Authors

  1. Lefrak, Linda MS, RN

Abstract

Neonates are at high risk for developing an infection during their hospital stay in the neonatal intensive care unit. Increased risk occurs because of immaturity of the neonate's immune system, lower gestational age, severity of illness, surgical procedures, and instrumentation with life support devices such as vascular catheters. Neonates become colonized with bacteria prior to or at delivery and also during their hospital stay. They can then become infected with those bacteria if there is a breakdown in the primary defenses such as tissue injury due to skin breakdown, nasal erosion, or trauma to the respiratory tract. Neonates are also at high risk for bacterial translocation due to the altered permeability of the intestinal mucosa, loss of commensal flora, and bacterial overgrowth. The unit-based neonatal care team must implement global care delivery and safety practices, utilize published care guidelines, know and apply evidence-based practices from collaborative quality improvement efforts and other sources, and use auditing and monitoring practices that can identify risks and lead to better practice options to prevent infections. This article presents several aspects of global neonatal care delivery, including vascular access, which may reduce the risk of systemic infection during the hospitalization.

 

Article Content

In the past decade, there have been tremendous efforts made to reduce infection risk in the neonatal intensive care unit (NICU) through the work of national and state-based collaboratives comprising interdisciplinary healthcare team members. These collaboratives, such as the Vermont Oxford Network and others, have examined evidence, developed practice guidelines for quality improvement, and subsequently tracked patient outcomes based on those changes. Many of these infection prevention practices focus primarily on vascular access. There is clear evidence that all practices, or global care delivery, must be evaluated if the risk of infection can be effectively impacted.

 

As with many neonatal complications, preventing infection requires a comprehensive approach to care delivery. Evidence to support the care is essential as is the clarity about the practice recommendations and the assessment of those practice recommendations over time. Key elements of each practice implementation and sustained efforts rely on:

  

* Use of evidence-at the highest level available.

 

* Written unit procedures/protocols/guidelines addressing and standardizing each practice.

 

* Education about the practice.

 

* Auditing of compliance and understanding by all staff members caring for neonates.

 

* Auditing of primary outcomes such as the rate of infection in the target population.

 

Global care delivery that addresses major elements of care, such as care of the skin and respiratory systems, is essential to achieving the most effective practice improvement. Comprehensive risk reduction of hospital-acquired infection (HAI) in the neonatal patient requires that each of the following care categories be examined for opportunities to impact infection risk: hand hygiene, nails, and jewelry; the environment; skin care; respiratory care, gastrointestinal tract care and enteral feeding; and vascular access and devices. Each of these is reviewed and established guidelines referenced.

 

HAND HYGIENE, NAILS, AND JEWELRY

Effective hand hygiene is a critical foundation and a basic practice that has been shown to reduce the risk of HAIs in the NICU.1 Current recommendations from the Centers for Disease Control and Prevention (CDC)1 include antimicrobial agents that are the most efficacious, initial and interim wash times, adjunct use of alcohol hand gels, nail length, and glove use.1 Research of hand hygiene practices supports the use of antimicrobial agents that are effective against bacteria, viruses, and fungi. These agents should also be safe for caregivers and used with compatible lotions to maximize skin integrity in the caregivers. A focus on maintenance of skin integrity and staff acceptance of agents is critical for compliance.

 

Initial wash time, sometimes called a scrub-in procedure, is completed on entry into the NICU for the first time each day. There is no clear reference in the CDC guideline regarding entry into an NICU. The goal of this practice is initial hand decontamination, and the data come from research on surgical scrubs.1 The initial wash should include thorough cleansing of the hands and nails. The initial wash time varies by unit, but hand washing research has shown that 1 to 2 minutes of wash time is adequate to decontaminate hands, with no clear evidence evaluating the difference in these 2 times. Longer than 2 minutes of wash time has not shown improved hand decontamination and may lead to skin injury. Interim washing between patients or after handling of contaminated items is not referenced in the CDC guideline, and unit practices vary. No studies have compared different washing times for the interim wash. Some units use no timed guideline, whereas others have concrete time frames that are difficult to audit and in some cases viewed by staff as unrealistic. If the washing is thorough, 10 to 15 seconds may be reasonable, and unit-based outcomes should guide this recommendation. Hands that are not visibly soiled may be decontaminated with alcohol gels and achieve the same result in less time.1 The number of times a gel can or should be used safely is also not clear in the guidelines and at some point NICUs should select a frequency and make it a policy. An important understanding for gel use is that gel does not replace the use of a soap wash for soiled hands. Most importantly, the techniques for using gels and initial and interim washing should be taught and audited and the agents, both soaps and gels, should be readily available throughout the NICU and support areas. Staff members are often in the best position to recommend dispenser locations and identify workflow problems that lead to dispensers not containing the agents as needed.

