Investigation and control of a meticillin-resistant Staphylococcus aureus (MRSA) outbreak in a Level 2 neonatal unit in England: findings from a cohort study.

Clinical trials show that antimicrobial-impregnated central venous catheters reduce catheter-related bloodstream infection in adults and children receiving intensive care, but there is insufficient evidence for use in newborn babies. The objectives were (1) to determine clinical effectiveness by conducting a randomised controlled trial comparing antimicrobial-impregnated peripherally inserted central venous catheters with standard peripherally inserted central venous catheters for reducing bloodstream or cerebrospinal fluid infections (referred to as bloodstream infections); (2) to conduct an economic evaluation of the costs, cost-effectiveness and value of conducting additional research; and (3) to conduct a generalisability analysis of trial findings to neonatal care in the NHS. Three separate studies were undertaken, each addressing one of the three objectives. (1) This was a multicentre, open-label, pragmatic randomised controlled trial; (2) an analysis was undertaken of hospital care costs, lifetime cost-effectiveness and value of information from an NHS perspective; and (3) this was a retrospective cohort study of bloodstream infection rates in neonatal units in England. The randomised controlled trial was conducted in 18 neonatal intensive care units in England. Participants were babies who required a peripherally inserted central venous catheter (of 1 French gauge in size). The interventions were an antimicrobial-impregnated peripherally inserted central venous catheter (coated with rifampicin-miconazole) or a standard peripherally inserted central venous catheter, allocated randomly (1 : 1) using web randomisation. Study 1 - time to first bloodstream infection, sampled between 24 hours after randomisation and 48 hours after peripherally inserted central venous catheter removal. Study 2 - cost-effectiveness of the antimicrobial-impregnated peripherally inserted central venous catheter compared with the standard peripherally inserted central venous catheters. Study 3 - risk-adjusted bloodstream rates in the trial compared with those in neonatal units in England. For study 3, the data used were as follows: (1) case report forms and linked death registrations; (2) case report forms and linked death registrations linked to administrative health records with 6-month follow-up; and (3) neonatal health records linked to infection surveillance data. Study 1, clinical effectiveness - 861 babies were randomised (antimicrobial-impregnated peripherally inserted central venous catheter, n = 430; standard peripherally inserted central venous catheter, n = 431). Bloodstream infections occurred in 46 babies (10.7%) randomised to antimicrobial-impregnated peripherally inserted central venous catheters and in 44 (10.2%) babies randomised to standard peripherally inserted central venous catheters. No difference in time to bloodstream infection was detected (hazard ratio 1.11, 95% confidence interval 0.73 to 1.67; p = 0.63). Secondary outcomes of rifampicin resistance in positive blood/cerebrospinal fluid cultures, mortality, clinical outcomes at neonatal unit discharge and time to peripherally inserted central venous catheter removal were similar in both groups. Rifampicin resistance in positive peripherally inserted central venous catheter tip cultures was higher in the antimicrobial-impregnated peripherally inserted central venous catheter group (relative risk 3.51, 95% confidence interval 1.16 to 10.57; p = 0.02) than in the standard peripherally inserted central venous catheter group. Adverse events were similar in both groups. Study 2, economic evaluation - the mean cost of babies' hospital care was £83,473. Antimicrobial-impregnated peripherally inserted central venous catheters were not cost-effective. Given the increased price, compared with standard peripherally inserted central venous catheters, the minimum reduction in risk of bloodstream infection for antimicrobial-impregnated peripherally inserted central venous catheters to be cost-effective was 3% and 15% for babies born at 23-27 and 28-32 weeks' gestation, respectively. Study 3, generalisability analysis - risk-adjusted bloodstream infection rates per 1000 peripherally inserted central venous catheter days were similar among babies in the trial and in all neonatal units. Of all bloodstream infections in babies receiving intensive or high-dependency care in neonatal units, 46% occurred during peripherally inserted central venous catheter days. The trial was open label as antimicrobial-impregnated and standard peripherally inserted central venous catheters are different colours. There was insufficient power to determine differences in rifampicin resistance. No evidence of benefit or harm was found of peripherally inserted central venous catheters impregnated with rifampicin-miconazole during neonatal care. Interventions with small effects on bloodstream infections could be cost-effective over a child's life course. Findings were generalisable to neonatal units in England. Future research should focus on other types of antimicrobial impregnation of peripherally inserted central venous catheters and alternative approaches for preventing bloodstream infections in neonatal care. Current Controlled Trials ISRCTN81931394. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 57. See the NIHR Journals Library website for further project information.

