Quality of antenatal care as a risk factor for early onset neonatal infections in Rio de Janeiro, Brazil

Background: Neonatal infection is a serious public health problem. The aim of this study was to assess the influence of the antenatal care on the risk of early-onset neonatal healthcare associated infection in two Brazilian maternities. Methods: Cohort study - Newborns admitted at two public neonatal intensive care units from 2008 to 2009 were included in the study. Data on antenatal and perinatal variables were collected from maternal prenatal cards and medical charts. Newborns were actively surveyed for early-onset neonatal healthcare associated infection, defined as a neonatal infection diagnosed within 48 h after birth. Multiple logistic regression was used to assess variables independently associated with early-onset neonatal healthcare associated infection. Results: 561 neonate-mother pairs were included in the study. Early-onset neonatal health-care associated infection was diagnosed in 283 neonates (51%), an incidence rate of 43.5/1000 live births. Neonates whose mothers had less then six antenatal visits were under risk significantly higher for early-onset neonatal healthcare associated infection (OR = 1.69, 95% CI = 1.11-2.57), after adjusting for birth weight, membranes ruptured for >18 h, maternal complications during delivery, maternal infection at admission, and hospital where patients received care. Conclusions: The risk of neonatal early-onset neonatal healthcare associated infection was significantly associated with insufficient number of antenatal care visits. Further studies assessing the quality of antenatal care and targeting its improvement are warranted. .

Quality of antenatal care as a risk factor for early onset neonatal infections in Rio de Janeiro, Brazil.

BACKGROUND: Neonatal infection is a serious public health problem. The aim of this study was to assess the influence of the antenatal care on the risk of early-onset neonatal healthcare associated infection in two Brazilian maternities. METHODS: Cohort study - Newborns admitted at two public neonatal intensive care units from 2008 to 2009 were included in the study. Data on antenatal and perinatal variables were collected from maternal prenatal cards and medical charts. Newborns were actively surveyed for early-onset neonatal healthcare associated infection, defined as a neonatal infection diagnosed within 48h after birth. Multiple logistic regression was used to assess variables independently associated with early-onset neonatal healthcare associated infection. RESULTS: 561 neonate-mother pairs were included in the study. Early-onset neonatal healthcare associated infection was diagnosed in 283 neonates (51%), an incidence rate of 43.5/1000 live births. Neonates whose mothers had less then six antenatal visits were under risk significantly higher for early-onset neonatal healthcare associated infection (OR=1.69, 95% CI=1.11-2.57), after adjusting for birth weight, membranes ruptured for >18h, maternal complications during delivery, maternal infection at admission, and hospital where patients received care. CONCLUSIONS: The risk of neonatal early-onset neonatal healthcare associated infection was significantly associated with insufficient number of antenatal care visits. Further studies assessing the quality of antenatal care and targeting its improvement are warranted.

Infection prevention and control measures for acute respiratory infections in healthcare settings: an update.

Viruses account for the majority of the acute respiratory tract infections (ARIs) globally with a mortality exceeding 4 million deaths per year. The most commonly encountered viruses, in order of frequency, include influenza, respiratory syncytial virus, parainfluenza and adenovirus. Current evidence suggests that the major mode of transmission of ARls is through large droplets, but transmission through contact (including hand contamination with subsequent self-inoculation) and infectious respiratory aerosols of various sizes and at short range (coined as "opportunistic" airborne transmission) may also occur for some pathogens. Opportunistic airborne transmission may occur when conducting highrisk aerosol generating procedures and airborne precautions will be required in this setting. General infection control measures effective for all respiratory viral infections are reviewed and followed by discussion on some of the common viruses, including severe acute respiratory syndrome (SARS) coronavirus and the recently discovered novel coronavirus.

Infection prevention and control measures for acute respiratory infections in healthcare settings: an update

Viruses account for the majority of the acute respiratory tract infections [ARIs] globally with a mortality exceeding 4 million deaths per year. The most commonly encountered viruses, in order of frequency, include influenza, respiratory syncytial virus, parainfluenza and adenovirus. Current evidence suggests that the major mode of transmission of ARIs is through large droplets, but transmission through contact [including hand contamination with subsequent selfinoculation] and infectious respiratory aerosols of various sizes and at short range [coined as [opportunistic] airborne transmission] may also occur for some pathogens. Opportunistic airborne transmission may occur when conducting highrisk aerosol generating procedures and airborne precautions will be required in this setting. General infection control measures effective for all respiratory viral infections are reviewed and followed by discussion on some of the common viruses, including severe acute respiratory syndrome [SARS] coronavirus and the recently discovered novel coronavirus

Comparison of national and subnational guidelines for hand hygiene.

Hand hygiene promotion is considered as the cornerstone for healthcare-associated infection prevention. Over the past years, hand hygiene guidelines have been developed by different agencies at international, national and subnational levels. A comparison of these documents could help in understanding recommendations in different parts of the world and the methods used for their development. Guidelines were identified through search engines, electronic libraries, and personal contacts, and their content was analysed using an adapted version of a tool from the European DG XII-funded HARMONY project. Twenty-two guidelines were retrieved and 21 were evaluated. Documents varied in scope, approach, content and terminology. Some were primarily advisory directives, whereas others focused on the technical issues of why, when, and how to perform hand hygiene. The extent to which evidence was collected and assessed varied considerably and details were provided only in very few. Grading systems and definitions to indicate the strength of evidence and recommendations also differed. The intended outcome was to improve hand hygiene practices in healthcare, thus leading to a reduction of healthcare-associated infections and/or antimicrobial resistance. Although overall agreement on indications and procedures was noted, the range and depth of recommendations on best practices and implementation varied. Essential aspects such as compliance measurement and audits to assess guideline effectiveness were neglected in most documents. In conclusion, there is a need for a more consistent approach leading to recommendations based on a thorough evaluation of evidence and applicable worldwide. Aspects related to implementation and impact monitoring deserve greater attention.

