Nosocomial Infections In A Neonatal Intensive Care Unit In .
EMHJ Vol. 16Eastern Mediterranean Health JournalLa Revue de Santé de la Médiderranée orientaleNo. 1 2010Nosocomial infections in a neonatal intensive careunit in south-western Saudi ArabiaA.A. Mahfouz,1,2 T.A. Al-Azraqi1,3 F.I. Abbag,4 M.N. Al-Gamal,1,5 S.Seef 1,5 and C.S. Bello1,6 عدوى املستشفيات يف وحدة الرعاية املركزة للولدان يف جنوب غرب السعودية كورنيلوس بيللو ، سعد سيف ، حممد نرص اجلمل ، فؤاد إدريس عباق ، طارق األزرقي ، أمحد عبد الرمحن حمفوظ باململكة ، قاست دراسة أترابية وقوع عوامل االختطار لعدوى املستشفيات يف وحدة الرعاية املركزة للولدان يف مستشفى الباحة العام : اخلالصة ،%19.2 وكان معدل االنتشار يف الفرتة ، منهم بالعدوى 77 أصيب ، ساعة عىل األقل 48 مولود بقوا يف الوحدة 401 ومن بني . العربية السعودية والعدوى األولية املنقولة بالدم ،)%50( االلتهاب الرئوي : وكانت أكثر العداوى انتشار ًا هي . أيام - مريض 1000 عدوى لكل 13.7 ومعدل الوقوع :%95 وفاصلة ثقة ،2.69 جرى حتديد التهوية امليكانيكية (بنسبة أرجحية ، ويف حتليل حتوف لوجستي .)%6.5( واجللد واألنسجة الرخوة ،)%40.9( ويتعرض الولدان . ) كعاميل اختطار ُي ْعتَدُّ هبام إحصائي ًا 11.35 – 2.78 :%95 وفاصلة ثقة ،5.62 ) والتغذية الكاملة باحلقن (نسبة أرجحية 5.19 – 1.39. املصابون بعدوى املستشفيات لثالثة أضعاف خطر املوت مقارنة بالولدان غري املصابني بعدوى املستشفيات ABSTRACT A cohort study measured the occurrence and risk factors of nosocomial infections in the neonatalintensive care unit of Abha general hospital, Saudi Arabia. Of 401 neonates who stayed at least 48 hours in theunit, 77 developed infections, a period prevalence of 19.2% and an incidence of 13.7 infections per 1000 patientdays. The most frequent infections were: pneumonia (50.0%), primary bloodstream (40.9%) and skin and softtissues (6.5%). In logistic regression analysis, mechanical ventilation (OR 2.69, 95% CI: 1.39–5.19) and totalparenteral nutrition (OR 5.62, 95% CI: 2.78–11.35) were identified as significant risk factors. Neonates sufferingfrom nosocomial infections had more than 3 times the risk of dying compared to neonates free of infection.Infections nosocomiales dans un service de soins intensifs néonatals du sud-ouest de l’Arabie saouditeRÉSUMÉ Une étude de cohorte a mesuré la fréquence des infections nosocomiales et leurs facteurs de risquedans le service de soins intensifs néonatals de l’hôpital général d’Abha (Arabie saoudite). Sur 401 nouveau-nésayant séjourné au moins 48 heures dans le service, 77 ont contracté des infections, avec une prévalence de19,2 % au cours de la période et une incidence de 13,7 infections pour 1 000 jours-patient. Les infections les plusfréquentes étaient la pneumonie (50,0 %), les bactériémies primaires (40,9 %) et les infections de la peau et destissus mous (6,5 %). Dans l’analyse de régression logistique, la ventilation artificielle (OR 2,69, IC 95 % : 1,395,19) et l’alimentation parentérale totale (OR 5,62, IC 95 % : 2,78-11,35) ont été identifiées comme facteurs derisque significatifs. Les nouveau-nés souffrant d’infections nosocomiales avaient plus de 3 fois plus de risques demourir que les autres.Asir Regional Committee for Nosocomial Infection Control; 5Asir General Directorate of Health Affairs, Asir, Saudi Arabia.Department of Family and Community Medicine; 3Department of Internal Medicine; 4Department of Child Health; 6Department of ClinicalMicrobiology, College of Medicine, King Khalid University, Asir, Saudi Arabia (Correspondence to A.A. Mahfouz: mahfouz2005@gmail.com).12Received: 04/07/07; accepted: 02/09/0740
املجلد السادس عرش العدد األول IntroductionNeonatal deaths account for over a thirdof the global burden of child mortality[1]. In many developing countries neonatal mortality rates (deaths in the first28 days of life) are as high as 40–50 per1000 live births [2,3], with infectionsbeing the major cause of death [4,5].Unfortunately, hospitals in developingcountries are at high risk of infectiontransmission, and improvements inneonatal outcomes are subverted byhospital-acquired infections and theirassociated morbidity, mortality and cost[6–9]. These infections can be attributed to lack of knowledge and trainingabout basic infection control processes,coupled with inadequate infrastructure,systems of care and resources. This hasserious consequences when devicessuch as intravenous catheters and ventilators are introduced without sufficientattention to the substantial risk of infection they