An outbreak of meticillin-resistant Staphylococcus aureus colonization in a neonatal intensive care unit: use of a case–control study to investigate and control it and lessons learnt

Detection, survival, and persistence of Staphylococcus capitis NRCS-A in neonatal units in England

Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

IntroductionSildenafil is increasingly used to treat PPHN secondary to chronic lung disease in neonates. Severity of PPHN has been linked to increased mortality at two years.1 There is no national...

Babies born to mothers living in more deprived areas and from ethnic minority groups are at a higher risk of dying during the neonatal period. Preterm and unwell term babies are cared for in neonatal units, and this population contributes substantially to the child mortality rate. The extent of and reasons for socioeconomic and ethnic inequalities in neonatal unit outcomes are unclear. We aimed to evaluate socioeconomic and ethnic inequalities in characteristics and mortality of babies admitted to National Health Service (NHS) neonatal units in England and Wales. In this retrospective cohort study, any baby that was born at or after 22 weeks' gestation and admitted to an NHS neonatal unit in England and Wales, received neonatal care, and had clinical data registered in the National Neonatal Research Database was eligible for inclusion. Our primary exposures of interest were index of multiple deprivation (IMD) and maternal ethnicity. We assessed inequalities in in-unit mortality before discharge using nested logistic regression models, estimating crude, confounder-adjusted, and case-mix adjusted odds of mortality. Case-mix variables on admission were gestational age, birthweight, sex, maternal age, smoking during pregnancy, the presence of any congenital anomaly, obstetric problem, and previous medical problem in the mother. Between Jan 1, 2012, and Dec 31, 2022, 709 569 babies were included in the analysis and there were 11 257 (1·6%) neonatal unit deaths. Of the 678 550 babies with complete IMD information, 649 180 (95·7%) babies were born to mothers living in England and 29 308 (4·3%) to mothers living in Wales. 561 621 (79·1%) babies had complete information on exposures and case-mix variables on admission used for logistic regression. More babies in neonatal units were born to women from the most deprived decile (102 419 [15·1%]) compared with the least deprived decile (43 882 [6·5%]). Babies born to women from the most deprived decile were at increased risk of mortality (odds ratio [OR] 1·63 [95% CI 1·48-1·81]) than babies born to women from the least deprived decile. After adjusting for ethnicity, the OR was 1·52 (1·38-1·69), and after adjusting for case-mix, the OR was 1·23 (1·10-1·37). Babies born to mothers who were Black had an OR for mortality of 1·81 (1·67-1·95) compared with mothers who were White, attenuated to 1·68 (1·55-1·81) after adjusting for deprivation, and 1·14 (1·05-1·24) in the case-mix adjusted model. Babies born to mothers who were Asian had an OR for mortality of 1·48 (1·39-1·57) compared with mothers who were White, attenuated to 1·40 (1·32-1·49) after adjusting for deprivation, and 1·36 (1·27-1·45) in the case-mix adjusted model. There are stark socioeconomic and ethnic inequalities in babies admitted to and who die in neonatal units in England and Wales. Mortality inequalities are partly explained by case-mix on entry to the neonatal unit, suggesting in-unit factors such as care practices explaining residual inequalities. Further work to investigate the role of care practices is required, as well as policies and practices to address upstream drivers of these inequalities. Hugh Greenwood Legacy Fund, University of Liverpool, and National Institute for Health and Care Research.

