Late onset sepsis in newborn babies: epidemiology and effect of a bundle to prevent central line associated bloodstream infections in the neonatal intensive care unit

Resende, Daiane Silva; Peppe, Anna Laura Gil; Reis, Heloisio dos; Abdallah, Vânia Olivetti Steffen; Ribas, Rosineide Marques; Gontijo Filho, Paulo Pinto

doi:10.1016/j.bjid.2014.09.006

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Brazilian Journal of Infectious Diseases

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Original Articles • Braz J Infect Dis 19 (1) • Jan-Feb 2015 • https://doi.org/10.1016/j.bjid.2014.09.006 copy

Late onset sepsis in newborn babies: epidemiology and effect of a bundle to prevent central line associated bloodstream infections in the neonatal intensive care unit

Authorship SCIMAGO INSTITUTIONS RANKINGS

Aim:

We assessed late onset sepsis (LOS) rates of neonates in a neonatal intensive care unit (NICU) before and after implementing an evidence-based bundle to prevent these infections in a country with poor resources.

Methods:

We evaluate trends of LOS between October 2010 and August 2012 in a large tertiary hospital in Brazil. We designed a protocol based of CDC guidelines for insertion of maintenance of central venous catheter targeted to reduction of bloodstream infections. During this period two major events occurred: a great increase of LOS rates in January months and relocation of the unit to a provisory place. Additionally we evaluated the risk factors and etiology of these infections.

Results:

A total of 112 (20.3%) cases deﬁned as LOS were found. The overall incidence rate of LOS in the study was 16.1/1000 patient/days and 23.0/1000 CVC-days. Our monthly rates data of LOS/1000 patient-day reveal ﬂuctuations over the studied period, with incidence rates of these infections in staff vacation period (January 2011 and 2012) signiﬁcantly higher (59.6/1000 patients-days) than compared with the other months rates (16.6/1000 patients-days) (IRR = 3.59; p < 0.001). As opposite, the incidence rates of LOS during relocation period was lower (10.3/1000 patients-days) when compared with baseline period 26.7/1000 patients-days (IRR = 2.59; p = 0.007). After the intervention period, these rates decreased in the post intervention period, when compared with preintervention 14.7/1000 patients-days and 23.4/1000 patients-days, respectively (IRR = 1.59; p = 0.04).

Conclusion:

Through simple infection control measures, LOS can be successfully controlled especially in NICUs of limited resources countries such as ours.

Late onset sepsis; Bundle; Neonates

Epidemiological indicators	N (%)
Sepsis	178 (32.3)
LOS	139 (25.2)
Clinical criteria	32 (23.2)
Microbiological criteria	107 (76.9)
LOS/1000 patient-days	16.1
LOS/1000 CVC-days	23.0

	Total 542	Neonates		Univariate analysis		Multivariate analysis
		With LOS 112 (20.3%)	Without LOS 439 (79.6%)	p-value	OR (95%CI)	p-value	OR (95%CI)
Characteristics
Gestational age <37 weeks	366	86 (76.7)	280 (65.1)	0.01	1.77 (1.07–2.95)	0.04	1.83 (1.03–3.26)
Birth weight <1500 g	173	60 (53.5)	113 (26.2)	<0.001	3.24 (2.06–5.09)	0.01	2.70 (1.16–3.74)
Apgar at 5 min <5	14	2 (1.7)	12 (2.7)	0.74	0.69 (0.10–2.50)	-	-
SNAPPE II score
0–10	192	28 (25.0)	164 (38.1)	0.01	0.54 (0.33–0.88)	-	-
11–20	119	20 (17.8)	99 (23.0)	0.29	0.73 (0.41–1.27)	-	-
21–30	65	22 (19.6)	43 (10.0)	0.008	2.20 (1.21–4.00)	-	-
31–40	41	11 (9.8)	30 (6.9)	0.41	1.45 (0.66–3.14)	-	-
>40	72	21 (18.7)	51 (11.8)	0.07	1.71 (0.95–3.09)	-	-
CVC	359	106 (94.6)	253 (58.8)	<0.001	12.36 (5.10–31.93)	<0.001	5.10 (2.32–11.26)
Parenteral nutrition	223	77 (68.7)	146 (33.9)	<0.001	4.28 (2.68–6.86)	-	-
Mechanical ventilation	242	76 (67.8)	166 (38.6)	<0.001	3.36 (2.11–5.35)	<0.001	2.72 (1.65–2.42)
Length of stay >7 days	308	90 (80.3)	218 (50.6)	<0.001	3.38 (2.35–6.80)	<0.001	3.13 (1.85–5.31)

Microorganisms	LOS n = 107 (%)
Staphylococcus epidermidis	41(38.3)
Other CNS	7 (16.5)
Staphylococcus aureus	14 (13.0)
Enterococcus faecalis	6 (5.5)
Other GPC	3 (2.8)
Escherichia coli	8 (7.4)
Enterobacter cloacae	1 (0.9)
Klebsiella pneumoniae	9 (8.4)
Citrobacter koseri	2 (1.8)
Serratia marcescens	2 (1.8)
Stenotrophomonas maltophilia	1 (0.9)
Acinetobacter baumannii	2 (1.8)
Pseudomonas aeruginosa	1 (0.9)
Other GNB	1 (0.9)
Candida spp.	9 (8.3)

Major event	Incidence rate/1000 patient-days		IRR	P (95%CI)
Months of January	January Months	Other Months	IR (months of January)/IR (other months)	<0.001 (1.85–6.60)
	59.6	16.6	3.59
Unit relocation	Baseline	Relocation	IR (baseline)/IR (relocation)	0.007 (1.20–3.66)
	26.7	10.3	2.59
Intervention	Pre-intervention	Post-intervention	IR (baseline)/IR (follow up)	0.04 (1.01–2.69)
	23.4	14.7	1.59

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E-mail: bjid@bjid.org.br

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[1] *Corresponding author at: Uberlândia Federal University, Pará Avenue, 1720 Umuarama, Uberlândia, MG, Brazil. E-mail address: daianeresendebio@hotmail.com (D.S. Resende).