A Study on Ventilator-associated Pneumonia as a Risk for Nosocomial Infection in Mechanically Ventilated Neonates In NICU of Assiut University Children Hospital (Nicu Eta)
Condition: Neonatal SEPSIS; Nosocomially Acquired Neonatal Sepsis
MeSH terms: Pneumonia; Sepsis; Toxemia; Pneumonia, Ventilator-Associated; Neonatal Sepsis; Cross Infection
Study type: Observational

Summary: 
      Abstract

      Background: Neonatal ventilator associated pneumonia (VAP) is a major hospital-acquired
      infection in acute care settings, associated with high mortality and poor outcome. VAP is
      considered a preventable infection if the risk factors are managed effectively. The purpose
      of this study is to evaluate prevalence of ventilator associated pneumonia, its causative
      organisms, its risk factors and outcome at our NICU.

      This study used CDC guidelines for infant's ≤1 year old to diagnose neonatal VAP, in period
      from April 2018 to March 2019.
    

Detailed description: 
      Background:

      Neonatal deaths represent third of the global burden of child mortality [1]. In Egypt,
      Infections such as pneumonia, meningitis, sepsis/septicemia and other infections account for
      28% of deaths during the neonatal period, Survival cannot be achieved without substantial
      reductions in infection-specific neonatal mortality [2]. Neonatal sepsis is usually
      classified as early or late onset sepsis. Early sepsis occurs within the first 72 hours of
      birth and late neonatal sepsis occurs after 72 hours of birth. Early neonatal sepsis is
      associated with acquisition of microorganism from mother Late neonatal sepsis usually occurs
      due to the lack of aseptic working conditions [3]. The occurrence of late sepsis is
      considered an important indicator of quality of care. Mechanical ventilation is an essential,
      life-saving therapy for patients with critical illness and respiratory failure. These
      patients are at high risk for complications and poor outcomes, including death,
      Ventilator-associated pneumonia (VAP), Sepsis, pulmonary embolism, barotrauma, and pulmonary
      edema. Such complications can lead to longer duration of mechanical ventilation, longer stays
      in the intensive care unit (ICU) and hospital, increased healthcare costs, and increased risk
      of disability and death [4, 5]. Ventilator associated pneumonia (VAP) is defined as a
      nosocomial lower airway infection, i.e. pneumonia, in intubated patients with onset after 48
      h or more of invasive mechanical ventilation [6]. VAP is usually caused by airway
      colonization by potential pathogens; Sources of airway colonization can be the patient's own
      flora, i.e., bacterial overgrowth in oral secretions, reflux and aspiration of gastric fluid
      or the patient's environment with its caretakers and equipment [7, 8].

      Mechanically ventilated babies face a particular risk because artificial airways bypass the
      body's defenses against inhaled pathogens and offer new routes for non-air borne pathogens.
      Intubation associated lesions of pharynx and trachea lead to bacterial colonization by the
      deterioration of the swallowing reflex and the ciliary functions [9].VAP is one of the most
      frequently diagnosed nosocomial infections [10] and, after suspected early onset sepsis,
      second most reason for antibiotic intervention in Neonatal Intensive Care Unit (NICU) [11,
      12].VAP incidence can be reduced by infection control measures such as VAP-prevention-bundles
      [13]. Regarding diagnosis of VAP episode requires a combination of radiological, clinical,
      and laboratory criteria. However Center for Disease Control and Prevention/ National
      Nosocomial Infection Surveillance (CDC/NNIS) criteria refers to infants younger than 1 year
      and do not define specific criteria for the newborn period in term or preterm infants. In
      spite of this lack of specificity, most studies of VAP performed in NICUs are based on these
      criteria [14].

      Keywords: Newborn, Mechanical ventilation, ventilator-associated pneumonia, risk factors,
      causative organisms.

      'Method's: Design: A prospective, observational cohort surveillance, was carried out at our
      Neonatal Intensive Care Unit (NICU) was done during a period from April 2018 to March 2019 to
      neonates who needed mechanical ventilation, reviewing data of diagnosis of neonates with
      ventilation associated pneumonia used .

      Setting: Our NICU is a level III, part of a university-teaching hospital, receives referrals
      from the whole Upper Egypt. It has approximately 1450 case per year, approximately ~ 5
      patients per day. It has approximately 450 case needs MV per year.