 

Fingernails can harbor bacteria and fungi. The current recommendation is that nails be natural and no longer than 4 mm, with shorter length preferred.2,3 Rings, watches, and bracelets should not be worn in the NICU due to the risk that organisms will be under the jewelry and difficult to remove with soaps or gels. The practice of not allowing staff to wear jewelry in the NICU remains a difficult standard to enforce, with staff claiming the right to wear a simple wedding band, and the fact that staff coming from other parts of the hospital are allowed to wear such items in other settings with high-risk vulnerable patients. The CDC document on hand washing states that data show the only substantial risk of jewelry is the documented increased skin colonization under rings.2 Sharing of the data with staff may be essential to improve compliance. As with many rules in the NICU, lack of compliance often is a sign of staff not believing the facts or evidence behind the rule. The hand hygiene document from the CDC is comprehensive and contains many studies on effective hand decontamination. Units with ongoing concerns about infection rates should consider a unit-based review of the CDC document to determine whether their hand hygiene practices meet the recommendations.

 

THE ENVIRONMENT

Evidence shows that some organisms can survive on surfaces throughout the NICU for long periods of time. A study by Oelberg et al4 showed that DNA markers, used to serve as a surrogate marker of microbial transmission pathways, were recovered from multiple sites after only a single pod of a 6-pod NICU was inoculated with the marker. Samples were collected at 0, 4, 8, 24, 48 hours and 7 days after the single-pod inoculation. One thousand three hundred samples were collected and analyzed for the markers, and these samples included nonpatient care areas such as the nurses' break room. Fifty-eight percent of all sites sampled were positive for the DNA marker throughout all time points, with a peak at 8 hours. Twenty-three percent stayed positive at 7 days. The most consistently positive sites within all pods were the blood gas analyzers, computer mice, phone handles, charts, ventilator knobs, door handles, radiant warmer control buttons, patient monitors, and personnel hands. These results support the need for nurse-driven cleaning of patient care areas, beyond cleaning that is the responsibility of the housekeeping or environmental services department. Nurses often touch bedside equipment or nonclean areas and then return to patient care. Wipe down of these areas would reduce the contamination. The analysis of contamination in this study also supports the need for hand hygiene as a basis for all infection risk reduction options.4 It is important to note that some organisms that can be pathogenic to infants are in the patient care environment and do not come to the patient via the nurse's hands. All individual patient care equipment, including ventilators, monitors, and charts, can be sources of cross contamination to infants who share care providers.

 

Inanimate surfaces can be sources for outbreaks of nosocomial infections, and the literature shows that bacteria, fungi, and viruses can survive on surfaces for a few hours or as long as 4 months.5 Nursing practice for infection prevention should incorporate a wipe down of patient-related bedside equipment with an antimicrobial/antiviral cloth at the beginning of each shift. The cloth used should not damage the surfaces of the monitor or incubator prior to introduction and have efficacy against bacteria, fungi, and viruses. This wipe down should include, but not be limited to, incubator doors, radiant warmer controls, chart covers, computer mice, bedside work surfaces, monitor controls, and work phones. Additional strategies include organizing each bedside into a designated clean or soiled area to guide where equipment is stored, creating a standard set-up of bedside drawers to separate all equipment for vascular access from areas with items such as diaper creams, and labeling all multiuse solutions such as chlorhexidine with the patient name and expiration date if applicable. The cleanliness of the bedside of each infant should then be a joint responsibility of the environmental services department and the care providers.

 

SKIN CARE

The skin of a newborn infant provides a primary barrier to microbial invasion through a combination of an acidic pH and overall integrity.6 Recent research on the importance of the human microbiome and its potential importance to disease prevention has led to increased discussion on the use of soaps and bathing practices that may alter the normal flora and the role it plays.7 It is clear that the acid mantle of the skin is protective against bacterial invasion. Skin integrity itself is a secondary barrier. Because of skin immaturity in premature infants, the epidermis can be stripped or injured with the application and removal of monitoring devices such as electrodes and pulse oximeter probes. With the skin being a potential large portal of entry for microorganisms to internal structures, it is essential that skin health and integrity remain a foundation of infection risk reduction in the NICU.

