Suhas M. Nafday

Statewide NICU Central-Line-Associated Bloodstream Infection Rates Decline After Bundles and Checklists

OBJECTIVE: In 2008, all 18 regional referral NICUs in New York state adopted central-line insertion and maintenance bundles and agreed to use checklists to monitor maintenance-bundle adherence and report checklist use. We sought to confirm whether adopting standardized bundles and using central-line maintenance checklists reduced central-line–associated bloodstream infections (CLABSI). METHODS: This was a prospective cohort study that enrolled all neonates with a central line who were hospitalized in any of 18 NICUs. Each NICU reported CLABSI and central-line utilization data and checklist use. We used χ2 to compare CLABSI rates in the preintervention (January to December 2007) versus the postintervention (March to December 2009) periods and Poisson regression to model adjusted CLABSI rates. RESULTS: Each study period included more than 55 000 central-line days and more than 200 000 patient-days. CLABSI rates decreased 67% statewide (risk ratio: 0.33 [95% confidence interval: 0.27–0.41]; P < .0005); after adjusting for the altered central-line–associated bloodstream infection definition in 2008, by 40% (risk ratio: 0.60 [95% confidence interval: 0.48–0.75]; P < .0005). A total of 13 of 18 NICUs reported using maintenance checklists for 10% to 100% of central-line days. The checklist-use rate was associated with the CLABSI rate (coefficient: −0.57, P = .04). A total of 10 of 18 NICUs were independent CLABSI rate predictors, ranging from 1 site with greatly reduced risk (incidence rate ratio: 0.04, P < .0005) to 1 site with greatly increased risk (incidence rate ratio: 2.87, P < .0005). CONCLUSIONS: Although standardizing central-line care elements led to a significant statewide decline in NICU CLABSIs, site of care remains an independent risk factor. Using maintenance checklists reduced CLABSIs.

Targeted short-term fluconazole prophylaxis among very low birth weight and extremely low birth weight infants

OBJECTIVES. To assess whether targeted short-term fluconazole prophylaxis reduces late-onset (>3 days of age) invasive fungal infection (IFI) among very low birth weight infants and extremely low birth weight (ELBW) infants and to assess mortality rates, toxicity, and costs associated with this intervention. METHODS. An observational study of 2 subsequent epochs of inborn infants with birth weight of <1500 g or gestational age of <32 weeks, 1 before (control) and 1 after (fluconazole) initiation of routine targeted fluconazole prophylaxis in March 2003, was performed. Targeted fluconazole (3 mg/kg) prophylaxis was administered to infants for whom a decision was made to administer broad-spectrum antibiotics for >3 days. RESULTS. IFI was observed for 13 (6.3%) of 206 infants in the control epoch and 2 (1.1%) of 178 in the fluconazole epoch, with a common odds ratio of 0.166. Logistic regression analysis taking into account all published factors (except for fungal colonization) showed that the fluconazole epoch was associated significantly with lower IFI rates. We observed no change in late (>3 days) mortality rates (11 of 206 infants in the control epoch vs 8 of 178 infants in the prophylaxis epoch). The mortality rate for ELBW infants with IFI was low (15%) in our study. Fluconazole was administered to 81% of ELBW infants, who received a median of 8 doses, and 41% of larger infants, who received a median of 5 doses. The intervention was cost-effective, and the effective number needed to treat to prevent 1 IFI was 10. CONCLUSIONS. This study suggests that targeted short-course fluconazole prophylaxis in very low birth weight and ELBW infants may be efficacious and cost effective.

Development of a statewide collaborative to decrease NICU central line-associated bloodstream infections

Objective:To characterize hospital-acquired bloodstream infection rates among New York States 19 regional referral NICUs (at regional perinatal centers; RPCs) and develop strategies to promote best practices to reduce central line-associated bloodstream infections (CLABSIs).Study Design:During 2006 and 2007, RPC NICUs reported bloodstream infections, patient-days and central line-days to the Department of Health, and shared their results. Aiming to improve, participants created a central line-care bundle based on visiting a potentially best performing NICU and reviewing the literature.Result:All 19 RPCs participated in this quality initiative, contributing 218 096 patient-days and 56 911 central line-days of observation. Individual RPC nosocomial sepsis infection (NI) rates ranged from 1.0 to 5.8 NIs per 1000 patient-days (2006), and CLABSI rates ranged from 2.6 to 15.1 CLABSIs per 1000 central line-days (2007). A six-fold rate variation among RPC NICUs was observed. Participants unanimously approved a level-1 evidence-based central line-care bundle.Conclusion:Individual RPC rates and consequent morbidity and resource use attributable to these infections were substantial and varied greatly. No center was without infections. It is hoped that the cooperation and accountability exhibited by the RPCs will result in a major network for characterizing performance and improving outcomes.