entail [10–12].The Asir region (population of1 200 000) is located in the south-westof Saudi Arabia covering an area of morethan 80 000 km2. Primary health care(PHC) services in Abha health district,the capital of Asir, are provided througha widespread network of 36 urban andrural health centres, providing servicesto a population of 129 465. Each PHCcentre has well-defined catchment areaand population. Secondary care is provided at Abha general hospital wherealmost all deliveries are performed.Our objective was to study the occurrence and risk factors of nosocomialinfections (NIs) at Abha general hospitalneonatal intensive care unit (NICU).MethodsAbha general hospital is a 100-bedgeneral hospital with an average of 300births a month and a 15-bed NICU.The NICU consists of 4 rooms witha capacity of 15–30 hospital-born neonates. The NICU was staffed with 22registered nurses/nurse assistants, 5 per املجلة الصحية لرشق املتوسط shift, a ratio of nurses/nurse assistantsto NICU patients of 1:5. The registerednurses supervised the team and weredirectly responsible for the care of themost severely ill patients. The medicalstaff included neonatologists, 1 on callevery 24 hours and 4 who worked ona daily basis. One of these neonatologists was responsible for the NICU for24-hour periods. A chief physician anda registered nurse were responsible forthe neonatal unit as a whole. Consultantsupport was available when necessaryfrom nearby Asir central tertiary hospital.A physical therapist was also present inthe unit for 8-hour periods. There were5 hand-washing sinks in the NICU, 1 atthe entrance, 1 at the nurse’s station, and1 sink for each 10 m2. Six conventionalventilators provided assisted ventilationon a conventional basis.A cohort of all neonates attendingAbha NICU from 1 January 2004 to 31March 2005 and who remained at least48 hours were followed up and evaluated. All neonates were examined atthe time of admission and the followinginformation was recorded: gestationalage, birth weight, Apgar score at 1 and5 minutes, maternal predisposing factors, mode of delivery, length of stayand exposure to vascular catheter,endotracheal intubation, mechanicalventilation, antibiotic therapy and totalparenteral nutrition. Surveillance fordevelopment of NI, death and transferto other units was conducted 2–3 timesa week and recorded using a manualspreadsheet. The outcome variable wasacquisition of a NI, assessed and classified using Centers for Disease Controland Prevention definitions [13].Data were analysed using SPSS, version 12.0. Univariate analysis methodswere used at 5% level of significance.Multivariate logistic regression analysiswas used to identify potential risk factors.ResultsDuring the study period, 401 neonateswere admitted to Abha NICU and remained at least 48 hours. There were233 males (58.1%) and 168 females(41.9%). The 5 primary reasons foradmission to the NICU were pretermand hyaline membrane disease (50.5%),transient tachypnoea of newborn(8.2%), meconium asphyxia syndrome(6.2%) and birth asphyxia (4.1%). Therewere 54 neonates with a congenitalanomaly (13.7%). Half the neonateswere born through unassisted vaginaldelivery (50.3%) and half by caesareansection (47.7%) or instrumental delivery (2.0%). The mean length of stay was14.0 (SD 19.5) days and median 8 days.In all, 77 neonates developed a NI, aperiod prevalence of 19.2% and incidenceof 13.7 NIs per 1000 patient-days observation. The commonest sites of infection were: lungs (pneumonia) (50.0%),blood (primary bloodstream infection)(40.9%), skin and soft tissues (6.5%) andurinary tract (2.6%). Table 1 shows theTable 1 Distribution of isolated pathogens related to nosocomial infections inAbha neonatal intensive care unit (n 77 infants)Isolated organismsNo. of infants%Coagulase-negative Staphylococcus spp.1823.4Klebsiella spp.1722.1Enterobacter cloacae1620.8810.4Methicillin-resistant Staphylococcus aureusGroup B Streptococcus11.3Serratia spp.56.5Escherichia coli67.8Staphylococcus aureus11.3Other Gram-negative bacilli56.541
