understanding of NICU Management

1. INFECTION & ANTIBIOTIC
Purbangshu Chatterjee

2. What is NICU?
 Neonatal intensive care unit, (NICU) and also
called a Special Care Nursery, newborn intensive care
unit, intensive care nursery (ICN), and special care
baby unit (SCBU) is a unit of a hospital specializing in
the care of ill or premature newborn infants

3. History of modern NICU
 Mid 1800, Dr. Stephane Tarnier invented the incubator
 Dr.Pierre Budin is known as the father of modern
perinatology, and his seminal work The Nursling (Le
Nourisson in French) became the first major
publication to deal with the care of the neonate
 Dr. Martin Couney and his permanent installment of
premature babies in incubators at Coney Island

4. Cont….
 1970s NICUs were an established part of hospitals in the
developed world.
 1980s, over 90% of births took place in hospital . The
emergency dash from home to the NICU with baby in a
transport incubator had become a thing of the past,
 1979 study showed that 20% of babies in NICUs for up to a
week were never visited by either parent. Centralized or
not,
 1980s few questioned the role of NICUs in saving babies.
Around 80% of babies born weighing under 1.5 kg now
survived, compared to around 40% in the 1960s.
 1982 in Britain pediatricians could train and qualify in the
sub-specialty of neonatal medicine.

5. Common diseases in a NICU
 prematurity and extreme low birth weight,
 Perinatal asphyxia,
 Major birth defects,
 Sepsis,
 Neonatal Jaundice,
 Respiratory distress Syndrome
 The leading cause of death in NICUs is generally
Necrotizing Enterocolitis.
 Intracranial Hemorrhage
 chronic bronchopulmonary dysplasia

6. Major challenges in NICU
 Nosocomial infection in the neonatal intensive
care unit
 Risk factors for nosocomial infection (Host,
Nursury environment, invasive procedures
 Indiscriminate uses of Antibiotic at NICU leads to
resistance of Antobiotic
 Prevention & Control
 Policies & procedures

7. Nosocomial infections
 Nosocomial infections are infections that are a result
of treatment in a hospital or a healthcare service unit.
Infections are considered nosocomial if they first
appear 48 hours or more after hospital admission or
within 30 days after discharge.
 Nosocomial comes from the Greek word nosokomeio
(νοσοκομείον) meaning hospital (nosos = disease,
komeo = to take care of).
 This type of infection is also known as a hospital-
acquired infection

8. Epidemiology of N.I. in the New
Born
 Not well understood
 Definitions are not standardized
 Intrapartum vs PeriPartum vs. Postpartum acquisition
of Pathogen
 Maternal vs. Hospital acquired infections
 Short Hospital Stay of the normal New born
 Early Onset vs. Late Onset vs. very Late Onset of
Infections

10. Present of scenario NI
 In the US, the CDC & P estimate that roughly 1.7 million
hospital-associated infections, from all types of
microorganisms, including bacteria, combined, cause or
contribute to 99,000 deaths each year.
 In Europe, the category of Gm -ve infections are estimated
to account for two-thirds of the 25,000 deaths each year.
 Nosocomial infections can cause severe pneumonia and
infections of the UTI, bloodstream and other parts of the
body. Many types are difficult to attack with antibiotics,
and anti biotic resistance is spreading to Gm -ve bacteria
that can infect people outside the hospital

11. Etiology of NICU Acquired Infection
Changing Etiology over the time
 1950’s S.aureus
 1960’s Gram negative bacteria
 1970’s Group B Streptococci
 1980’s MRSA & CONS
 1990’s Enterococci, Resistant gm –ves , MRSA, CONS

12. Risk Factors for N.I. in NICU
 Birth weight
 Length of stay to NICU
 Duration of exposure of devices
1. Central venous catheters
2. Mechanical Ventilations
 Over crowding & Understaffing
 Lipid therapy (risk of CONS)
 Prolonged therapy with antibiotics & steroids

13. Clinical characteristics of
nosocomial infections
A retrospective cohort study on nosocomial infections (NI) in
the NICU was performed in the Children's Hospital of
Zhejiang University,
 The most common infection site was pneumonia and
bloodstream infection. Low admission age, long NICU stay,
and mechanical ventilation were risk factors for NI.
 Klebsiella pneumonia was the most common pathogen,
followed by Acinetobacter baumannii,
 Staphylococcus epidermidi,
 Pseudomonas aeruginosa,
 Enterobacter cloacae,
 Stenotrophomonas maltophilia.