 

A comprehensive evidence-based guideline for skin care can be found in the Third Edition of the Neonatal Skin Care Clinical Practice Guideline published by the Association for Women's Health, Obstetric, and Neonatal Nurses.8 Staff need to be educated on the role of the skin and its barrier function and then taught skin care practices to preserve this function. These practices include, but are not limited to, delay of initial bath or vernix removal, bathing procedures that use soap known to preserve the acid mantle, infrequent bathing of very low-birth-weight infants, gentle application and removal of all adhesive devices, standardized preparative solutions for invasive procedures, gentle repositioning to prevent pressure injuries, use of pectin-based barriers under adhesives when feasible, and monitoring for skin injury and the root causes.

 

Skin injury reporting, tracking, and management should be formalized to support risk-reduction strategy.8 Such tracking could also audit for compliance of pectin use for under adhesive devices. Skin injuries should be aggressively treated with occlusive bacteriostatic options such as oxygen-permeable transparent dressings or thin pectin covering.8 Plans for injury care should be written in bedside care plans. Injury tracking may lead to improvement strategies that will decrease risk of occurrence and therefore the need to treat.

 

RESPIRATORY CARE

The entire respiratory tract remains a portal of entry for bacterial, fungal, or viral colonization and infection in neonates. Infection risk is increased in neonates who require respiratory support or some degree of instrumentation such as continuous positive airway pressure or intubation. Recent national efforts have reduced the absolute numbers of ventilator-associated pneumonias in the NICU, but the respiratory tract remains an organ system where infectious agents can be introduced into the bloodstream.9

 

All respiratory care practices should be reviewed and standardized with a focus on equipment preparation and use, and risk of each practice to induce tissue injury that could lead to infection. The NICU team should be engaged in developing respiratory care procedures, due to the interdisciplinary nature of respiratory care delivery. Standardized care practices include assembly of equipment for intubation, management of suction equipment, management of ventilator circuits, cleaning and storage of all respiratory equipment, review of all respiratory practices for compliance with current evidence, and a system to audit for compliance to standards and review of adverse outcomes.

 

The procedure of suctioning has been shown to be a potential source of airway injury as well as hypoxia and hypercarbia.10 Suctioning procedures should have clear guidelines for indication and should minimize the use of saline, utilize closed devices to reduce catheter contamination, and include monitoring for methods of suctioning to guarantee that endotracheal procedures have safety measures that do not allow the catheter to enter the trachea, only the tube lumen. This often requires a customized card at the bedside for each infant indicating safe suctioning depth when intubated. This depth number is not easily found in electronic or paper records and is often safest if posted on the infant's ventilator for all care providers, including break relief and cross coverage.

 

Intubation itself should include a procedure for equipment preparation that maintains as much sterility as possible when equipment is assembled prior to the intubation. Use of a standard premedication protocol will manage the pain, reduce the secretions, and provide short-term paralysis that has been shown to reduce the number of attempts required for successful intubation. Reduced number of attempts will reduce airway trauma and a potential portal of bacterial entry into the airway.11-13 Accidental extubation should be tracked and root causes ascertained to determine the need for practice changes and reduce the traumatic risk of additional invasive procedures to the respiratory tract.14

 

Ventilator-associated pneumonia bundles were developed to reduce the risk of infection and have been implemented in most NICUs over the past decade.15-18 Standard recommended practices include effective hand hygiene before suctioning, no routine suctioning, minimal use of saline for suctioning, elevation of the head of the bed, clearing of oral secretions before suctioning, closed suctioning systems, and oral care than often includes swabbing with colostrum. There are now commercial preparations available for neonatal oral care if colostrum is not available.19-22 All ventilator-associated pneumonia prevention strategies should be audited for compliance on a regular basis and elements that can be included in admission order sets to reduce the chance of the practice not being implemented. The best opportunity for ensuring compliance with the use of oral colostrum swabs is to include it in the admission order set for all newborn infants who cannot go to breast. The order should include volume, method of application, and frequency.

