Level Neonatal Intensive Care Unit Research Articles

Chronic lung disease in very low birth weight infants: Persistence and improvement of a quality improvement process in a tertiary level neonatal intensive care unit.

We previously demonstrated a significant reduction in our incidence of chronic lung disease in our NICU using potentially better practices of avoiding delivery room endotracheal intubation and using early nasal CPAP. We sought to demonstrate whether these improvements were sustained and or improved over time. We conducted a retrospective, cross-sectional analysis of infants 501-1500 grams born at our hospital between 2005 and 2013. Infants born during the 2005-2007, 2008-2010 and 2011-2013 epochs were grouped together, respectively. Descriptive analysis was conducted to determine the number and percent of maternal and neonatal characteristics by year grouping. Chi-squared tests were used to determine whether there were any statistically significant changes in characteristics across year groupings.. Two outcome variables were assessed: a diagnosis of chronic lung disease based on the Vermont Oxford Network definition and being discharged home on supplemental oxygen. There was a statistically significant improvement in the incidence of chronic lung disease in infants below 27 weeks' gestation in the three year period in the 2011-2013 cohort compared with those in the 2005-2007 cohort. We also found a statistically significant improvement in the number of infants discharged on home oxygen with birth weights 751-1000 grams and infants with gestational age less than 27 weeks in the 2011-2013 cohort compared to the 2005-2007 cohort. We demonstrated sustained improvement in our incidence of CLD between 2005 and 2013. We speculate that a multifaceted strategy of avoiding intubation and excessive oxygen in the delivery room, the early use of CPAP, as well as the use of volume targeted ventilation, when needed, may help significantly reduce the incidence of CLD.

Influence of Maternal Graduation on the Cognitive Development of Very Low-Birth-Weight Infants

Background: Very low-birth-weight infants with birth weight less than 1,500 g have an increased risk for a worse neurocognitive outcome. Early therapeutic intervention can reduce the level of developmental disorder. To detect the infants with the need of early support it is important to define risk factors affecting the development beside birth weight. Method: During the years 2009 to 2013, a total of 209 very low-birth-weight infants were treated in our neonatal intensive care unit level 1, of which 187 survived. With standardized questionnaire the maternal graduation was asked. At the corrected age of 24 months, we performed a follow-up examination with the Bayley Scales of Infant Development II to the families. The collected data were analyzed with Excel and the statistical program GraphPad Prism (version 4.0). Results: Eleven percent of the parents gave no information about the maternal graduation, 9% of the mothers did not have any school degree, 16% had a certificate of lower German secondary education, 25% had a certificate of middle secondary education, 8% had higher German secondary education, and 31% had a final German secondary-school examination. One hundred fifty (80%) of the surviving infants had participated the follow-up examination. Both participation of the follow-up examination and MDI (mental developmental index) were depending on the maternal graduation. Conclusion: Very low-birth-weight infants of women with low socioeconomic status rarely take part in follow-up examinations and have a worse neurocognitive outcome. In our region (Ruhrgebiet) the part of mothers without or with low school graduation is higher than in other regions of Germany. It is important to register the maternal graduation to detect families with the need of follow-up examinations and early interventions.

Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension

Hypertensive diseases of pregnancy are associated with severe maternal morbidity and remain common causes of maternal death. Recently, national guidelines have become available to aid in recognition and management of hypertension in pregnancy to reduce morbidity and mortality. The increased morbidity related to hypertensive disorders of pregnancy is presumed to be associated with the development of severe hypertension. However, there are few data on specific treatment or severe maternal morbidity in women with acute severe intrapartum hypertension as opposed to severe preeclampsia. The study aimed to characterize maternal morbidity associated with women with acute severe intrapartum hypertension, and to determine whether there was an association between various first-line antihypertensive agents and posttreatment blood pressure. This retrospective cohort study of women delivering between July 2012 and August 2014 at 15 hospitals participating in the California Maternal Quality Care Collaborative compared women with severe intrapartum hypertension (systolic blood pressure >160 mm Hg or diastolic blood pressure >105 mm Hg) to women without severe hypertension. Hospital Patient Discharge Data and State of California Birth Certificate Data were used. Severe maternal morbidity using the Centers for Disease Control and Prevention criteria based on International Classification of Diseases-9 codes was compared between groups. The efficacy of different antihypertensive medications in meeting the 1-hour posttreatment goal was determined. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression. There were 2252 women with acute severe intrapartum hypertension and 93,650 women without severe hypertension. Severe maternal morbidity was significantly more frequent in the women withsevere hypertension (8.8%) compared to the control women (2.3%) (P< .0001). Severe maternal morbidity rates did not increase with increasing severity of blood pressures (P= .90 for systolic and .42 for diastolic). There was no difference in severe maternal morbidity between women treated (8.6%) and women not treated (9.5%) (P= .56). Antihypertensive treatment rates were significantly higher in hospitals with a level IV neonatal intensive care unit (85.8%) compared to a level III neonatal intensive care unit (80.2%) (P < .001), and in higher-volume hospitals (84.5%) compared to lower-volume hospitals (69.1%) (P < .001). Severe maternal morbidity rates among severely hypertensive women were significantly higher in hospitals with level III neonatal intensive care unit level compared to hospitals with a level IV neonatal intensive care unit (10.6% vs 5.7%, respectively; P < .001), and significantly higher in low-delivery volume hospitals compared to high-delivery volume hospitals (15.5% vs 7.6%, respectively; P < .001). Only 53% of women treated with oral labetalol as first-line medication met the posttreatment goal of nonsevere hypertension, significantly less than those treated with intravenous hydralazine, intravenous labetalol, or oral nifedipine (68%, 71%, and 82%, respectively) (P= .001). Severe intrapartum hypertension remained untreated in 17% of women. Women with acute severe intrapartum hypertension had a significantly higher risk of severe maternal morbidity compared to women without severe hypertension. Significantly lower antihypertensive treatment rates and higher severe maternal morbidity rates were seen in lower-delivery volume hospitals.

Pattern of morbidity and mortality of neonates admitted in tertiary level neonatal intensive care unit in Nalanda Medical College and Hospital, Patna, Bihar, India

Background: The objective of the study was t o determine the disease pattern and causes of neonatal mortality in tertiary level neonatal care unit. Methods: Retrospective, analytic and descriptive study, clinical, hospital based. Divisions of neonatology, NMCH, Patna, during January 2012 to December 2015, total 4 year, all neonates less than 28 days were included. Baseline epidemiological clinical data and outcome were recorded in predesigned format. Results: Study comprised of total 4457 neonates’ morbidity pattern showed maximum share of prematurity 1762 cases, sepsis 1157 cases, birth asphyxia 1162 cases, meconium aspiration syndrome 304 cases, congenital malformations 98 cases, neonatal jaundice 614 cases, and 319 IUGR case. Mortality was 1043 cases. Out-born cases 83%, early neonatal mortality was 638 cases. Case fatality for prematurity was 25.93%, birth asphyxia 20.99%, congenital malformations 14.28%, sepsis 17.98% and MAS 15.46%. Conclusions: Prematurity, neonatal sepsis and birth asphyxia are leading causes of neonatal mortality in our study. Interventions to reduce preterm delivery, low birth weight and birth asphyxia should be planned and implemented by health care managers at community level. Mortality is still unacceptably high; improvements in neonatal care at different levels will definitely reduce the neonatal deaths.

Cerebral Oxygen Saturation to Guide Oxygen Delivery in Preterm Neonates for the Immediate Transition after Birth: A 2-Center Randomized Controlled Pilot Feasibility Trial

To assess if monitoring of cerebral regional tissue oxygen saturation (crSO2) using near-infrared spectroscopy (NIRS) to guide respiratory and supplemental oxygen support reduces burden of cerebral hypoxia and hyperoxia in preterm neonates during resuscitation after birth. Preterm neonates <34(+0) weeks of gestation were included in a prospective randomized controlled pilot feasibility study at 2 tertiary level neonatal intensive care units. In a NIRS-visible group, crSO2 monitoring in addition to pulse oximetry was used to guide respiratory and supplemental oxygen support during the first 15 minutes after birth. In a NIRS-not-visible group, only pulse oximetry was used. The primary outcomes were burden of cerebral hypoxia (<10th percentile) or hyperoxia (>90th percentile) measured in %minutes crSO2 during the first 15 minutes after birth. Secondary outcomes were all cause of mortality and/or cerebral injury and neurologic outcome at term age. Allocation sequence was 1:1 with block-randomization of 30 preterm neonates at each site. In the NIRS-visible group burden of cerebral hypoxia in %minutes, crSO2 was halved, and the relative reduction was 55.4% (95% CI 37.6-73.2%; P = .028). Cerebral hyperoxia was observed in NIRS-visible group in 3 neonates with supplemental oxygen and in NIRS-not-visible group in 2. Cerebral injury rate and neurologic outcome at term age was similar in both groups. Two neonates died in the NIRS-not-visible group and none in the NIRS-visible group. No severe adverse reactions were observed. Reduction of burden of cerebral hypoxia during immediate transition and resuscitation after birth is feasible by crSO2 monitoring to guide respiratory and supplemental oxygen support. ClinicalTrials.gov: NCT02017691.

