Nosocomial infections in a Dutch neonatal intensive care unit: surveillance study with definitions for infection specifically adapted for neonates
Introduction
The incidence of nosocomial infections in neonatal intensive care units (NICUs) is high; it has been reported to occur in up to 30% of all neonates.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 Diagnosis of infection, especially in preterm neonates, is difficult because symptoms of infection are often non-specific and different from those in older infants.20, 21 In addition, as diagnostic procedures are different in the NICU, the definitions of such infections for children aged <1 year of the Centers of Disease Control and Prevention (CDC) are less suitable in this patient population.22 The lack of standardized definitions for nosocomial infection in the NICU and the huge diversity in patient mix in different NICUs makes comparison of studies on the incidence of infection in neonates difficult.23 Lacking better definitions, the National Nosocomial Infections Surveillance System (NNIS), consisting of approximately 140 American NICUs, uses the CDC definitions for children aged <1 year as the best available for surveillance.24
Diagnosis of bloodstream infection (BSI) in premature neonates is hampered by several factors, including the relatively small volume of blood that can be drawn for culture, which compromises sensitivity.25, 26 Also, the diagnosis of ventilator-associated pneumonia is more difficult in neonates than in older children because of the low sensitivity of chest X-rays.27, 28, 29
The NICU of our hospital is a level III NICU. Indications for admission are: preterm birth (<32 weeks of gestation), respiratory distress, infections, congenital malformations and birth asphyxia. The aims of this prospective surveillance study were: (1) to test the applicability of CDC definitions for children aged <1 year adjusted for neonates for detection of nosocomial infection; (2) to determine the incidence of nosocomial infection in the NICU of the VU University Medical Center, Amsterdam based on these definitions; and (3) to identify risk factors for nosocomial infection in our NICU.
Section snippets
Definitions of nosocomial infections
Definitions for infection surveillance were developed by the Department of Medical Microbiology and Infection Control and the Department of Neonatology. CDC definitions for children aged <1 year for BSI, pneumonia, meningitis, urinary tract infection (UTI), eye infection, infection of the umbilicus, and skin infection were adjusted with respect to specific neonatal symptomatology and diagnostic procedures. During the surveillance period, problems with definitions were discussed regularly. After
Surveillance
Surveillance was performed over two periods: February–November 1998 and June 1999–December 2000. A total of 742 neonates was included. We recorded 264 infections in 191 neonates. General information on the study population, the incidence of infection and the causative agents is provided in Table I, Table II, Table III, respectively. BSI and pneumonia were the most frequently occurring nosocomial infections. BSI was predominantly caused by coagulase-negative staphylococci and other Gram-positive
Discussion
CDC definitions for children aged <1 year are not suitable in some aspects for (preterm) neonates. Symptomatology of infection is different in this patient category. Irritability, apathy and grey skin colour are considered to be symptoms of possible infection, but they are difficult to assess and somewhat subjective.21 A classic symptom of infection, which is used as a defining symptom in all studies on nosocomial infections, is body temperature above 38.0 °C. Body temperature, however, acts
Acknowledgements
We are indebted to L.E.A. Boeijen-Donkers, infection control practitioner, and E.F. Ree, neonatologist, for participation in the surveillance. W.C. van der Zwet is supported by an AGIKO grant of ‘The Netherlands Organization for Scientific Research’.
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Current address: Department of Medical Microbiology, Erasmus University Hospital, Rotterdam, The Netherlands.