Behavioural considerations for hand hygiene practices: the basic building blocks.

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

Control of a cluster of community-associated, methicillin-resistant Staphylococcus aureus in neonatology.

To control an outbreak of community-associated MRSA (CA-MRSA) in a neonatology unit, an investigation was conducted that involved screening neonates and parents, molecular analysis of MRSA isolates and long-term follow-up of cases. During a two-month period in the summer of 2000, Panton-Valentine leukocidin (PVL)-producing CA-MRSA (strain ST5-MRSA-IV) was detected in five neonates. The mother of the index caseshowed signs of mastitis and wound infection and consequently tested positive for CA-MRSA. A small cluster of endemic, PVL-negative MRSA strains (ST228-MRSA-I) occurred in parallel. Enhanced hygiene measures, barrier precautions, topical decolonization of carriers, and cohorting of new admissions terminated the outbreak. Four months after the outbreak, the mother of another neonate developed furunculosis with the epidemic CA-MRSA strain. One infant had persistent CA-MRSA carriage resulting in skin infection in a sibling four years after the outbreak. In conclusion, an epidemic CA-MRSA strain was introduced by the mother of the index case. This spread among neonates and was subsequently transmitted to another mother and a sibling. This is the first report of a successfully controlled neonatology outbreak of genetically distinct PVL-producing CA-MRSA in Europe.

Ralstonia pickettii and Burkholderia cepacia complex bloodstream infections related to infusion of contaminated water for injection.

Ralstonia pickettii and Burkholderia cepacia complex isolates are causes of healthcare-associated infection related to contamination of intravenously administered products. Based on microbiological and epidemiological data and molecular typing by pulsed-field gel electrophoresis, we report the occurrence of two outbreaks of R. pickettii and B. cepacia complex bloodstream infections. The first outbreak occurred from August 1995 to September 1996, and the second outbreak occurred from 28 March to 8 April 1998, affecting adults and neonates, respectively. Infusion of contaminated water for injection was the source of infection.

Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit: risk factors for infection and colonization.

An outbreak of extended spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBLKp) infections in a neonatal intensive care unit (NICU) prompted a prospective investigation of colonization and infection with this pathogen. From August 1, 1997 to May 30, 1999, neonates admitted to the NICU for more than 24 h were screened for ESBLKp acquisition. Neonatal gastrointestinal screening was performed by means of faecal sampling within 48 h of admission and then weekly until discharge. Isolates were typed using pulsed-field gel electrophoresis (PFGE). Time-dependent proportional hazard models were used to identify independent effects of invasive procedures and antimicrobials after controlling for duration of stay at the NICU. During the study period, 464 neonates were admitted and 383 were regularly screened. Infections occurred in 13 (3.4%) neonates and 206 (53.8%) became colonized. Independent risk factors for colonization during the first nine days in the NICU were the antimicrobial combination cephalosporin plus aminoglycoside [hazard rate (HR)=4.60; 95% CI: 1.48-14.31], and each NICU-day was associated with a 26% increase in the hazard rate for colonization (HR=1.26; 95% CI: 1.16-1.37). Previous colonization (HR=5.19; 95% CI: 1.58-17.08) and central vascular catheter use (HR=13.89; 95% CI: 2.71-71.3) were independent risk factors for infection. In an outbreak setting the proportion of neonates colonized with ESBLKp was observed to increase with the duration of stay and antimicrobial use, and once colonized, infants exposed to invasive devices may become infected.

Neonatal late-onset bloodstream infection: attributable mortality, excess of length of stay and risk factors.

BACKGROUND: Bloodstream infection represents a major threat among neonates under intensive care with considerable impact on morbidity and mortality. This study evaluated extra stay, attributable mortality and the risk factors associated with late-onset bloodstream infection (LO-BSI) among neonates admitted to a neonatal intensive care unit during a 4-year period. METHODS: A retrospective matched cohort study was conducted. For each case, there was one control patient without LO-BSI matched for sex, birth weight, gestational age, duration of hospitalization prior to the date of LO-BSI in the respective cases, underlying illness and birth date. A novel test, sequential plan, was employed for attributable mortality analysis in addition to standard tests. Multiple logistic regression was employed for risk factor analysis. RESULTS: Fifty pairs of cases and controls were compared. LO-BSI prolonged hospital stay of 25.1 days in pairs where both subjects survived. Overall attributable mortality was 24% (95% CI: 9-39% p < 0.01) and specific attributable mortality due to Staphylococcus epidermidis was 26.7% (95% CI: 23-30.4%; p = 0.01). Blood and/or blood components transfusion was independently associated with neonatal LO-BSI (OR: 21.2; 95% CI: 1.1-423). CONCLUSIONS: LO-BSI infection prolongs hospital stay and is associated with increased mortality among neonates. In the present series, blood transfusion was a significant risk factor for LO-BSI.