Work-Related Burden on Physicians and Nurses Working in Neonatal Intensive Care Units: A Survey

Aim: This study aimed at exploring the type, degree, and duration of work-related burden on neonatal physicians and nurses working in tertiary level neonatal intensive care units, its impact on their private life, and at assessing which coping strategies were found helpful. Methods: Transversal descriptive study using an anonymous questionnaire. Results: Fifty-two neonatal physicians and 60 nurses took part in this survey (response rate 77%). Altogether, 78% stated that the difficult medical and ethical dilemmas represent a burden to them. 87% experienced this work burden as momentary, and 12% as long-lasting. In 40% of the respondents, their private life was affected. Exhaustion was the most frequently cited stress symptom (physicians 25%, nurses 15%). Close to 90% of the caregivers were offered a platform for team debriefings and discussions or pastoral assistance by their hospital, but most of the respondents found relief from stress through discussions with family members and friends (20%), and through their hobbies (15%), or both (43%). Conclusion: Working in a NICU environment represents a burden for the majority of neonatal health care providers. Exhaustion was the most frequent symptom. Social contacts with family and friends and hobbies are the coping strategies found most helpful. Staff meetings, debriefing platforms and pastoral assistance help alleviate work-related stress. Keywords: Coping; Coping behavior; Exhaustion; Work-related stress; NICU

Effects of a Birth Hospital’s Neonatal Intensive Care Unit Level and Annual Volume of Very-Low-Birth-Weight Infant Deliveries on Morbidity and Mortality

Annual volume of deliveries better predicts risk-adjusted mortality among preterm infant than neonatal intensive care unit (NICU) levels. However, it is unknown whether NICU level and annual volume of very-low-birth-weight (VLBW) deliveries differentially affect neonatal morbidity. In this retrospective, population-based cohort study, the authors evaluated birth records of 72,431 infants (500- to 1499-g birth weight) born between 1999 and 2009, in order to assess independent effects of VLBW deliveries and NICU level on risk of various neonatal morbidities. Primary outcomes were individual morbidity-mortality composites of death or bronchopulmonary dysplasia, necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and severe intraventricular hemorrhage (IVH). Secondary outcomes included death (in the NICU or in-hospital), age at death, and individual morbidities without mortality. The NICU levels were I (basic well-newborn care), IIA/B (resuscitation, stabilization, and available mechanical ventilation/noninvasive positive airway pressure of preterm infants before transfer), IIIA (comprehensive care), and IIIB/C (comprehensive care for VLBW infants). Statistical analysis used multivariate logistic regression models, adjusted for covariates and other confounders. Results show that proportion of VLBW infants born at NICU level IIIB/C increased from 68.8% to 72.6% during the study period, whereas those born at NICU level I decreased from 9.5% to 7.9% (P < 0.001). Delivery at lower-level NICUs and lower-volume hospitals was associated with earlier mortality, within the first 24 hours of life, for VLBW infants (66% level I vs 48% level IIIB/C). In terms of composite morbidity-mortality, birth at hospitals with low (≤10) VLBW infant deliveries per year was associated with the highest risk-adjusted probability of death (15.3%), death/severe IVH (17.5%), and death/NEC (19.3%). Rates of complications were also higher for infants born in level I or II NICUs than those born in level IIIB/C NICUs. Risk-adjusted probability of death or ROP was highest among infants born at level IIIB/C NICU (32.6%) and lowest among infants at hospitals with level IIIA (25.5%). In contrast to all these results, when looking at individual morbidities instead of composites, risk-adjusted probability of each morbid condition, except IVH, was lowest among infants at level I NICUs or low VLBW infant deliveries per year. However, this result may be due to a “protective” effect from the high early mortality rate of 66%, meaning infants passed away before morbidities could develop. Overall, higher and earlier mortality rates among preterm infants at lower-level NICUs prevented the authors’ ability to assess full effect of birth hospital on morbidity. However, low volume of deliveries (<50 per year) was a strong risk factor for infant morbidity and death, for example, death/severe IVH and death/NEC. This risk was 15% to 36% higher after adjusting for NICU level. In addition, morbidity-mortality composite outcomes showed that VLBW infants delivered at high-level NICUs had improved outcomes compared with those delivered at low-level ones. The authors thus recommend transferring high-risk pregnancies to hospitals with high-level NICUs and a high-volume of VLBW deliveries.

