Risk factors and prevention of late-onset sepsis in premature infants
Introduction
Late-onset sepsis (LOS) is a common complication of prolonged admission to the neonatal intensive care unit (NICU) following preterm birth [1]. Neonatal sepsis is categorized as either early-onset (EOS) or LOS. EOS, often due to group B Streptococci or Escherichia coli, occurs in the first 3 days of life and is associated with prolonged rupture of membranes, maternal colonization with group B Streptococci, and prematurity [2], [3]. LOS occurs after the third day of life and, among premature infants, is most often caused by Gram-positive organisms [1], [4].
Section snippets
Organisms
The causative organism in LOS is an important predictor of overall outcome. Gram-positive organisms account for 45–77% of infections [1], [2], [5]. Of the Gram-positive organisms, coagulase-negative Staphylococci are the most prevalent [1], [2], [4], [6], [7]. In a large cohort of infants who had blood cultures drawn, mortality was similar between infants with a negative first blood culture 8% (390/4648) and those infants with Gram-positive infections 6% (10/169), HR = 0.74; 95% CI 0.4–1.39 (
Morbidities
Premature infants enrolled in the NICHD's Neonatal Research Network Generic Database undergo developmental testing at 18–22 months corrected age. Neurodevelopmental impairment at this visit is defined as a score of < 70 on Mental or Psychomotor Developmental Index on the Bayley Scales of Infant Development II, cerebral palsy, blindness, or deafness. Using multivariable analysis, investigators demonstrated that extremely low birth weight (ELBW, < 1000 g birth weight) infants who developed sepsis
Birth weight and gestational age
LOS is more common among the most premature infants [1], [2], [3], [5], [10], [13]. Among infants < 750 g birth weight, the cumulative incidence of LOS is 43% [1]. In a cohort of infants admitted to 250 NICUs in the US, there were 374 infections for every 1000 admissions for infants < 750 g birth weight and only 7 infections per 1000 admissions in infants > 2500 g birth weight (Table 1). The majority of the infections occur in the first 40 days of life (Fig. 2) [14]. Invasive candidiasis occurs in
Handwashing
Proper hand hygiene is the most important methods of preventing the spread of nosocomial infections [18]. Hand hygiene educational programs decrease infection rates in the NICU [19], [20], [21], as has the implementation of a designated infection control healthcare worker [22].
Although improving handwashing compliance is important, sustaining compliance over long periods of time is difficult. A study comparing several previously published hand hygiene programs in adult populations found the
Safety of interventions
Before implementation of widespread interventions to prevent LOS, clinicians must evaluate infection rates in their own nursery. For example, in a NICU with a cumulative incidence of invasive candidiasis of 1.2%, 100 infants would need to be treated with fluconazole prophylaxis to prevent 1 infection (Table 2). However, for NICUs where the cumulative incidence is 17.9%, only 7 infants would need to be treated to prevent one infection.
Prophylaxis studies frequently have high control (or placebo
Conclusion
LOS is common in premature infants and is associated with significant mortality, neurodevelopmental impairment among survivors, and increased health care costs. Although several interventions have proven effective under specific conditions, aside from improved hand hygiene, larger studies performed at sites with baseline infection rates representative of most NICUs and analysis of long term outcome data (resistance, neurodevelopmental outcomes) are needed before widespread adoption of these
Conflict of interest
Dr. Downey has no conflicts to declare.
Dr. Benjamin receives support from the United States Government for his work in pediatric and neonatal clinical pharmacology (1R01HD057956-02, 1R01FD003519-01, 1U10-HD45962-06, 1K24HD058735-01, and Government Contract HHSN267200700051C), the non profit organization Thrasher Research Foundation for his work in neonatal candidiasis (http://www.thrasherresearch.org), and from industry for neonatal and pediatric drug development
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2021, Journal of Neonatal NursingCitation Excerpt :Klebsiella pneumoniae has been the most common gram-negative organism in LOS within this population (Downey et al., 2010; Hornik et al., 2012; Perlman et al., 2007) and unfortunately has the highest mortality with some studies reporting up to 74% mortality in preterm infants (Downey et al., 2010). Both central venous catheters and mechanical ventilation utilization increases the risk of LOS(Downey et al., 2010). If an infant has any clinical changes that raise a concern for LOS, an evaluation should begin immediately.
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