14. Gm+ve Infection in NICU
Prevention
 Coagulase –ve Staphylococci
1. Aseptic technique for insertion and handling of devices
2. Prevention of contamination during surgery
 MRSA outbreak (include infections in NICU patients
with CA--MRSA strains)
1. Cultures of nacres & skin lesions of infants - HCW
2. Improve under staff & over crowding
3. Contact precautions for known or suspected infected
infants
4. Cohorting
5. Attempt to eliminate neonatal colonization

15. Gm+ve Infection in NICU
Prevention…..
 Vancomycin resistant enterococci
1. Contact precautions for colonized or infected infants
2. Judicious use of antibiotics

16. Gm-ve bacteria in NICU
Prevention
 E.coli , Klebsiella sp, Enterobactor sp.
 18 – 19% of BSI
 30% Nosocomial Pneumonia
Prevention:
 Elimination of standing water
 Disinfection of shared equipments
 Appropriate handling of devices
 Sterile water in nebulizer & humidifiers
 Contact precautions for colonized or infected infants

17. Causative pathogens of bacterial
infections : NICU
 Common organisms Klebsiella, Escherichia coli (E. coli),
Pseudomonas and Staphylococcus aureus (S.aureus).
 Less common organisms Enterobacter, Citrobacter,
Salmonella and Streptococcus groups B and D
 Uncommon organisms Group B streptococcus (common
cause of neonatal sepsis in the West, but infrequent in
India)
 Organisms in EOS Streptococcus agalactiae, E. coli,
Haemophilus influenza and Listeria monocytogenes.
 Organisms in LOS Coagulase-negative Staphylococcus
(CoNS), S. aureus, E. coli, Klebsiella species, Pseudomonas
aeruginosa, Enterobacter species, Candida species,
Streptococcus agalactiae, Serratia species, Acinetobacter
species and anaerobes.
 Organisms in LBW neonates with sepsis : Coagulase-
negative Staphylococcus (CoNS) and Acinetobacter

18. Fungi in NICU
 Very Important cause of Infection
 7 – 13% of BSI in NICU
 3rd Most common cause of late onset of sepsis in
VLBW infants
 Candida spp most common & C.albicans & C.
tropicalis also common
 Other yeasts : Malassezia furfur , aspergillis

19. Fungi Prevention in NICU
 Prevention is a challenge
 Fluconazole prophylaxis
 Removal of intra vascular infected catheters
 NICU air & equipments should be free from dust

20. Nosocomial infection in a
NICU – A Study
 Among 528 infants enrolled, 60 (11.4%) had 97 nosocomial infections.
 The survival rate was 92%.
 The prevalence of nosocomial infections was 17.5%:
 bloodstream infection, 4.7%,
 clinical sepsis, 6.3%,
 pneumonia, 5.1%,
 urinary tract infections (UTIs), 0.7%,
 surgical site infection, 0.7%.
 Intervention-associated infection rate: central intravascular catheter–
associated bloodstream infection, 13.7%,
 TPN-associated bloodstream infection,
 15.8%, ventilator-associated pneumonia,
 18.6%, surgical site infection 13.7%,
 urinary catheter–associated UTI 17.3%.
 Patients with a birth weight <1000 g (relative risk, 11.8, 95% confidence interval,
7.66-18.18; P < .001) were at the greatest risk for nosocomial infection.
AJIC, APRIL2007 PAGE 190-195 - TAIWAN

21. Antibiotic usage in neonates
 Antibiotics are one of the most abused drugs in the
neonatal unit.
 While appropriate usage is definitely helpful,
indiscriminate use of antibiotics could lead to
emergence of multidrug resistance in previously
susceptible isolates.
 Adopting and implementing a rational antibiotic
policy would help alleviate this problem to a
significant extent.

22. Antibiotic Usage in the NICU
 Antibiotic Use in Neonatal Intensive Care Units
and Adherence with Centers for Disease Control
and Prevention 12 Step Campaign to Prevent
Antimicrobial Resistance
 The CDC 12-Step Campaign can be modified for
neonatal populations. Inappropriate antibiotic
prescribing was common in the study NICUs.
Improvement efforts should target antibiotic use 72
hours after initiation, particularly focusing on
narrowing therapy and instituting protocols to limit
prophylaxis.