Measuring severe maternal morbidity: validation of potential measures

Both maternal mortality rate and severe maternal morbidity rate have risen significantly in the United Sates. Recently, the Centers for Disease Control and Prevention introduced International Classification of Diseases, 9th revision, criteria for defining severe maternal morbidity with the use of administrative data sources; however, those criteria have not been validated with the use of chart reviews. The primary aim of the current study was to validate theCenters for Disease Control and Prevention International Classificationof Diseases, 9th revision, criteria for the identification of severe maternal morbidity. This analysis initially required the development of a reproducible set of clinical conditions that were judged to be consistent with severe maternal morbidity to be used as the clinical gold standard for validation. Alternative criteria for severe maternal morbidity were also examined. The 67,468 deliveries that occurred during a 12-month period from 16 participating California hospitals were screened initially for severe maternal morbidity with the presence of any of 4 criteria: (1) Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, diagnosis and procedure codes; (2) prolonged postpartum length of stay (>3 standard deviations beyond the mean length of stay for the California population); (3) any maternal intensive care unit admissions (with the use of hospital billing sources); and (4) the administration of any blood product (with the use of transfusion service data). Complete medical records for all screen-positive cases were examined to determine whether they satisfied the criteria for the clinical gold standard (determined by 4 rounds of a modified Delphi technique). Descriptive and statistical analyses that included area under the receiver operating characteristic curve and C-statistic were performed. The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria had a reasonably highsensitivity of 0.77 and a positive predictive value of 0.44 with a C-statistic of 0.87. The most important source of false-positive cases weremothers whose only criterion was 1-2 units of blood products. The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria screen rate ranged from 0.51-2.45% among hospitals. True positive severe maternal morbidity ranged from0.05-1.13%. When hospitals were grouped by their neonatal intensive care unit level of care, severe maternal morbidity rates were statistically lower at facilities with lower level neonatal intensive care units(P < .0001). The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria can serve as a reasonable administrative metric for measuring severe maternal morbidity at population levels. Caution should be used with the use of these criteria for individual hospitals, because case-mix effects appear to be strong.

Neonatal Cortical Auditory Evoked Potentials Are Affected by Clinical Conditions Occurring in Early Prematurity.

Cortical auditory evoked potentials may serve as an early indicator of developmental problems in the auditory cortex. The aim of the study was to determine the effect on neonatal cortical auditory processing of clinical conditions occurring in early prematurity. Sixty-seven preterm infants born at 29 weeks mean gestational age (range, 23-34 weeks) were recorded at a mean postconception age of 35 weeks, before discharge from the third level neonatal intensive care unit. The average of 330 responses to standard 1000 Hz pure tones delivered in an oddball paradigm was recorded at frontal location. Data of 45 of 67 recruited premature infants were available for analysis. Mean amplitudes calculated from the data points of 30 milliseconds centered on P1 and N2 peaks in the waveforms of each subject were measured. The effect of perinatal clinical factors on cortical auditory evoked responses was evaluated. The amplitude of P1 component was significantly lower in infants with bronco-pulmonary dysplasia (P = 0.004) and retinopathy of prematurity (P = 0.03). The multivariate analysis, done to evaluate the relative weight of gestational age and bronco-pulmonary dysplasia and/or retinopathy of prematurity on cortical auditory evoked potentials components, showed an effect of clinical factors on P1 (P = 0.005) and of gestational age on N2 (P = 0.02). Cortical auditory processing seems to be influenced by clinical conditions complicating extremely preterm birth.

Effects of a Birth Hospital's Neonatal Intensive Care Unit Level and Annual Volume of Very Low-Birth-Weight Infant Deliveries on Morbidity and Mortality.