 

GASTROINTESTINAL TRACT AND ENTERAL FEEDING

Bacterial contamination of enteral feedings and feeding tubes, and the subsequent complications from such contamination, has been well documented in the literature.23-25 A study by Mehall et al23 showed that 71 of 125 tubes cultured after a 7-day dwell time were contaminated with greater than 1000 colony forming units (CFUs) per milliliter, with a mean colony count of almost a million CFUs. The patients with contamination had a higher incidence of feeding intolerance. Of those infants who had higher contamination of the tubes, 7 developed necrotizing enterocolitis and 4 required surgery. At the time of surgery, cultures grew the same organisms recovered intraoperatively as the ones cultured from their feeding tubes. The authors made the observation about the possible connection between bacterial overgrowth in the gastrointestinal tract and bacterial contamination in enteral products and supplies. The contamination of enteral products can result in diarrhea, bacterial translocation (BT) with sepsis, and possibly death. The entire process of providing enteral nutrition for NICU infants as well as the overall health of the intestinal tract is one of the most critical aspects of infection risk reduction in the NICU. To this end, the American Dietetic Association (ADA) publishes Guidelines for the Preparation of Human Milk and Formula in Health Care Facilities.26 These guidelines focus on practices that reduce the risk of contamination of nutrients during collection, preparation, and administration. Additional research has focused on the role of intestinal colonization in the preterm infant as well as the effect on injury, resection, hypoperfusion, distention, and change in commensal bacteria as they relate to infection risk, including necrotizing enterocolitis.27-28

 

These studies and ADA guidelines recommend standardization of formula and breast milk preparation, including designated Milk Zones for formula preparation that are cleaned and maintained in a way similar to areas designated for vascular line assembly. To reduce contamination, there is also a recommendation to develop hang times for continuous feedings and these times vary on the basis of the enteral product, with shorter times recommended for breast milk than a product that is originally sterile, such as commercial ready-to-feed infant formulas. There are also guidelines for refrigeration limits, tubing and syringe change frequency, and use of additives such as fortifiers and protein supplements. The focus of all management of enteral nutrition products and supplies is based on the practice that minimizes the risk of bacterial contamination of the enteral product or the device used to deliver the feeding. Each NICU should review the ADA document and compare the guideline with current practice. In some cases, unit-based discussion is needed regarding recommendations that may be technically difficult in select patients. For example, in the section titled "Delivery and Bedside Management of Infant Feedings," there is a recommendation that the tubing used for intermittent feedings be flushed with sterile water after each feeding or medication administration.26 The intent of this flushing recommendation is to clear the tube of the substrate (milk) that can lead to bacterial growth. In the extremely low-birth-weight infant, this may lead to fluid excess and the same result could be achieved with a flush of air to clear the tubing contents.

 

Reducing infection risk in NICU infants requires a global focus on the health of the neonatal intestinal tract. The gastrointestinal tract is one of the largest organs of the body that provides an infection barrier.27-28 The intestine is colonized after birth with commensal micro flora that facilitates the evolution of normal nutrient absorptive function, digestion, and mucosal health. This colonization can be adversely affected by gestation, mode of delivery, type of feeding, and the use of antibiotics.27 The premature infant is more vulnerable to infection from bacteria that may translocate to systemic organs and tissues and lead to a systemic infection.

 

Factors associated with infection via the intestinal tract include, but are not limited to, delay in feeding, intestinal distension, bowel hypoperfusion, poor oxygenation of the bowel, and abnormal bacterial colonization.29-31 Animal studies in rats showed that when animals were compared for the presence of BT, the group inoculated with Escherichia coli and that which became distended had an 80% incidence compared with 30% of the rats that were distended with no E coli inoculation, and 20% of rats only inoculated with E coli.32 The risk of distension in premature and sick infants needs to be addressed in the creation of "standardized feeding" protocols and practices, not just as a sign of potential intolerance but as a risk of BT and subsequent systemic infection.33

 

In January 2013, the National Healthcare Safety Network introduced a modified definition for laboratory-confirmed bloodstream infection (BSI).34 The definition provides a mechanism to designate a BSI as related to mucosal barrier injury (MBI), but this pathogenesis is less well defined and understood in the neonatal population. A recently published multicenter retrospective cohort study sought to develop a candidate definition for central line-associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) condition and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants.35 The intent is to better understand the etiology of the bloodstream infection in this group of infants and focus interventional research and care delivery that could address this source of infection. Additional advantages would be the preservation of infant vascular access if the infection can be treated effectively with the catheter in place.