23. Rational antibiotic usage in
neonates
The various issues related to the use of antibiotics
In NICU can be discussed under the following
headings:
 A. When to start?
 B. What to start?
 C. When to stop?
 D. What’s the optimum route and dose?
 E. Special situations

24. When to start antibiotics?
The decision to start antibiotics is usually dependent
upon two factors:
1. The infant is symptomatic
2. At-risk for sepsis and if the diagnostic tests
suggest an infectious etiology

25. Existing practice in major neonatal units
3RD GEN
CEPH+AMINO
Piperacillin
tzobactam+
amino
Fluoroquin
ol.+amino
OTHERS
First line
(n=16)*
5 (31.2%) 1 (6.2%) 1 (6.2%) Ampicillin+
Aminogly.:3 (18.8%);
Co-amoxiclav+
Aminogly.:3
(18.8%)
Second line
(n=16)*
Third line
(n=16)*
1 (6.2%)
0
7 (43.8%)
3 (18.8%)
3 (18.8%)
1 (6.2%)
Cefoperazone-
sulbactum:
1 (6.2%);
Netilmycin*: 2
(12.5%)
Meropenem: 6
(37.5%);Vancomyci
n:
8 (50.0%);
Fluconazole: 1
(6.2%)
Reserve
(n=16) *
1 (6.2%) 1 (6. 2%) Meropenem: 8
(50.0%);
Cefoperazone-
sulbactum: 2
(12.5%)

26. Antibiotic policy in neonatal units
- NICU of India:
 A combination of third generation cephalosporin
with an aminoglycoside (mostly amikacin) is used
as the first line of antibiotic therapy in about one
third of the units surveyed (6/17; 35..3%).
 About half of the units use piperacillin-tazobactam as
the second line agent (8/17; 47.0%),
 vancomycin as third line, and meropenem as the
reserve drug (8/17 each; 47%)
JOURNAL OF NEONATOLOGY VOL-23 JAN - MARCH 2009

27. Choice of antibiotics
 Early and late onset sepsis: ampicillin plus gentamicin
 Early onset meningitis: ampicillin plus gentamicin
 Late onset meningitis: ampicillin, gentamicin (or
amikacin), and/or cefotaxime
 Suspected staphylococcal sepsis, focal skin, bone, joint
infections, omphalitis: methicillin/nafcillin plus
gentamicin
 For sepsis of suspected GI origin: ampicillin,
gentamicin/amikacin, plus clindamycin (or piperacillin)
 Nosocomial infection in setting with MRSA: vancomycin
plus gentamicin (and/or ceftazidime, if high prevalence of
 pseudomonas)

28. How to restrict antibiotic usage
in NICU
 Don’t use prophylactic antibiotics
 Consider carefully whether antibiotics are needed
 Avoid broad spectrum antibiotics
 Avoid cefotaxime and other beta-lactam drugs
 Always do a blood culture
 Obtain blood culture report at 36-48 hours
 Shorten duration of treatment
 Stop antibiotics when no infection evident at 36-48 hours
 Treat LOS for gram negative infections and wherever
possible wait for culture before treating gram positive
infection

29. NICU Infection Control Polocies
 Isolation Precautions : single use items ,
 skin & cord care : Topical ointment Therapy
 Insertion & Maintenance of Devices : PICC, CVC,
Ventilator
 Hand Hygiene : Waterless hand rub, Artificial nails
 Special Attire
 Visitor control
 Co bedding
 Ventilator tube change

30. Reference Page
 N. B. Mathur, ECAB Clinical Update: Pediatrics; Neonatal
Sepsis, Elsevier, 2009
 Indian J Pediatr 2008; 75 (3):261–266
 Journal of Neonatology Vol. 23, No. 1, January–March 2009
 Eastern Journal of Medicine 15 (2010) 133-138
 Clark R, Powers R, White R, et al. Prevention and
treatment of nosocomial sepsis in the NICU. J Perinatol
2004; 24: 446-453
 Unique aspects of Infection control in NICU – Dr.Jo Ann
Harris : sep 2007