The annual volume of deliveries of very low-birth-weight (VLBW) infants has a greater effect on mortality risk than does neonatal intensive care unit (NICU) level. The differential effect of these hospital factors on morbidity among VLBW infants is uncertain. To assess the independent effects of a birth hospital's annual volume of VLBW infant deliveries and NICU level on the risk of several neonatal morbidities and morbidity-mortality composite outcomes that are predictive of future neurocognitive development. Retrospective, population-based cohort study (performed in 2014) of all VLBW infants without severe congenital anomalies delivered in all hospitals in California, Missouri, and Pennsylvania between January 1, 1999, and December 31, 2009 (N = 72,431). Risk-adjusted odds ratios and risk-adjusted probabilities were determined by logistic regression. The primary study outcomes were the individual composites of death or bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity, and severe intraventricular hemorrhage. Among the 72,431 VLBW infants in the present study, birth at a hospital with 10 or less deliveries of VLBW infants per year was associated with the highest risk-adjusted probability of death (15.3% [95% CI, 14.4%-16.3%]), death or severe intraventricular hemorrhage (17.5% [95% CI, 16.5%-18.6%]), and death or necrotizing enterocolitis (19.3% [95% CI, 18.1%-20.4%]). These complications were also more common among infants born at hospitals with a level I or II NICU compared with infants delivered at hospitals with a level IIIB/C NICU. The risk-adjusted probability of death or retinopathy of prematurity was highest among infants born at hospitals with a level IIIB/C NICU and lowest among infants born at hospitals with a level IIIA NICU. When the effects of NICU level and annual volume of VLBW infant deliveries were evaluated simultaneously, the annual volume of deliveries was the stronger contributor to the risk of death, death or severe intraventricular hemorrhage, and death or necrotizing enterocolitis. The risk of death or severe intraventricular hemorrhage and death or necrotizing enterocolitis was lowest among infants born in hospitals that had both a high volume of VLBW infant deliveries and a high-level NICU. Antenatal transfer of high-risk pregnancies to these hospitals may reduce mortality and improve outcomes.

Antibiotics Before Removal of Percutaneously Inserted Central Venous Catheters Reduces Clinical Sepsis in Premature Infants.

Evaluate the incidence of postcatheter removal clinical sepsis when antibiotics were infused prior to the removal of percutaneously inserted central venous catheters (PICCs). A retrospective chart review of premature neonates (n = 196) weighing ≤1250 g at birth with 218 PICC line removals in the presence or absence of antibiotics at a tertiary level neonatal intensive care unit (NICU) between January 1, 2010, and May 31, 2012. Charts were reviewed looking for the presence of clinical sepsis defined as a sepsis workup including white blood cell count, differential, C-reactive protein, blood and/or cerebral spinal fluid (CSF), and urine cultures along with at least 48 hours of antibiotic therapy given within 72 hours after removal of a PICC line. Antibiotics were considered present at line removal if given within 12 hours before catheter removal either electively or at completion of a planned course. When antibiotics were given within 12 hours before PICC line removal, only 2% of the line removal episodes (1/48) resulted in a neonate developing clinical sepsis versus 13% (21/165) when no antibiotics were given prior to removal (p = 0.03, Fisher's exact test). Despite the increased use of elective antibiotics with line removal, there was no increase in total antibiotic usage due to the overall decrease in episodes of clinical sepsis or changes in antibiogram susceptibility patterns. There was an 11% absolute decrease and a 6-fold relative decrease in postcatheter removal clinical sepsis events in premature neonates who received antibiotics prior to PICC line removal.

Incidence, clinical characteristics and attributable mortality of persistent bloodstream infection in the neonatal intensive care unit.

BackgroundAn atypical pattern of neonatal sepsis, characterized by persistent positive blood culture despite effective antimicrobial therapy, has been correlated with adverse outcomes. However, previous studies focused only on coagulate-negative staphylococcus infection.MethodsAll episodes of persistent bloodstream infection (BSI), defined as 3 or more consecutive positive blood cultures with the same bacterial species, at least two of them 48 hours apart, during a single sepsis episode, were enrolled over an 8-year period in a tertiary level neonatal intensive care unit. These cases were compared with all non-persistent BSI during the same period.ResultsWe identified 81 episodes of persistent BSI (8.5% of all neonatal late-onset sepsis) in 74 infants, caused by gram-positive pathogens (n=38, 46.9%), gram-negative pathogens (n=21, 25.9%), fungus (n=20, 24.7%) and polymicrobial bacteremia (n=2, 2.5%). Persistent BSI does not differ from non-persistent BSI in most clinical characteristics and patient demographics, but tends to have a prolonged septic course, longer duration of feeding intolerance and more frequent requirement of blood transfusions. No difference was observed for death attributable to infection (9.8% vs. 6.5%), but neonates with persistent BSI had significantly higher rates of infectious complications (29.6% vs. 9.2%, P < 0.001), death from all causes (21.6% vs. 11.7%, P = 0.025), and duration of hospitalization among survivors [median (interquartile range): 80.0 (52.5-117.5) vs. 64.0 (40.0-96.0) days, P = 0.005] than those without persistent BSI.ConclusionsAlthough persistent BSI does not contribute directly to increased mortality, the associated morbidities, infectious complications and prolonged septic courses highlight the importance of aggressive treatment to optimize outcomes.

G124(P) Is it time to enforce rigorous infection control guidelines for visitors attending the neonatal intensive care unit?