EMHJ Vol. 16Eastern Mediterranean Health JournalLa Revue de Santé de la Médiderranée orientaleNo. 1 2010distribution of isolated pathogens relatedto NIs. The most frequently isolatedorganisms were coagulase-negativeStaphylococcus spp. (23.4%), Klebsiellaspp. (22.1%) and Enterobacter cloacae(20.8%).Using logistic regression analysisto identify risk factors associated withNIs (Table 2) the following significantrisk factors were identified: mechanicalventilation (adjusted OR 2.69, 95%CI: 1.39–5.19) and total parenteralnutrition (adjusted OR 5.62, 95% CI:2.78–11.35). Sex, birth weight, methodof delivery, gestational age and intravenous line were not associated withdevelopment of NIs.During the study period 87 neonatesdied (21.7%). Mortality among neonatessuffering from NIs (40.3%) was significantly higher compared with neonatesfree from NIs (17.3%) (χ2 19.33, P 0.05). Neonates suffering from NIs had3 times the risk of dying compared withneonates free from NIs (crude OR 3.23, 95% CI 1.80–5.70).DiscussionBabies are born without an endogenousmicrobial flora and rapidly becomecolonized with microbes encounteredin the maternal genital tract and theirimmediate postnatal environment [14].Since their immature immune systemsare unable to provide a robust defenceagainst virulent pathogens, neonatesare at high risk of developing invasiveinfections if exposed to pathogenicmicroorganisms. Premature neonatesTable 2 Multivariate analysis of potential risk factors determining nosocomial infections in Abha neonatal intensive care unit(n 401 infants)VariableNosocomial justed OR95% 0.18–2.525.62*2.78–11.350.960.14–6.84Mode of deliveryPresence of congenital anomaliesLow birth weight ( 1500 g)Gestational ageMechanical ventilationIntravenous line50.0Total parenteral heal intubation*P 0.05OR odds ratio; CI confidence interval.42
املجلد السادس عرش العدد األول are at especially high risk of infectionbecause of their lack of protectivematernal antibodies, underdevelopedinnate immunity and their fragile, easily damaged skin. However, while thenewborn intrinsically faces an increasedrisk of infection, failures at critical pointsin the system of care can greatly increasethis risk. The rapid development ofmedical technology has enhanced ourability to improve the quality and lengthof life of neonates, particularly infantsborn with congenital defects or extremeprematurity. This growing populationof fragile patients is often dependent forsurvival on therapeutic interventionsthat are associated with complicationsof infections that can result in neonatalmorbidity and mortality [15,16].The present study showed a relatively high prevalence of NIs in AbhaNICU of 19.2% with an incidence rateof 13.7 infections per 1000 patient-daysobservation. Previous studies have documented widely varying infection ratesbetween individual institutions. A prospective multicentre study conductedby the European Study Group found aninfection rate of 7% in 7 NICUs [17].The USA national point prevalence survey, a collaborative study in 29 hospitalsrepresenting 19 states, found a NICUinfection rate of 11.4% [18]. In Spain astudy found an incidence rate of 1.6 NIsper 100 patients-day observation in theNICU [19]. In developing countries,investigators in Brazil and Indonesiahave reported rates of hospital-acquiredinfections to be as high as 51%–52%among all NICU admissions [12,16].Although the Centers for Disease املجلة الصحية لرشق املتوسط Control and Prevention definitions areusually used in these studies, it may bedifficult to make direct comparisonswith these data because of inconsistencies in surveillance or study methods, such as intensity of surveillance,prospective versus retrospective datacollection, infection detection methodsand the populations included.Bacteraemia, pneumonia, urinarytract infections and sensory organ infections are the most common NIs reported in the literature, with 40% to 70%for bacteraemia and 15% to 30% forrespiratory infection [16,19,20]. Theseare in agreement with our results.The present study showed that themost frequently isolated organisms werecoagulase-negative Staphylococcus spp.,Klebsiella spp. and Ent. cloacae. In developing countries Gram-negative rodsare major pathogens of NIs in NICUs.Gram-negative rods were isolated fromat least 60% of positive blood culturesin developing regions of the world [16].K. pneumoniae is the major pathogen,responsible for 16%–28% of bloodculture-confirmed sepsis in differentregions of the world. Africa and SouthAsia also have high rates of Sta. aureus infections, whereas Latin America, SouthEast Asia and the Middle East have highreported rates of coagulase-negativestaphylococcal infections that might bedue to their adoption of sophisticatedtertiary