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Health care-associated infection (HCAI), also referred to as nosocomial or hospital acquired, is an infection that a patient acquires and (a) becomes evident 48 hours or more after admission, (b) was not present or incubating at the time of admission to the hospital, and (c) develops while the patient is receiving treatment of other conditions. Neonates admitted to the neonatal intensive care unit (NICU) frequently contract HCAIs1 and may present with a wide range of symptoms, including fulminant sepsis, particularly late-onset sepsis (LOS). A significant number of HCAIs are preventable, even in the high-risk and vulnerable NICU population. Therefore, any discussion of HCAI management must also emphasize the role of preventive measures (refer to chapter 53).


Risk Factors


Recognition of risk factors for HCAIs is important when evaluating an acutely ill/decompensating patient for a possible HCAI.


  1. Patient related: These risk factors are strongly influenced by the gestational age or weight at birth.2 With decreasing gestational age and birth weight, the more likely it is that an HCAI can occur as there is an underdeveloped immune response, increased hospital length of stay, severity of illness, exposure to NICU-related risk factors (see next item), and development of chronic and exacerbating medical conditions such as chronic lung disease (CLD) or necrotizing enterocolitis (NEC).

  2. NICU related: These risk factors include the following:

    1. indwelling intravascular or transmucosal catheters,

    2. mechanical ventilation,

    3. total parenteral nutrition (TPN) and intralipids,

    4. broad-spectrum antibiotic therapy,

    5. treatment with histamine2 receptor antagonists (H2 blockers),

    6. steroid administration, and

    7. exposure to the endemic microbial flora of the NICU environment as well as its health care workers.3, 4, and 5


Clinical Signs and Symptoms


The clinical presentation can range from nonspecific and subtle to severe, multisystem organ dysfunction. Common presenting findings are the following:


  1. Neurological:

    1. temperature instability (fever or hypothermia);

    2. apnea (unrelated to/distinct from apnea of prematurity);

    3. lethargy or irritability, hypotonia, poor suck; and

    4. seizures.

  2. Respiratory:

    1. Tachypnea;

    2. grunting, flaring, retracting, or decreased breath sounds;

    3. worsening gas exchange by blood gas, increased oxygen requirement, pulse oximetry, etc;

    4. change in chest x-ray findings, and

    5. new onset or change in character of sputum and increased respiratory secretions and suctioning requirements (for ventilated patients).

  3. Cardiovascular:

    1. tachycardia or bradycardia;

    2. arrhythmia;

    3. cyanosis; and

    4. hypotension, prolonged capillary refill time, mottled appearance, cool and clammy skin.

  4. Hematological:

    1. leukopenia or leukocytosis,

    2. anemia, and

    3. thrombocytopenia,

  5. Skin:

    1. jaundice,

    2. petechiae,

    3. purpura, and

    4. pallor or cyanosis.

  6. Gastrointestinal:

    1. abdominal distension, feeding intolerance, emesis;

    2. diarrhea or bloody stools; and

    3. ileus or absent bowel sounds.

  7. Renal:

    1. oliguria or anuria and

    2. pyuria or malodorous urine.


Diagnostic Tests/Laboratory Testing


Testing should always include consideration of the patient’s risk factors for HCAIs with the caveat that not all “positive” cultures signify the presence of an infection (warranting treatment). Clinicians should also follow available diagnostic guidelines where available (see chapter 53).


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