ObjectiveTo evaluate variation in trends in bloodstream infection (BSI) rates in neonatal units (NNUs) in England according to the data sources and linkage methods used.MethodsWe used deterministic and probabilistic methods to link clinical records from 112 NNUs in the National Neonatal Research Database (NNRD) to national laboratory infection surveillance data from Public Health England. We calculated the proportion of babies in NNRD (aged <1 year and admitted between 2010–2017) with a BSI caused by clearly pathogenic organisms between two days after admission and two days after discharge. We used Poisson regression to determine trends in the proportion of babies with BSI based on i) deterministic and probabilistic linkage of NNRD and surveillance data (primary measure), ii) deterministic linkage of NNRD-surveillance data, iii) NNRD records alone, and iv) linked NNRD-surveillance data augmented with clinical records of laboratory-confirmed BSI in NNRD.ResultsUsing deterministic and probabilistic linkage, 5,629 of 349,740 babies admitted to a NNU in NNRD linked with 6,660 BSI episodes accounting for 38% of 17,388 BSI records aged <1 year in surveillance data. The proportion of babies with BSI due to clearly pathogenic organisms during their NNU admission was 1.0% using deterministic plus probabilistic linkage (primary measure), compared to 1.0% using deterministic linkage alone, 0.6% using NNRD records alone, and 1.2% using linkage augmented with clinical records of BSI in NNRD. Equivalent proportions for babies born before 32 weeks of gestation were 5.0%, 4.8%, 2.9% and 5.9%. The proportion of babies who linked to a BSI decreased by 7.5% each year (95% confidence interval [CI]: -14.3%, -0.1%) using deterministic and probabilistic linkage but was stable using clinical records of BSI or deterministic linkage alone.ConclusionLinkage that combines BSI records from national laboratory surveillance and clinical NNU data sources, and use of probabilistic methods, substantially improved ascertainment of BSI and estimates of BSI trends over time, compared with single data sources.

Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization and infection among infants at a level III neonatal intensive care unit

BackgroundInfants born at 34+0 to 36+6 weeks gestation are defined as ‘late preterm’ infants. It is not clear whether these babies can be managed on the postnatal ward (PNW) or routinely need to be admitted to the neonatal unit after birth.AimTo conduct a national survey of admission practice for late preterm and low birth weight infants directly to the PNW after birth in England.MethodsAll neonatal units were identified from the Standardised Electronic Neonatal Database (SEND). Individual units were contacted and data collected on their admission practice.ResultsAll 180 neonatal units in England responded. 49, 84 and 47 Units were Special Care Units (SCUs), Local Neonatal Units (LNUs) and Neonatal Intensive Care Units (NICUs) respectively. 161 units (89%) had written guidelines in relation to direct PNW admission for late preterm infants.The mean gestational age of infants admitted directly to the PNW was significantly lower in LNUs compared to SCUs and NICUs compared to LNUs. Mean birth weight limit for direct PNW admission was significantly lower in NICUs compared to SCUs.72 units had PNW nursery nurses. There was no significant difference in gestational age or birth weight limit for direct PNW admission in the presence of PNW nursery nurses.ConclusionsAdmission practices of late preterm infants directly to the PNW varies according to designation of neonatal unit in England. Further studies are needed to establish the factors influencing these differences.

Introduction and aimsNecrotising Enterocolitis predominantly affects premature infants, and it is the commonest and most severe gastrointestinal emergency in this patient group. Enterally fed probiotics are a promising new approach...