 

Increasing evidence shows that the ability to receive even small quantities of colostrum improves the colonization process and also the transmission of immune properties in newborns. If the infant cannot go to the breast due to illness or immaturity, the swabbing of the mouth with small volumes of colostrum can achieve these benefits.20-22 The newborn infant receiving own mother's milk will continue to receive immune properties, normal maternal flora, and a host of other protective components not available in infant formula. For these reasons and more, the programs that focus on the promotion and support of breast milk feeding will have global effects on infection risk reduction in NICU infants.36

 

VASCULAR ACCESS AND DEVICES

For the past decade, most infection risk-reduction strategies have focused on vascular access. The push from The Joint Commission and national and state collaboratives such as the Vermont Oxford Network have been aimed at reducing the numbers of HAIs due to the use of vascular devices. Significant gains have been made in the reduction of BSIs during this period.37 The 2012 CDC publication titled "Guidelines for the Prevention of Intravascular Catheter-Related Infections" provided the first evidence-based recommendations since 2002.38 These guidelines provide the evidence available at that time for both pediatric and adult patient populations and the recommendations are divided into 5 categories based on the level of evidence, including a substantial list of unresolved issues. The publication has received a variety of interpretations in individual neonatal units, but there are some practices that have been widely accepted and placed into care bundles that guide unit practice.

 

There has also been a significant effort to improve the accuracy of infection diagnosis and the timing of results and treatment. Procedures should be developed to reduce the rates in false-positive or false-negative cultures. Unit efforts should include a review of all procedures related to obtaining a culture, tracking of potential false-positives for factors that may have contributed, monitoring of the volume of samples submitted for adequacy, call-back procedures from the microbiology department for timeliness, "critical value" reporting procedures, and timing of initial antibiotic administration. No specific recommendations are made for these practices in the CDC document and evidence is not conclusive about technique. Orders for a blood culture should specifically include the site from where the culture is desired and the blood sample volume should be at least 1 mL.39-40 Volumes of less than 1 mL are associated with false-negative results, an incidence of 20% as shown in studies from the 1980s.40 Infectious disease specialists may encourage more volume, but in the small neonatal patient, a milliliter of blood represents a percentage of total volume that is similar to the volume percentage recommended in older patients. Practitioners have also been encouraged to evaluate all positive cultures, not only for whether an episode is due to a true infection but also to determine if the culture results are related to a secondary source, for example, an acute abdomen with bowel perforation. This evaluation is critical to reduce the removal of a life-sustaining catheter that is not the source of the infection. The National Healthcare Safety Network surveillance definition states, "The surveillance definition overestimates the true incidence of catheter-related blood stream infections (CRBSI) because not all BSIs originate from the catheter."38

 

A guideline is a set of recommended care practices that are supported with higher levels of evidence and have been widely adopted. Such guidelines are issued by the CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) and each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact.38 The categories are broken down into practices that are Strongly Recommended and the level of evidence (1A and 1B), required by state or federal regulations (1C), supported with suggestive clinical or epidemiologic studies (11), and Unresolved issues. The following are practices supported by the highest levels of evidence and include the following:

  

1. Education, training, and staffing requirements of healthcare workers in the indication, procedure for insertion, and maintenance of intravascular catheters. Examples of this include the recommendation of a dedicated insertion team, audits for compliance to procedures. Category 1A

 

2. Prompt removal of catheters no longer essential. Category 1A

 

3. The use of sterile gloves for insertion of arterial, central, and midline catheters. Category 1A. *This recommendation has not been widely adopted in that many peripheral arterial lines are not inserted using sterile technique.

 

4. Use of maximal barrier precautions when inserting central venous lines (CVCs), peripherally inserted central catheters (PICCs). Category 1A

 

5. Skin preparation with more than 0.5% chlorhexidine-based preparation before CVC insertion, or tincture of iodine or 70% alcohol if chlorhexidine is contraindicated. Category 1A

 

6. Sterile gauze or semipermeable transparent dressings that are changed when damp or loosened, no routine use of antibiotic ointment at the site, no submersion in baths or showers, and no routine dressing changes in pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. (38) Category 1B.

 

7. Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months if the CLABSI rate has not been substantially reduced despite other prevention measures. Category 1B. This does not support the routine use of chlorhexidine gluconate-impregnated sponges in that the use is for patients with recurrent infections, older than 2 months, not responding to other prevention practice. The data in randomized trials showed no statistical difference in BSIs with these sponges, only reduced site colonization.