neonatal care with a high rate ofinvasive device use [16].Neonates in Abha NICU on mechanical ventilation had significantly2.7 times higher risk of developingNIs compared with other neonates.Similarly, in Riyadh, Saudi Arabia themean ventilator-associated pneumoniarate in the paediatric ICU was 8.87 per1000 ventilation-days with a ventilationutilization rate of 47% [21].Neonates in Abha NICU on totalparenteral nutrition had a significantly5.6 times greater risk of developingNIs compared with other neonates.Similarly, in Riyadh, a study showedthat in paediatric ICUs, patients whohad total parenteral nutrition infusedthrough the line had 8.6 times greaterrisk of developing NIs [22]. This maybe due to the severity of illness or a deficiency in adhering to parenteral fluidinfusion guidelines. Standard infectioncontrol practices—hand hygiene, isolation, aseptic techniques, cleaning anddisinfection or sterilization of reusedequipment and elimination of pointsources of contamination—minimizemany such hazards. Alcohol-basedantiseptics for hand hygiene are an appealing innovation because of their efficacy in reducing hand contaminationand their ease of use, especially whensinks and supplies for hand-washing arelimited [23].The results of this study will assist indeveloping intervention strategies forthe prevention of NIs in NICUs in theregion. Interventions should target theuse of total parenteral nutrition (indications, preparation, storage, administration and time of use) and mechanicalventilation. More continuing medicaleducation programmes are needed forthe health care team to improve theircompetence.References1.Lawn JE et al. Why are 4 million newborn babies dying eachyear? Lancet, 2004, 364:399–401.2.Saving Newborn Lives. The state of the world’s newborns: a reportfrom Saving Newborn Lives. Washington DC, Save the Children,2001.3.Hyder AA, Wali SA, McGuckin J. The burden of disease fromneonatal mortality: a review of South Asia and Sub-SaharanAfrica. British journal of obstetrics and gynaecology, 2003,110:894–901.4.Mother–baby package: a road map for implementation in countries. Geneva, World Health Organization, 1993.5.Stoll BJ. Neonatal infections: a global perspective. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus and newborninfant, 5th ed. Philadelphia, WB Saunders, 2001:139–68.43
EMHJ Vol. 16Eastern Mediterranean Health JournalLa Revue de Santé de la Médiderranée orientaleNo. 1 20106.Nejjari N et al. Infections nosocomiales a Acinetobacter experience du service de neonatologie de Casablanca. [Nosocomialinfections caused by Acinetobacter: experience in a neonatalcare unit in Casablanca.] La Tunisie médicale, 2003, 81:121–5.15.Klein JO. Bacterial sepsis and meningitis. In: Remington JS,Klein JO, eds. Infectious diseases of the fetus, newborn and infants, 5th ed. Philadelphia, WB Saunders, 2001:943–84.7.Yalcin AN. Socioeconomic burden of nosocomial infections.Indian journal of medical science, 2003, 57:450–6.16.Zaidi A et al. Hospital-acquired neonatal infections in developing countries. Lancet, 2005, 365:1175–88.8.Raza MW et al. Developing countries have their own characteristic problems with infection control. Journal of hospitalinfection, 2004, 57:294–9.17.Raymond J, Aujard Y. Nosocomial infections in pediatric patients: a European, multicenter prospective study. EuropeanStudy Group. Infection control and hospital epidemiology, 2000,21:260–3.9.Richards C et al. Klebsiella pneumoniae bloodstream infectionsamong neonates in a high-risk nursery in Cali, Colombia. Infection control and hospital epidemiology, 2004, 25:221–5.18.Sohn A et al. Prevalence of nosocomial infections in neonatalintensive care unit patients: results from the first national pointprevalence survey. Journal of pediatrics, 2001, 139(6):821–7.10.Ho JJ. Late onset infection in very low birth weight infants inMalaysian level 3 neonatal nurseries. Pediatric infectious diseasejournal, 2001, 20:557–60.19.Urrea M et al. A prospective incidence study of nosocomialinfections in a neonatal care unit. American journal of infection,2003, 31(8):505–7.11.Martinez-Aguilar G et al. Outbreak of nosocomial sepsis andpneumonia in a newborn intensive care unit by multiresistantextended-spectrum beta-lactamase producing Klebsiella pneumoniae: high impact on mortality. Infection control and hospitalepidemiology, 2001, 22:725–8.20. Kilani RA, Basamad