Fulminant Late-Onset Sepsis in a Neonatal Intensive Care Unit, 1988–1997, and the Impact of Avoiding Empiric Vancomycin Therapy

Karlowicz, M. Gary; Buescher, E. Stephen; Surka, A. E.

doi:10.1542/peds.106.6.1387

Cited by 195 publications

(166 citation statements)

References 8 publications

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“…We have shown previously that a single-site blood culture should be sufficient to document sepsis in symptomatic infants, and is biologically plausible because young infants have high-colony-count bacteremia, the bacterial clearance is slower and the bacteremia more continuous in newborns with sepsis than in older patients. 16 The distribution of pathogens causing sepsis in a specific hospital unit is usually considered when empiric antibiotics are selected, but 'this approach assumes that all pathogens causing sepsis have equal likelihood of causing severe complications including meningitis and death,' 17,18 and that all antibiotics will have good cerebrospinal fluid penetration and be equally effective to treat meningitis, which is commonly associated with Gram-negative sepsis. In reality, when empiric antibiotics for late-onset sepsis are selected, one should be especially concerned about fulminant late-onset Gram-negative sepsis, in which infants die before pathogens and antibiotic susceptibilities have been identified, often in <48 h of onset of illness.…”

Section: Discussionmentioning

confidence: 99%

“…In reality, when empiric antibiotics for late-onset sepsis are selected, one should be especially concerned about fulminant late-onset Gram-negative sepsis, in which infants die before pathogens and antibiotic susceptibilities have been identified, often in <48 h of onset of illness. 18 With changing patterns of organisms (e.g., coagulase-negative Staphylococcus and Candida) causing most of the late-onset sepsis cases in NICUs, neutropenia in VLBW infants will more likely result from other causes such as benign late-onset neutropenia, as described by Omar et al 19 rather than sepsis. While the isolated finding of neutropenia in a stable preterm infant may not warrant a sepsis evaluation or aggressive management, neutropenia in a sick infant may be ominous and may serve as an early warning for Gram-negative bacterial sepsis unless proven otherwise.…”

Section: Discussionmentioning

confidence: 99%

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Can neutrophil responses in very low birth weight infants predict the organisms responsible for late-onset bacterial or fungal sepsis?

et al. 2006

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Can neutrophil responses in very low birth weight infants predict the organisms responsible for late-onset bacterial or fungal sepsis?

et al. 2006

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“…Completed part 2 surveys were received from 278 clinicians, including 277 attending neonatologists or fellows-72% of eligible clinicians at the 35 hospitals. There was a median of 6 respondents per NICU (range: [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Thirteen NICUs (38%) also participated in the Vermont Oxford Neonatal Network, and 9 (26%) participated in the National Nosocomial Infections Surveillance (NNIS) system high-risk nursery component.…”

Section: Characteristics Of Participating Nicusmentioning

confidence: 99%

Evaluation and Treatment of Neonates With Suspected Late-Onset Sepsis: A Survey of Neonatologists’ Practices

Rubin

Sánchez

Siegel³

et al. 2002

Pediatrics

150

111

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ABSTRACT.Objective. To ascertain current diagnostic and treatment practices for suspected late-onset sepsis in infants in neonatal intensive care units (NICUs) and identify areas that may benefit from clinical practice guidelines.Methods. During June 2000, we conducted a multicenter survey of neonatologists and infection control professionals regarding practices related to late-onset sepsis in NICUs at children's hospitals participating in the Pediatric Prevention Network.Results. Personnel at 35 hospitals with NICUs completed surveys; 34 were infection control professionals, and 278 were neonatology clinicians, primarily attending neonatologists or neonatology fellows. At these facilities, coagulase-negative staphylococci (CoNS) were the most frequent blood culture isolate from infants with lateonset sepsis accounting for 54% of bloodstream infections. When late-onset sepsis was suspected, 83% of clinicians drew only 1 blood culture when no central venous catheter was present or when a central vascular was present with no blood return. Thirty-two percent obtained 1 or more C-reactive protein concentration determinations. Sixty percent of clinicians prescribed a vancomycin-containing regimen for a 900 g, 3-week-old infant with suspected late-onset sepsis. The presence of a central venous catheter or shock increased empiric vancomycin use. The presence of methicillin-resistant Staphylococcus aureus in the NICU did not increase vancomycin use, but a vancomycin restriction policy decreased empiric vancomycin use. Clinicians at an individual NICU tended to have similar empiric antibiotic-prescribing practices: in 29 (83%) of 35 centers >75% of respondents had similar practice with regard to prescribing a vancomycin-containing regimen for empiric therapy. Forty-seven percent to 85% completed a full course of antimicrobials when a single blood culture was obtained and grew CoNS, but a significantly lower percentage of respondents (22%-47%) completed a full course when 1 of 2 blood cultures obtained grew CoNS. Eleven percent of respondents removed an umbilical catheter at the time of suspected sepsis, but fewer than 5% removed a nonumbilical central venous catheter for suspected sepsis. L ate-onset sepsis-invasive infection occurring in neonates older than 3 days-occurs in approximately 10% of all neonates and in Ͼ25% of very low birth weight infants (Յ1500 g) who are hospitalized in neonatal intensive care units (NICUs). 1 In NICUs, these infections are often associated with vascular catheters, and coagulase-negative staphylococci (CoNS) are the most commonly reported pathogens, accounting for Ͼ50% of bloodstream infections. 2,3 In this setting, the vast majority of CoNS are resistant to methicillin. NICU infants with suspected late-onset sepsis are typically treated with empiric antimicrobial therapy that often includes vancomycin. However, there are national recommendations that vancomycin use in hospitals be restricted because exposure of patients to vancomycin is a risk factor for emergence of vancomycinresistant ...