AIMTo establish how neonatal units in England and Wales currently confirm longline tip position, immediately after insertion of a longline.METHODSWe conducted a telephone survey of 170 neonatal units (37 special care baby units, 81 local neonatal units and 52 neonatal intensive care units) across England and Wales over the period from January to May 2016. Data was collected on specifically designed proformas. We gathered information on the following: Unit Level designation; whether the unit used longlines and specific type used? Modality used to confirm longline tip position? Whether guide wires were routinely removed and contrast injected to determine longline position? The responders were primarily senior nurses.RESULTSWe had 100% response rate. Out of the total neonatal units surveyed (170) in England and Wales, 141 units (83%) used longlines. Fifty-five out of 81 local neonatal units (68%) using longlines, used ones that came with guide wires; a similar percentage of neonatal intensive care units, i.e., 31 out of 52 units (60%) did the same. All of those units used radiography, plain X-rays, to establish longline tip position. Out of 55 local neonatal units using longlines with guide wires, 42 (76%) were not removing wire to use contrast while this figure was 58% (18 out of 31 units) for neonatal intensive care units. Overall, only 49 out of 141 units (35%) of the units using longlines were using contrast. However it was interesting to note that use of contrast increased as one moved from special care baby units (25%, 2 out of 8 units) to local neonatal units (28%, 23 out of 81 units) and neonatal intensive care units level (46%, 24 out of 52 units) designation.CONCLUSIONNeonatal units in England and Wales are overwhelmingly relying on plain radiographs to assess longline tip position immediately after insertion. Despite evidence of its usefulness, and in the absence of perhaps more accurate methods of assessing longline tip position in a reliable and consistent way, e.g., ultrasonography, contrast is only used in a third of units.

Objective To assess the impact of reorganisation of neonatal specialist care services in England after a UK Department of Health report in 2003.Design A population-wide observational comparison of outcomes over...

ObjectiveTo identify the primary reasons for term admissions to neonatal units in England, to determine risk factors for admissions for jaundice and to estimate the proportion who can be cared...

AimTo conduct national survey of admission practice for near term and low birth weight (B Wt) infants directly to postnatal ward (PNW) after birth.MethodAll Neonatal Units in England contacted over...

BackgroundBreast milk has significant benefits for preterm babies, but ‘very preterm’ babies are unable to feed directly from the breast at birth. Their mothers have to initiate and sustain lactation through expressing milk for tube feeding until their babies are developmentally ready to feed orally. There are wide disparities between neonatal units in England in rates of breast milk feeding at discharge. This study explored health professionals’ experiences of barriers and facilitators to their role in supporting breast milk feeding and breastfeeding for very preterm babies.Methods12 health professionals were interviewed, from four neonatal units in England with high or low rates of breast milk feeding at discharge. Interviews were analysed using comparative thematic analysis.ResultsFive themes were developed: ‘The role of the infant feeding specialist’, ‘Achieving a whole team approach to breast milk feeding’, ‘Supporting initiation of breastfeeding’ ‘Supporting long-term expressing’, ‘Supporting the transition to breastfeeding’. There were notable differences between neonatal units in the time allocated to specialist feeding support, the team’s sense of collective responsibility for supporting feeding, leadership, the use of external standards as levers for change, and training for the multi-disciplinary team. The feeding challenges faced by mothers of very preterm babies could be made worse where there was no joined-up working between neonatal and postnatal staff; inadequate facilities for mothers to stay with their babies; and when opportunities were missed to give information about the importance of early initiation of expressing and to support mothers’ confidence during the transition to direct breastfeeding.ConclusionsEffective support can be influenced by having a supernumerary post dedicated to infant feeding; strong leadership that champions breast milk feeding and breastfeeding within Family Integrated Care; maintaining accountability by using existing quality improvement tools and accredited standards for neonatal units; and training for the whole multi-disciplinary team that encourages and enables every member of staff to take an appropriate share of responsibility for consistently informing and assisting mothers with expressing and breastfeeding. Joined-up working between staff on antenatal and postnatal wards and neonatal units is important to enable integrated feeding support for the mother-baby dyad.