Chapter 53: Health Care-Associated Infections in the NICU

INTRODUCTION

Health care-associated infection (HCAI), also referred to as nosocomial or hospital-acquired infection, is an infection that a patient acquires and becomes evident 48 hours or more after admission to a hospital, it was not present or incubating at the time of admission to the hospital, and develops while the patient is receiving treatment of other conditions. These infections are associated with more serious illness, prolongation of stay in a health care facility, increased long-term disability, excess deaths, and high additional financial burden on health care and patients and their families.

The HCAIs commonly encountered in the neonatal intensive unit (NICU) are as follows:

1. Bloodstream infection (BSI), primarily catheter-associated bloodstream infection (CABSI), the most common HCAI in the NICU

2. Ventilator-associated pneumonia (VAP)

3. Catheter-associated urinary tract infection (CAUTI)

4. Surgical site infection (SSI)

5. Ventricular shunt-associated infection

EPIDEMIOLOGY

Incidence

According to the World Health Organization, the incidence rate of HCAIs in the United States is 4.5%; prevalence in the European countries is 7.1%; and in the low- and middle-income countries it varies from 5.7% to 19.1%. The overall annual direct medical costs of HCAI to US hospitals ranges from $28.4 to $45 billion, and the benefits of prevention range from $5.7 to $31.5 billion.¹ In 2002, the estimated number of HCAIs in US hospitals, adjusted to include federal facilities, was approximately 1.7 million, of that number, there were 33,269 among newborns in high-risk nurseries and 19,059 among newborns in well-baby nurseries; an estimated 98,987 deaths were associated with HCAIs.²

The Pediatric Prevention Network Study showed that of the 827 NICU patients surveyed, 11.4% had 116 hospital-acquired infections: 52.6% bloodstream, 12.9% lower respiratory tract, 8.6% ear-nose-throat, and 8.6% urinary tract infections (UTIs).³ The National Healthcare Safety Network (NHSN) reported the highest incidence of device-associated infections (DAIs) was in neonates weighing 750 g or less.⁴

Hands are the most common vehicles to transmit health care-associated pathogens (Table 53-1). Transmission of pathogens from one patient to another via health care workers’ hands requires 5 sequential steps:

1. Germs are present on the patient’s skin and surfaces in the patient’s surroundings.

2. By direct and indirect contact, the patient’s germs contaminate health care workers’ hands.

3. Germs survive and multiply on health care workers’ hands.

4. Inadequate hand cleansing results in hands remaining contaminated.

5. Microorganisms are cross transmitted between two patients via a health care worker’s hands.