. They often show an increased need for oxygen and respiratory support.

When that happens, time becomes crucial. Relying on lab results such as an elevated white blood-cell count, C-reactive protein (CRP) level or blood culture for diagnosis may simply take too long. Practitioners often must rely on their clinical assessment skills to assist them in identifying the onset of infection and responding. Delays in the initiation of empirical therapy have been associated with higher mortality rates in infants.

While the data vary from study to study, mortality rates of untreated neonatal sepsis are estimated to be as high as 50 percent. With that thought in mind, practitioners would do well to pay close attention to details like heart rates. Data suggest babies with sepsis have abnormal heart rate characteristics for up to 24 hours preceding a sudden clinical deterioration.

The good news is there are various tools available to assist the practitioner in quantifying the baby’s illness. The Score for Neonatal Acute Physiology (SNAP) and the Neonatal Therapeutic Intervention Scoring System (NTISS) can assist in determining the baby’s severity of illness. Ideally, if the baby’s infection can be identified in its early stages before the child begins to decline, treatment can be initiated and outcomes improved.

Preventing infections altogether would, of course, be ideal. The No.1 way to prevent infections is applying appropriate infection-control techniques such as good scrubbing/hand washing and gowning techniques.

Royal Press Beating

Ironically, this preventive measure received considerable international press recently. Much to his chagrin, Britain’s Prince William was photographed holding a premature baby. The royal was in his shirtsleeves and wearing a watch, and the photo op was supposed to spark warm fuzzy feelings.

Instead, it prompted an outpouring of criticism, including print ads by health care professionals who used the opportunity to pass their message: “This is how not to hold a premature baby.”

Most of us who work in NICUs do not have to worry about negative press too much. We do scrub on entering the unit. Those disposable bristly brush/sponge scrubs we sometimes use, though still popular in some places, are probably not necessary, however. Data have shown they are no more effective than antiseptic soap for hand hygiene and they are now no longer considered necessary for initial scrubbing.

Our faux pas is usually not washing our hands properly between babies. It is easy to overlook that precaution, particularly when we are in a hurry. Nonetheless, studies show it is a common mistake. Waterless cleansers, usually alcohol-based, are one alternative in an emergency, provided they are used in accordance with their directions.

Sounds like a no-brainer, but few of us know we need to use enough waterless cleaner to keep our hands “wet” for 15-20 seconds before the waterless cleaner evaporates.

Studies have also shown that proper line management is essential to preventing infections in the NICU. As RTs, we don’t have a lot of control over this arena. We can, on the other hand, control practices that can contribute to respiratory infections such as reducing the duration of endotracheal intubation through good ventilator management, using sterile techniques during suctioning and preventing circuits from becoming contaminated (and changing them when they do).

Hospitals are places where people should get well. That goes for babies too. It can happen faster and better if caregivers take some precautions to avoid spreading pathogens.

Margaret Clark is a Georgia practitioner.

Outbreak of P. Aeruginosa Closes NICU Temporarily

The deaths of two premature babies at a California hospital NICU last month demonstrated how rapidly health care can go downhill.

The Los Angeles County Department of Public Health traced a fatal outbreak of P. aeruginosa at White Memorial Medical Center to contaminated laryngoscope blades.

To its credit, White Memorial closed its NICU and pediatric ICU until the contaminate could be eliminated. In the ensuing investigation, respiratory care therapists were questioned as to whether they were following proper cleaning procedures for the blades. According to an Associated Press report, the respiratory care department had recently taken over the duties of cleaning the equipment.

As a preventive measure, the hospital has stepped up its policy of requiring caregivers to wear protective coverings when caring for infants and re-educating staff about infection control policies.

Nearly 10 percent of the nearly two million cases of hospital-acquired infections can be traced to P. aeruginosa, which is easily spread by caregivers, medical instruments, disinfectants and food.

Hospital-acquired infections cause 90,000 deaths and contribute to $4.5 billion in health care costs annually, according to the Centers for Disease Control and Prevention.

There is no way to completely prevent these types of infections, according to Joseph Bocchini, MD, chief of pediatric infectious diseases at Louisiana State University Health Sciences Center.

Several years ago, a Pseudomonas outbreak in Pennsylvania was linked to improperly sterilized bronchoscopes.

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