 

8. No routine replacement of CVCs or PICCs. Category 1B.

 

9. Minimum of a cap, mask, sterile gloves, and a small sterile drape should be used during peripheral arterial catheter insertion. Category 1B

 

10. In patients not receiving blood, blood products, or fat emulsions, replace administration sets no more frequently than at 96-hour intervals but at least every 7 days. Category 1A. The recommendation comes from well-controlled studies that show this is safe, or less manipulation is better. Blood and lipid administration sets require daily changes due their known ability to support microbial growth.

 

11. Use hospital-specific or collaborative-based performance improvement initiatives in which strategies are bundled together to improve compliance with recommended practices. Category 1B

 

These practices should exist in unit-based procedure, protocol, and checklists, following review and approval in an interdisciplinary team format. Methods to review or drill down any confirmed infection should be developed to look for causative factors and potential practice improvement opportunities or the need for staff education around existing practice. These reviews can also be used for staff education on the presenting clinical signs, laboratory indices, timeliness of treatment, and outcomes. For those infections that have not been prevented, the diagnosis and treatment need to be evidence-based to reduce morbidity and mortality.

 

The CDC guidelines for preventions of CLABSI do not address many other practices such as hub care of claves, use of alcohol-impregnated caps for intravenous lines, line assembly procedure, how to administer medications into a central line, or whether or not to mix a new bag of fluids for a newly placed central line. Many of these questions have not been well studied and therefore should be based on a combination of theoretical rationale and support from suggestive clinical or epidemiologic studies. For example, the data on claves use have shown that the use of a clave on the end of a catheter allows the caregiver a smooth surface to disinfect versus the end of an open hub.40,41 The current claves have been designed to allow for ease of disinfection and have not been shown to be associated with colonization in the device or increase in infections when used. After the initial alarm and a rise in infection rates in some units when these devices were introduced, various in vitro studies were conducted, showing that even when the hub of the clave was inoculated with thousands of CFUs and then disinfected with alcohol with friction and time, the subsequent flushing of fluid through that hub resulted in no transmission of bacteria into the fluid.42-44

 

Reducing the line entries may reasonably reduce the risk of fluid path contamination or hub colonization. To this end, all intravenous medications should be reviewed for need, to evaluate the option for another route, or the safe administration through another peripheral vascular device. If the central catheter is the only safe option, then access and administration should most likely be through a dedicated medication line that is at the end of a long piece of tubing such as the microbore tubing used in many NICUs and capped by a clave that is effectively disinfected between administrations of medications.

 

Each unresolved practice should be reviewed in light of unit infection rates, potential morbidities of that practice, and cost in materials and labor. For example, if an infant has parenteral nutrition infusing in a peripheral intravenous line and the team assessment is that central access and total parenteral nutrition are needed, if that access is obtained in the morning and the new total parenteral nutrition bag is not available for 6 hours, should that new central device have a new sterile fluid for those 6 hours? The risks/cost to the patient are as follows: the parenteral nutrition in the peripheral intravenous line will infiltrate again during the 6-hour wait, the new sterile fluids for the new line is an additional cost and labor issue, and extra non-nutritive fluid for that 6 hours. The mixing of a new bag assumes that the fluid in the peripheral intravenous line is colonized or contaminated with bacteria. That is an unproven assumption that leads to a practice with cost and some risk. Many of these unresolved questions require team discussion and consensus that can be tracked for complications and or improved practice.

 

CONCLUSION

To comprehensively reduce infection risk for the infants in our care, we, as care providers, need to continue to address global care and safety. Infections in our patients are the result of a complex and dynamic series of events.45 All portals of entry or loci of infection must be considered to effectively reduce the risks. These portals include the skin, the respiratory tract, the intestinal tract, enteral nutrient delivery, and the vascular system. Bedside equipment such as computer mice and warmer controls needs to be disinfected as effectively as the hub of catheters. All environmental surfaces can be reservoirs of bacteria, fungi, and viruses. Hand hygiene is a basic building block for all infection risk reduction and needs to continue to be enforced and evaluated for compliance and effectiveness. Failure to address other practices that can introduce bacteria into the body such as traumatic intubation and suctioning will result in infections that vascular catheter care will not impact. It is time to think beyond the vascular bundle and systematically address global care delivery to maintain the integrity of all organ systems known to be infection barriers. All of what we do matters in infection risk reduction, not just the steps we take to assemble a central line.