      Patients:

      Inclusion criteria:

      All inborn and outborn neonates who were admitted to the our NICU during the April 2018-
      March 2019 were screened for study enrollment and were considered eligible if ventilated for
      more than 48 hours.

      Exclusion criteria:

      Neonates ventilated with Evidence of neonatal sepsis before ventilated. Meconium aspiration
      syndromes were excluded. Death within 48 hours of NICU admission.

      • Neonates In our study were classified into two groups; i. Group A: cases with suspected
      VAP. ii. Group B: cases without VAP. Because up to this point we don't know the lab result
      and microbiology. The diagnosis should be based on all of the three items of radiologic
      signs, clinical signs and Symptoms and microbiological findings Cernada M et al [15].

      Intervention:

        -  Medical records comprising charts, daily flow sheets, laboratory and radiographic
           reports were collected prospectively by the investigators.

        -  Neonates with suspected VAP in NICU: were diagnosed as VAP according to:

      (Modified CDC guidelines for infants≤1 year old)[5,6,13].

      All patient will be subjected to:

        1. Full history taking:

           Including: Patient data, Perinatal history, Present history, Family history.

        2. Full clinical examination:

           i. General physical assessment.

             1. Gestational age.

             2. Growth measurements.

             3. Vital data.

             4. General appearance. ii. Systems assessment.

             1. Neurological Examination.

             2. Respiratory Examination.

             3. Cardio-vascular Examination.

             4. Abdominal Examination. Then Monitoring of the ventilator settings, and fraction of
                inspired oxygen (FIO2).

           The clinical criteria for diagnosis; Worsening gas exchange: desaturations pulse
           oximetry less than 94%, increase ventilation demand,

           And at least three of the following Temperature instability Leukopenia (≤4000 WBC/mm3)
           or leukocytosis (>15,000 WBC/mm3) and left shift Band forms (10%) New onset of purulent
           sputum or change in character of sputum, or increased respiratory secretions Apnea,
           tachypnea, nasal flaring with retraction of chest wall or nasal flaring with grunting
           Wheezing, rales, or rhonchi

        3. Investigation:

             1. Imaging study chest x-ray on admission& follow up, ultrasound, CT scan when
                indicated.

             2. Complete blood count, capillary blood gases. C) Septic screening

                  1. Initial evaluation inflammatory mediator (C-reactive protein)

                  2. Blood culture.

                  3. Culture of bronchoalveolar lavage: aspirate for culture non-quantitative
                     cultures after the third day hen weekly until extubation. Antibiotic
                     sensitivity test will be done to all culture.

                     We tried to compare the results of BAL versus blood culture in the diagnosis
                     of VAP according to Cantey JB et al[12] ,aimed to intensive role of BAL.

                     Microorganisms isolated from blood were compared with that isolated from BAL.
                     According to results:

                  1. Full agreement: when the same strain of organism has been isolated from the
                     blood and endotracheal tube aspirate cultures,

                  2. Partial agreement: when the organisms in the blood were found as one of the
                     multiple isolates from the endotracheal tube,

                  3. No agreement: when the organism was found in the endotracheal tube aspirate
                     and blood was not the same,

        4. Lines of treatment:

             -  Initial (empirical) therapy is most often begun before a definite causative agent
                is identified.

             -  Continuing therapy is based on culture and sensitivity results, clinical course

      Ethical considerations:

      The aim of the study was explained to each parents of the child before the beginning of the
      process. A written consent was obtained from those who welcomed to participate in the study.
      Privacy and confidentiality of all data were assured.

      Statistical analysis:

      The data were tested for normality using the Kolmogorov-Smirnov test and for homogeneity
      variances prior to further statistical analysis. Categorical variables were described by
      number and percent (N, %), where continuous variables described by mean and standard
      deviation (Mean, SD). Chi-square test used to compare between categorical variables where
      compare between continuous variables by t-test (One Way ANOVA). A two-tailed p < 0.05 was
      considered statistically significant. All analyses were performed with the IBM SPSS 20.0
      software.
    

Intervention name(s): others
Intervention type(s): Other
Intervention description(s): others
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        porotocal of thesis ;