English title dissertation Infections in Neonatal Intensive Care
Name PhD (surname first) Van den Hoogen
Doctor is (has been) nurse
Date of promotion 08/09/2009
University University Medical Center Utrecht
Promotores Prof Dr F van Bel, Dr TG Krediet, Dr LJ Gerards
Abstract (English)

Neonatal infections are an important cause of morbidity and mortality in neonatal intensive care units. Epidemiological studies have shown shifts in causative agents.
At present Gram-positive microorganisms, in particular group B streptococci, are major causative microorganisms in early-onset sepsis, although the incidence of group B streptococcal sepsis is decreasing due to antimicrobial prophylaxis to the mother.
Coagulase-negative staphylococci are the major causative agents of late-onset nosocomial sepsis, although Gram-negative microorganisms and Candida species are increasingly important.

In-line filters in the intravenous (IV) administration sets are used to prevent the infusion of particles, endotoxins and bacteria, which may reduce infectious complications. We randomized infants to treatment with in-line filter (for clear fluids and lipid emulsions) or no filter placement. This study showed that in-line filters did not result in a significant decrease in nosocomial sepsis: sepsis occurred in 16% of the infants both with and without filters.

Administration of antibiotics during removal of the PCVC significantly reduced the occurrence of sepsis within 72 hours after removal in a group of 345 infants. In 22/213(10.3%) cases, sepsis occurred when no antibiotics were administered, versus 2/132 cases of sepsis (1.5%) when antibiotics were administered (p=0.002). This study suggests that removal of peripherally inserted central venous catheters is a risk for sepsis. Administration of antibiotics targeted at the time of removal of the catheter significantly reduced the incidence of sepsis. These results needed to be substantiated in a prospective study.

A prospective study on the effect of prophylactic administration of cefazolin during the procedure of removal of a PCVC was described. This study suggests that prophylactic administration of cefazolin may prevent CoNS-sepsis associated with the removal of a PCVC. Implementation of the prophylaxis might especially be beneficial in the group of infants with increased risk for CVC-related sepsis, i.e. with a gestational age < 32 weeks. The effect of a multimodal intervention program to improve the adherence to hand hygiene guidelines was studied among all Health Care Workers (HCWs) in the NICU. Multimodal intervention programs have been proven to be effective in the adherence to hygienic rules. The study comprised baseline observation sessions on adherence to hygienic rules, which were compared with observation during a second assessment performed after a period of 9 months with multimodal interventions, which included presentations on hand hygiene and actual data on nosocomial infections and drawing attention by posters and videos. The multimodal intervention program resulted in a significant increase in adherence to hygienic rules, from 23% adherence in the baseline assessment to 50% in the second assessment is. However, a result of 50% adherence is still too low and requires further improvement. We noticed in our studies that most neonatal infections are bloodstream infections, most probably associated with intravascular catheters, including peripherally inserted central venous catheters, umbilical catheters and surgically inserted central venous catheters. Prevention of these infectious complications is a major challenge. 1 Of major importance is a sustained attention to hygienic rules, which has been proven to increase with the use of a multimodal intervention program. 2 A great proportion of neonatal late-onset sepsis is associated with invasive procedures that are considered necessary in neonatal intensive care.The use of invasive procedures has to be judged with criticism. 3 Early introduction of enteral feeding in newborns limits the duration of total parenteral nutrition and the need for central venous access, which may decrease the incidence of infectious complications. 4 Implementation of a special “IV”-team, responsible for the insertion and management of central venous catheters in the NICU, may be beneficial to prevent and decrease adverse outcomes in the management of central lines. Efforts to decrease catheter related infections include proper antisepsis of the skin before insertion, antiseptic precautions during insertion, aseptic technique when entering the line and minimizing the number of entry into the line and decreasing catheter duration. 5 An infectious disease team, including paediatric infectious disease specialist, medical microbiologist, hospital hygiene specialist and neonatologist, plays an important role in the decision on treatment of infants with infectious diseases.

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