 

References

 

1. Boyce JM, Pitter D. Guideline for hand hygiene in health-care settings. MMWR Recomm Rep. 2002;51(RR16):1-44. [Context Link]

 

2. Gross A, Cutright DE, D'Allessandro SM. Bacterial carriage on the fingernails of OR nurses. AORN J. 1994;60:796, 799-805. [Context Link]

 

3. Pottinger J, Burns S, Manske C. Bacterial carriage by artificial nails versus natural nails. Am J Infect Control. 1989;17:340-344. [Context Link]

 

4. Oelberg DG, Joyner SE, Jiang X, Laborde D, Islam MP, Pickering LK. Detection of pathogen transmission in neonatal nurseries using DNA markers as surrogate indicators. Pediatrics. 2000;105:311-315. [Context Link]

 

5. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces. BMC Infect Dis. 2006;6:130. [Context Link]

 

6. Harpin VA, Rutter N. Barrier properties of the newborn infant's skin. J Pediatr. 1983;102;419-425. [Context Link]

 

7. Johnson CL, Versalovic J. The human microbiome and its potential importance to pediatrics. Pediatrics. 2012;129:950-960. [Context Link]

 

8. Lund CH, Brandon D, Holden AC, Kuller J, Hill CM. Neonatal Skin Care. Evidence-Based Clinical Practice Guideline. Washington, DC: AWHONN; 2013. [Context Link]

 

9. Ceballos K, Waterman K, Hulett T, Makic MFB. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Adv Neonatal Care. 2013;13:154-163. [Context Link]

 

10. Morrow BM, Argent C. A comprehensive review of endotracheal suctioning: effects, indications, and clinical practice. Pediatr Crit Care. 2008;9:465-477. [Context Link]

 

11. Duncan HP, Zurick NJ, Wolf AR. Should we reconsider awake neonatal intubation? A review of the evidence and treatment strategies. Pediatr Anesth. 2001;11:135-145. [Context Link]

 

12. Kumar P, Denson SE, Mancuso TJ; Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for nonemergency endotracheal intubation in the neonate. Pediatrics. 2010;125:608-615. [Context Link]

 

13. Allen KA. Premedication for neonatal intubation, which medications are recommended and why. Adv Neonatal Care. 2012;12:107-111. [Context Link]

 

14. Franck LS, Vaughn B, Wallace J. Extubation and reintubation in the NICU: opportunities to improve care. Pediatr Nurs. 1992;18:267-270. [Context Link]

 

15. Garland JS. Ventilator-associated pneumonia in neonates: an update. NeoReviews. 2014;15:e225-e235. [Context Link]

 

16. Cernada M, Brugada M, Vento M. Ventilator associated pneumonia in neonatal patients: an update. Neonatology. 2014;105:98-107. [Context Link]

 

17. Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A. Randomized, controlled trial on tracheal colonization of ventilated infants: can gravity prevent ventilator associated pneumonia? Pediatrics. 2008;122:770-774. [Context Link]

 

18. Tan B, Zhang F, Zhang X, et al. Risk factors for ventilator-associated pneumonia in the neonatal intensive care unit: a meta-analysis of observational studies. Eur J Pediatr. 2014;173:427-434. [Context Link]

 

19. Stefanescu BM, Hetu C, Slaughter JC, O'Shea TM, Shetty AK. A pilot study of Biotene OralBalance(R) gel for oral care in mechanically ventilated preterm neonates. Contemp Clin Trials. 2013;35:33-39. [Context Link]

 

20. Rodriquez NA, Meier PP, Groer MV, Zeller JM. Oropharyngeal administration of colostrum to extremely low birth weight infants: theoretical perspectives. J Perinatol. 2009;29:1-7. [Context Link]

 

21. Newburg DS, Walker WA. Protection of the neonate by the innate immune system of developing gut and of human milk. Pediatr Res. 2007;61:2-8. [Context Link]

 

22. Mathur NB, Dwarkadas AM, Sharma VK, Saha K, Jain K. Anti-infective factors in preterm human colostrum. Acta Paediatr Scand. 1990;79:1039-1044. [Context Link]

 

23. Mehall JR, Saltzman DA, Wallett T, Jackson RJ, Smith SD. Prospective study of the incidence and complications of bacterial contamination of enteral feeding in the neonate. J Pediatr Surg. 2002;37:1177-1182. [Context Link]

 