Nosocomial infections remain a major issue in neonatal intensive care units (NICU). This is related to numerous factors including, impaired immunity, fragile skin, and invasive lines. The impact of healthcare workers on infection transmission has been well documented, however little work has looked at the risk posed by visitors who frequently handle infants on NICU. Aims The aim of our study was to assess the existing infection control guidelines and their enforcement for visitors attending tertiary level NICUs across England and to recommend a standard set of guidelines to reduce the risk of infection in infants on NICU. Methods Our study included 46 level 3 NICUs across England during November 2013–March 2014. A survey questionnaire was set and the sister in charge was contacted by telephone. Results Among 46 units, 46(100%) responded to the survey. 27(58.7%) provided infection control leaflets for visitors, all of those included hand washing. 15 of the 27(55.5%) had multilingual leaflets. 34(73.9%) used a cot-side nurse or receptionist to enforce infection control policies. 11(23.9%) had no restricted visiting times, only if accompanied by parents. 42(91.3%) allowed siblings, however 2 excluded winter, 1 disallowed siblings under 6, and 1 only in infectious outbreaks. 26 (56.5%) had a limited handling policy. All allowed kangaroo care, 28(60.9%) of which stipulated only when the baby was stable. 10(21.7%) allowed it any time. 1(2.2%) only permitted on extubation and if lines were taken out. 42(91.3%) prohibited wearing coats. 3(6.5%) had a bare below the elbow policy and 25 (54.3%) asked that jewellery was removed. None of the units asked visitors to remove plain bands. All stipulated hand washing, however 44(95.6%) stipulated hand gelling. 3(6.5%) stipulated the wearing of gowns, and 4 (8.6%) asked visitors to wear gloves, both of which were only necessary if the baby had an infection. Conclusion Our study results have thrown light on variations in infection control policies for visitors to NICUs across England. A set of infection control guidelines and methods for their enforcement are proposed.

Surveillance of healthcare-associated infections in a neonatal intensive care unit in Italy during 2006-2010.

BackgroundHealthcare-associated infections (HAIs) are a frequent complication associated with hospitalization of infants in neonatal intensive care units (NICUs). The aim of this study was to evaluate and describe the results of surveillance of HAIs in a III level NICU in Naples, Italy during 2006–2010.MethodsThe surveillance covered 1,699 neonates of all birth weight (BW) classes with > 2 days NICU stay. Infections were defined using standard Centers for Disease Control and Prevention definitions adapted to neonatal pathology and were considered to be healthcare-associated if they developed > 2 days after NICU admission.ResultsOne hundred-fifty-three HAIs were diagnosed with a frequency of 9% and an incidence density of 3.5 per 1000 days of hospital stay. HAIs developed in all BW classes, but patients weighing ≤ 1000 g at birth were more affected with a decreasing trend from the lowest to the highest BW classes. Sepsis proved to be the most frequent infection (44.4%), followed by urinary tract infection (UTI) (28.8%), pneumonia (25.5%) and meningitis (1.3%). Device associated infections (i.e. central line-associated bloodstream infections (BSIs), umbilical catheter-associated BSI and ventilator associated pneumonias (VAPs) represented 64.1% of all HAIs. Most frequent pathogens responsible for all types of infections were: P. aeruginosa (17%), C. parapsilosis (16.3%), E. coli (13.1%), C. albicans (10.5%), non- extended spectrum beta-lactamase (ESBL) K. pneumoniae (7.8%), and coagulase-negative Staphylococci (5.2%). No microbiological diagnosis was achieved for 6.5% of infections.ConclusionsHAIs developed in all BW classes but low BW neonates were at major risk to acquire HAIs in our NICU. Use of central line-, umbilical-catheter and mechanical ventilation was associated with higher risk of infection. Our findings highlight the importance of an extensive surveillance approach in the NICU setting, which includes all BW classes of neonates and monitors infections associated with the use of medical devices.

Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants.

