Infections in Neonatal Intensive Care: Prevalence, Prevention and Antibiotic use

Neonatal infections are an important cause of morbidity in neonatal intensive care units (NICUs). Prematurity or very low birth weight is an important predisposing factor for neonatal infection. In addition, preterm infants have a compromized immune system and they often require invasive procedures that provide a portal of entry. The epidemiology of sepsis since 1978 on our NICU showed a decrease in incidence of early-onset sepsis. Group B streptococci and, less frequent, Escherichia coli were the most important microorganisms during the years, causing early-onset sepsis. The incidence of late-onset sepsis caused by Coagulase Negative Staphylococci (CoNS) and S. aureus increased significantly over the years. The increase of the use of central venous and arterial catheters probably contributed to the increase in infections in neonates. In contrary to studies in the USA, infections due to gram-negative microorganisms and fungi or yeasts were rare on our unit (incidence <0.3%). The use of antibiotics is high on the NICU. We showed that 85 - 90% of all admitted infants was treated with antibiotics, whereas the incidence of proven early-, and late-onset sepsis was much lower (range 1.2-2.4% and 7.1-14%, respectively). However, a significant decrease in length of antibiotic treatment was noted over the period for the most frequently used antibiotics. The results of this study emphasize that correct identification of infants with sepsis is difficult and remains a major challenge in attempts to further reduce antibiotic use and postpone the emergence of antibiotic resistant microorganisms. Prevention of neonatal sepsis is a major challenge. The use of in-line filters in the intravenous administration (IV) sets in neonates was randomly studied. This study showed that in-line filters did not result in a significant decrease in nosocomial sepsis. However, a more continuous administration of intravenous medication (especially cardio-inotropics) and parenteral nutrition was guaranteed, while there was no difference in costs of materials. For the purpose of patient safety the use of in-line filters in all IV administration systems may be recommended in neonatal intensive care units. In a retrospective and a prospective study on percutaneously inserted central venous catheter (PCVC) -removal and its relationship with sepsis, we showed that besides indwelling PCVC as a risk factor for late-onset sepsis also removal of a PCVC is a risk factor. Administration of antibiotics targeted at the time of removal of the catheter significantly reduced the incidence of sepsis. Very important in the prevention of late-onset sepsis in neonates is the adherence to hygienic rules. In varies studies it is shown that it is very difficult for medical and nursing healthcare workers to adhere to hygienic rules and hand hygiene. Multimodal intervention programs have been proven to be effective in the adherence to hygienic rules. Our multimodal intervention program resulted in a significant increase in adherence to hygienic rules, from 23% to 50%. However, a result of 50% adherence is still too low and requires further improvement.