24. Mehall J, Kite CA, Gilliam CH, Jackson RJ, Smith SD. Enteral feeding tube are a reservoir for nosocomial antibiotic-resistant pathogens. J Pediatr Surg. 2002;37:1011-1012. [Context Link]

 

25. Huller E, Kucerova E, Loughlin M, et al. Neonatal enteral feeding tubes as loci for colonization by members of the Enterobacteriaceae. Neonatal Intensive Care. 2010;23:37-43. [Context Link]

 

26. Robbins S, Meyers R, Hutsler D, et al. Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities. Washington, DC: Library of Congress; 2011. [Context Link]

 

27. Westerbeek EAM, van den Berg A, Lafeber HN, Knol J, Fetter WPF, van Elburg RM. The intestinal bacterial colonization in preterm infants: a review of the literature. Clin Nutr. 2006;25:361-368. [Context Link]

 

28. Sharma R, Tepas JJ, Hudak ML, et al. Neonatal gut barrier and multiple organ failure: role of endotoxin and proinflammatory cytokines in sepsis and necrotizing enterocolitis. J Pediatr Surg. 2007;42:454-461. [Context Link]

 

29. MacFie J. Current status of bacterial translocation as a cause of surgical sepsis. Br Med Bull. 2004;71:1-11. [Context Link]

 

30. Cole CR, Hansen NI, Higgins RD, et al. Bloodstream infections in very low birth weight infants with intestinal failure. J Pediatr. 2012;160:54-59. [Context Link]

 

31. Cole CR, Frem JC, Schmotzer B, et al. The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses. J Pediatr. 2010;156:941-947. [Context Link]

 

32. Kazez A, Saglam M, Doymaz MZ, Bulut Y, Asc Z. Detection of bacterial translocation during intestinal distension in rats using the polymerase chain reaction. Pediatr Surg Int. 2001;17:624-627. [Context Link]

 

33. Gephart SM, Hanson CK. Preventing necrotizing enterocolitis with standardized feeding protocols. Adv Neonatal Care. 2013;13:48-54. [Context Link]

 

34. See I, Iwamoto M, Allen-Bridson KT, Horan T, Magill SS, Thompson NP. Mucosal barrier injury laboratory-confirmed blood stream infections: results from a field test of a new National Healthcare Safety Network definition. Infect Control Hosp Epidemiol. 2013;34:769-776. [Context Link]

 

35. Coffin SE, Klieger SB, Duggan C, et al. Central line-associated bloodstream infection in neonates with gastrointestinal conditions: developing a candidate definition for mucosal barrier injury bloodstream infections. Infect Control Hosp Epidemiol. 2014;35:1391-1399. [Context Link]

 

36. AAP Policy Statement. Breastfeeding and the use of human milk. Pediatrics. 2012;129:600-603. [Context Link]

 

37. Ying JT, Goh VSK, Osiovich H. Reduction of central line-associated blood stream infection rates in a neonatal intensive care unit after implementation of a multidisciplinary evidenced-based quality implemented collaborative: 4 year surveillance. Can J Infect Dis Med Microbial. 2013;24:185-190. [Context Link]

 

38. O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Atlanta, GA: Centers for Disease Control and Prevention; 2011:1-126. [Context Link]

 

39. Polin RP; The Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Pediatrics. 2012;129:1006-1015. [Context Link]

 

40. Neal PR, Kleinan MB, Reynolds JK, Allen SP, Yau PL. Volume of blood submitted for cultures from neonates. Neonates. 1982;24:353-356. [Context Link]

 

41. Bouza E, Munoz P, Lopez-Rodriguez J, et al. The needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study. J Hosp Infect. 2003;54:279-287. [Context Link]

 

42. Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. J Assoc Vasc Access. 2007;12:140-142. [Context Link]

 

43. Arduino MJ, Bland LA, Danzig LE, McAllister SK, Aguero SM. Microbiologic evaluation of needleless and needle-access devices. Am J Infect Control. 1997;25:377-380. [Context Link]

 

44. Seymour VM, Dhallu TS, Moss HA, Tebbs SE, Elliot TS. A prospective clinical study to investigate the microbial contamination of a needleless connector. J Hosp Infect. 2000;45:165-168. [Context Link]

 

45. Bateman S, Seed PO. Precession of pediatric bacteremia and sepsis: covert operations and failures in diplomacy. Pediatrics. 2010;126:137-150. [Context Link]

 

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care practices; infection; neonatal care; risk reduction