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“…Many of the bacteria eliminated were Gram-negative bacilli known to be associated with serious nosocomial infections in the NICU. 28 eUVGI was associated with a reduction in colonization of patient airways and VAP. These results suggest that it is possible that airborne pathogens may contribute significantly to surface contamination and patient colonization.…”

Section: Discussionmentioning

confidence: 91%

Effect of enhanced ultraviolet germicidal irradiation in the heating ventilation and air conditioning system on ventilator-associated pneumonia in a neonatal intensive care unit

et al. 2011

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Objective: The objective of this study was to test the hypothesis that enhanced ultraviolet germicidal irradiation (eUVGI) installed in our neonatal intensive care unit (NICU) heating ventilation and air conditioning system (HVAC) would decrease HVAC and NICU environment microbes, tracheal colonization and ventilator-associated pneumonia (VAP).Study Design: The study was designed as a prospective interventional pre-and post-single-center study. University-affiliated Regional Perinatal Center NICU. Intubated patients in the NICU were evaluated for colonization, and a high-risk sub-population of infants <30 weeks gestation ventilated for X14 days was studied for VAP. eUVGI was installed in the NICU's remote HVACs. The HVACs, NICU environment and intubated patients' tracheas were cultured pre-and post-eUVGI for 12 months. The high-risk patients were studied for VAP (positive bacterial tracheal culture, increased ventilator support, worsening chest radiograph and X7 days of antibiotics).Result: Pseudomonas, Klebsiella, Serratia, Acinetobacter, Staphylococcus aureus and Coagulase-negative Staphylococcus species were cultured from all sites. eUVGI significantly decreased HVAC organisms (baseline 500 000 CFU cm À2 ; P ¼ 0.015) and NICU environmental microbes (P<0.0001). Tracheal microbial loads decreased 45% (P ¼ 0.004), and fewer patients became colonized. VAP in the highrisk cohort fell from 74% (n ¼ 31) to 39% (n ¼ 18), P ¼ 0.04. VAP episodes per patient decreased (Control: 1.2 to eUVGI: 0.4; P ¼ 0.004), and antibiotic usage was 62% less (P ¼ 0.013).Conclusion: eUVGI decreased HVAC microbial colonization and was associated with reduced NICU environment and tracheal microbial colonization. Significant reductions in VAP and antibiotic use were also associated with eUVGI in this single-center study. Large randomized multicenter trials are needed.

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Fulminant Late-Onset Sepsis in a Neonatal Intensive Care Unit, 1988–1997, and the Impact of Avoiding Empiric Vancomycin Therapy

Cited by 195 publications

References 8 publications

Can neutrophil responses in very low birth weight infants predict the organisms responsible for late-onset bacterial or fungal sepsis?

Can neutrophil responses in very low birth weight infants predict the organisms responsible for late-onset bacterial or fungal sepsis?

Evaluation and Treatment of Neonates With Suspected Late-Onset Sepsis: A Survey of Neonatologists’ Practices

Effect of enhanced ultraviolet germicidal irradiation in the heating ventilation and air conditioning system on ventilator-associated pneumonia in a neonatal intensive care unit

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