Infants in the neonatal intensive care unit (NICU) are subjected to stress, including sound of high intensity. The sound environment in the NICU is louder than most home or office environments and contains disturbing noises of short duration and at irregular intervals. There are competing auditory signals that frequently challenge preterm infants, staff and parents. The sound levels in NICUs often exceed the maximum acceptable level of 45 decibels (dB), recommended by the American Academy of Pediatrics. Hearing impairment is diagnosed in 2% to 10% of preterm infants versus 0.1% of the general paediatric population. Noise may cause apnoea, hypoxaemia, alternation in oxygen saturation, and increased oxygen consumption secondary to elevated heart and respiratory rates and may, therefore, decrease the amount of calories available for growth. Elevated levels of speech are needed to overcome the noisy environment in the NICU, thereby increasing the negative impacts on staff, newborns, and their families. High noise levels are associated with an increased rate of errors and accidents, leading to decreased performance among staff. The aim of interventions included in this review is to reduce sound levels to 45 dB or less. This can be achieved by lowering the sound levels in an entire unit, treating the infant in a section of a NICU, in a 'private' room, or in incubators in which the sound levels are controlled, or reducing the sound levels that reaches the individual infant by using earmuffs or earplugs. By lowering the sound levels that reach the neonate, the resulting stress on the cardiovascular, respiratory, neurological, and endocrine systems can be diminished, thereby promoting growth and reducing adverse neonatal outcomes. Primary objectiveTo determine the effects of sound reduction on growth and long-term neurodevelopmental outcomes of neonates. Secondary objectives1. To evaluate the effects of sound reduction on short-term medical outcomes (bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leukomalacia, retinopathy of prematurity).2. To evaluate the effects of sound reduction on sleep patterns at three months of age.3. To evaluate the effects of sound reduction on staff performance.4. To evaluate the effects of sound reduction in the neonatal intensive care unit (NICU) on parents' satisfaction with the care. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, abstracts from scientific meetings, clinical trials registries (clinicaltrials.gov; controlled-trials.com; and who.int/ictrp), Pediatric Academic Societies Annual meetings 2000 to 2014 (Abstracts2View(TM)), reference lists of identified trials, and reviews to November 2014. Preterm infants (< 32 weeks' postmenstrual age (PMA) or < 1500 g birth weight) cared for in the resuscitation area, during transport, or once admitted to a NICU or a stepdown unit. We performed data collection and analyses according to the Cochrane Neonatal Review Group. One small, high quality study assessing the effects of silicone earplugs versus no earplugs qualified for inclusion. The original inclusion criteria in our protocol stipulated an age of < 48 hours at the time of initiating sound reduction. We made a deviation from our protocol and included this study in which some infants would have been > 48 hours old. There was no significant difference in weight at 34 weeks postmenstrual age (PMA): mean difference (MD) 111 g (95% confidence interval (CI) -151 to 374 g) (n = 23). There was no significant difference in weight at 18 to 22 months corrected age between the groups: MD 0.31 kg, 95% CI -1.53 to 2.16 kg (n = 14). There was a significant difference in Mental Developmental Index (Bayley II) favouring the silicone earplugs group at 18 to 22 months corrected age: MD 14.00, 95% CI 3.13 to 24.87 (n = 12), but not for Psychomotor Development Index (Bayley II) at 18 to 22 months corrected age: MD -2.16, 95% CI -18.44 to 14.12 (n =12). To date, only 34 infants have been enrolled in a randomised controlled trial (RCT) testing the effectiveness of reducing sound levels that reach the infants' ears in the NICU. Based on the small sample size of this single trial, we cannot make any recommendations for clinical practice. Larger, well designed, conducted and reported trials are needed.

Audit of sepsis in neonatal surgeries at tertiary-care level hospital in India

Background: Postoperative sepsis, which has high morbidity and mortality, is a major problem affecting the outcome of neonatal surgeries. Adequate treatment and preventive measures for sepsis can decrease the morbidity and mortality in neonatal surgeries. Objective: (1) To study the incidence of sepsis in neonatal surgical patients and (2) To study the causative organisms and their sensitivity to antibiotics in such sepsis. Materials and Methods: A prospective, observational study was carried out in the tertiary-care level neonatal intensive care unit of SSG Hospital, Vadodara, Gujarat. Eighty newborns having a major surgery within the first 30 days of life were included in the study. Baseline data of the study participants were collected including antenatal and perinatal histories and evidence of postoperative sepsis. Complete examination and investigations including quantitative C-reactive protein (QCRP), WBC counts, blood culture, and treatment were also included. Conclusion: Incidence of postoperative sepsis in neonates was found to be 73.75%. We found coagulase-negative Staphylococcus aureus to be the most common organism (38%) cultured from blood, followed by Klebsiella (19%) and Acinetobactor (18.2%), which was sensitive to cefotaxime, amikacin, and piperacillin/tazobactam.

Antibiotic Prescribing Pattern in a Tertiary Level Neonatal Intensive Care Unit.