M. Pattern of proven bacterial sepsis in aneonatal intensive care unit in Riyadh—Saudi Arabia: a 2-yearanalysis. Le journal médical libanais, 2000, 48(2):77–83.21.Almuneef M et al. Ventilator-associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a 30-month prospective surveillance. Infection control and hospital epidemiology,2004, 25(9):753–8.12.Nagata E, Brito AS, Matsuo T. Nosocomial infections in a neonatal intensive care unit: incidence and risk factors. Americanjournal of infection, 2002, 30:26–31.13.Garner JS et al. CDC definitions for nosocomial infections.American journal of infection, 1988, 16:128–40.22. Almuneef M et al. Rate, risk factors and outcomes of catheter re lated blood stream infection in a pediatric intensive care unit inSaudi Arabia. Journal of hospital infection, 2006, 62(2):207–9.14.Harris J, Goldmann D. Infections acquired in the nursery:epidemiology and control. In: Remington JS, Klein JO, eds.Infectious diseases of the fetus, newborn and infants, 5th ed.Philadelphia, WB Saunders, 2001:1371–418.23. Brown SM et al. Use of an alcohol-based hand rub and qualityimprovement interventions to improve hand hygiene in a Russian neonatal intensive care unit. Infection control and hospitalepidemiology, 2003, 24:172–9.Note from the EditorWe wish to draw the kind attention of our potential authors to the importance of applying the editorial requirements ofEMHJ when preparing their manuscripts for submission for publication. These provisions can be seen in the Guidelinesfor Authors, which are available online at http://www.emro.who.int/emhj.htm, and are published at the end of the firstissue of each volume. We regret that we are unable to consider papers that do not conform to the Guidelines.44
unit, 77 developed infections, a period prevalence of 19.2% and an incidence of 13.7 infections per 1000 patient- days. The most frequent infections were: pneumonia (50.0%), primary bloodstream (40.9%) and skin and soft tissues (6.5%). In logistic regression analysis, mechanical ventilation (OR 2.69, 95% CI: 1.39–5.19) and total parenteral nutrition (OR 5.62, 95% CI: 2.78–11.35) were .
Fact Sheet; Neonatal Biology –An Overview Part 3. Journal of Neonatal Nursing, 17(4), 128-131. Petty, J. (2011b). Fact Sheet; Neonatal Biology –An Overview Part 2. Journal of Neonatal Nursing, 17(3), 89-91. Petty, J. D. (2011c). Fact Sheet; Neonatal Biology –An Overview Part 1. Journal of Neonatal Nursing, 17(1), 8-10. For further detail and more resources, go to the online resource .
(community-acquired or nosocomial). For nosocomial cases, investigations were extensive, collecting informa-tion concerning the acquisition unit and patient room . Alpes-Auvergne, Clermont-Ferrand, IRB 5891). Results From 01/03/2020 to 11/05/2020, 4811 samples from
Nosocomial Influenza and Vaccination of Healthcare Workers Dr. Helena Maltezou, Hellenic Center for Disease Control and Prevention A Webber Training Teleclass Hosted by Paul Webber paul@webbertraining.com www.webbertraining.com 3 Study of 1.561 nosocomial epide
Nosocomial Infections Infection acquired in the hospital: 48 hours after admission 5 billion annually: increased hospital length of stay, antibiotics, morbidity and mortality related to severity of underlying disease, immunosuppression, invasive medical interventions frequently caused by antibiotic-resistant organisms: MRSA, VRE, resistant Gram-File Size: 1MB
Neonatal and Paediatric Pharmacist’s Group Standards for Neonatal Intensive Care Units and the recognition of the essential contribution of the pharmacist to caring for our youngest patients. We will continue to work with our members working in neonatal and paediatric care
6.23 Neonatal conditions See Background Paper 6.23 (BP6_23Neonatal.pdf) Background The neonatal period is only the first 28 days of life and yet accounts for 40% of all deaths in children under five.1 Even within the neonatal period there is wide variation in mortality rates, with 75% of all neonatal deaths occurring in the first week of life –
4.2 Neonatal Wound Care Principles 11-13 4.2.1 Neonatal Wounds 12 4.2.2 Neonatal Skin 12 4.2.3 Management Factors 13 4.2.4 Dressing Procedures 13 4.3 Wound Dressing Grid 11 - 14 4.4 Basic Wound Care Procedure - algorithm 17 4.5 Wound Assessment Action Plan 18 - 19 4.6 Neonatal Stoma Care Guideline 20-23
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