Neonatal sepsis is a major cause of morbidity and mortality worldwide especially in developing countries, which justifies early diagnosis and prompt treatment with antibiotics. Antibiotics are the most frequently used medicines in Neonatal Intensive care units. Data regarding rational antibiotic use in neonates is very limited. Hence, it is essential that the antibiotic prescribing patterns be evaluated periodically for its rational use. Therefore, the present study been carried out to identify the prescribing patterns of antibiotics in neonatal intensive care unit of a tertiary care hospital, Western Maharashtra, India. A prospective observational study was carried out for 6 months between April to September 2014. The data regarding patient demographics and antibiotic use was collected daily in a structured proforma. Collected data was subjected to statistical analysis. Out of total 528 neonates with male preponderance (62%), 370 received antibiotics. Mean gestational age and birth weight were 35±3.2 weeks and 2±0.7 kg respectively. Mean length of hospital stay was 14.26±15.36 days (range 1 to 136 days). A total of 1123 antibiotics were prescribed to 370 neonates. The majority of neonates (55.9%) received between 1-2 antibiotics, 37.3% had 3 to 5 antibiotics prescribed, while 6.7% neonates were prescribed more than 5 antibiotics. Number of antibiotics used had statistically significant inverse relationship with gestational age. Among antibiotics; Amikacin, Cefotaxime and Levofloxacin were the drugs most often prescribed. Amikacin and Cefotaxime were given more to term infants whereas other antibiotics like Levofloxacin, Pipercillin- tazobactam and Meropenem were prescribed more to preterm and outborn neonates. The use of a high number of antibiotics is a common practice. Although the indications for use of most antibiotics could be justified, the increased frequency of anbiotics use in some neonates was of concern. Guidelines for the use of antibiotics in neonates are required and larger studies are needed on this issue.

Breakthrough bacteremia in the neonatal intensive care unit: Incidence, risk factors, and attributable mortality

An episode of breakthrough bacteremia, which was defined as positive blood cultures despite appropriate antibiotic therapy, imposes a treatment challenge in the neonatal intensive care unit (NICU). All episodes of breakthrough bacteremia from a tertiary level NICU in Taiwan between 2004 and 2011 were analyzed and compared with nonbreakthrough bacteremia. Breakthrough bacteremia was identified in 7.6% (72/942) of neonatal bacteremia, and 43 (59.7%) occurred as recurrent episodes. Gram-negative organisms (41.7%) and fungi (15.3%) accounted for more than half of all microorganisms in breakthrough bacteremia. Compared with nonbreakthrough bacteremia, breakthrough bacteremia was significantly associated with more severe disease, was more likely to require aggressive therapies, and had a higher rate of infectious complications. Previous use of broad-spectrum antibiotics (odds ratio [OR], 7.54; P<.001) and particular microbial etiologies (Pseudomonas aeruginosa: OR, 4.40; P=.025; fungi: OR, 2.70; P=.013) were independent risk factors for developing breakthrough bacteremia. The crude sepsis-attributable mortality rate was greater in breakthrough bacteremia episodes (16.7% vs 6.4%; P=.004), and this condition was independently associated with an increased risk of death (OR, 2.14; 95% confidence interval, 1.04-4.40; P=.040). Breakthrough bacteremia is not uncommon (7.6% of all bacteremia) in NICUs and represents a more severe form of neonatal bacteremia that is independently associated with an increased risk of death.

Referral of Very Low Birth Weight Infants to High-Risk Follow-Up at Neonatal Intensive Care Unit Discharge Varies Widely across California

To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative. Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral. In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ≤ 750 g vs 1251-1499g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment. There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.

PO-0523 Toxicity And Viral Load In Urine During Valganciclovir Therapy In Premature Infants

Background and aims Antiviral therapy with Valganciclovir, a relatively new but potentialtoxic oral drug, is recommended to prevent further hearing deterioration in infants with (congenital) CMV infection. Viral load monitoring can possibly beused as indicator for effective treatment. Methods A retrospective cohort study (2005–2010) in a third level neonatal intensive care unit. Neonates ≤32 weeks of gestational age (GA) with CMV infection treated with oral Valganciclovir (30 mg/kg/day) were included. Time interval (days) to reach CMV viral load below detection level ( 9 /L) and leukopenia ( 9 /L). Results Data of 6 infants, median gestational age 25 +2 (range 25 +1 –28 +4 ) weeks, 2 with congenital and 4 with postnatal infection, were analysed. Time interval between start of therapy and viral load below detection level was 25–54 days and below therapeutic level 10–31 days. 28/37 plasma samples were in the normal range, 3/37 above and 6/37 under the target concentration. Mild transient leukopenia (4.5 × 10 9 /L) occurred in 1 infant. No thrombocytopenia occurred. Conclusions A dosage of 30 mg/kg/day Valganciclovir in premature infants with CMV infection provided a fairly rapid decrease of CMV viral load in urine, without causing serious short term toxicity.