Splanchnic tissue oxygenation, but not brain tissue oxygenation, increases after feeds in stable preterm neonates tolerating full bolus orogastric feeding

Objective:The objective of this prospective, observational study was to test the hypothesis that tissue oxygenation in the splanchnic bed compared with tissue oxygenation in the cerebral circulation changes after feeding in preterm neonates who are tolerating full bolus orogastric feeds.Study Design:Clinically stable premature neonates with postmenstrual age between 32 and 356/7 weeks who were tolerating full bolus feedings were studied before feeding and 1 h after feeding using near-infrared spectroscopy. The ratio of oxygenated to reduced hemoglobin (tissue oxygenation index, TOI) in the splanchnic circulation bed was divided by the TOI in the cerebral circulation, thereby yielding the cerebro-splanchnic oxygenation ratio (CSOR). We compared TOI and CSOR before and after feeding. As the changes in TOI and CSOR had non-Gaussian distribution, nonparametric statistics were used.Result:Among 32 infants, CSOR increased significantly after feeding (median difference 0.08; range −0.48, +0.58; P=0.011), whereas pulse oximetry did not change significantly (P=0.600). The change in CSOR with feeding was associated with a significant increase in splanchnic TOI (preprandial median 43.8, range 25.2–68.4 vs postprandial 47.5, range 25.8–70.8; P=0.013), without any significant change in brain TOI (preprandial median 64.9, range 44.5–75.4 vs postprandial 58.9, range 42.2–72.3; P=0.153).Conclusion:This study indicates that CSOR and splanchnic TOI, but not brain TOI, increase significantly after feeding in stable preterm infants who are tolerating full orogastric feeds.

Is there an Advantage of Using Pressure Support Ventilation with Volume Guarantee in the Initial Management of Premature Infants with Respiratory Distress Syndrome? A pilot study

OBJECTIVE:To evaluate the feasibility of using the pressure support ventilation with volume guarantee (PSV-VG) as an initial ventilatory mode in preterm infants with respiratory distress syndrome (RDS) after surfactant treatment to achieve accelerated weaning of peak inspiratory pressure (PIP) and mean airway pressure (MAP).STUDY DESIGN:Initial 24-hour ventilatory parameters were compared in two groups of preterm infants managed by PSV-VG and the synchronized intermittent mandatory ventilation (SIMV) mode in a randomized controlled pilot study after surfactant treatment for RDS. A total of 16 babies were randomized to PSV-VG (1198±108 g [mean±SEM]; 27.9±0.6 weeks) and 18 babies to SIMV (birth weight 1055±77 g; gestational age 27.4±0.5 weeks). Repeated measures analysis of variance was used to compare serial values of PIP and MAP in the two groups.RESULTS:The PIP and MAP decreased over time (p<0.001) during the first 24 hours after surfactant administration in both groups but the decrease in MAP was faster in the SIMV group compared to PSV-VG group (p=0.035). The median numbers of blood gases during the first 24 hours were four and two in the SIMV and PSV-VG groups, respectively (p<0.001). The overall outcomes were not significantly different between the two groups.CONCLUSION:PSV-VG did not offer any ventilatory advantage over SIMV in the initial management of surfactant-treated premature newborns with RDS except for minimizing the number of blood gases.

Short-Chain Fatty Acids Induce Colonic Mucosal Injury in Rats with Various Postnatal Ages

Short chain fatty acids (SCFAs) may play a role in the pathogenesis of neonatal necrotizing enterocolitis. To evaluate the injurious effect of SCFAs on the colonic mucosa of rats at various postnatal developmental stages, we studied a total of 170 newborn Sprague-Dawley rats at postnatal ages days 3, 9, and 23. A 1.8-F silastic catheter or umbilical catheter was inserted rectally deep into the proximal colon of the rats. Rats from each of the three postnatal age groups were randomly divided to receive one of the following distinct SCFA solutions: acetic acid, butyric acid, propionic acid, or a mixture of above SCFAs solutions. An additional subgroup of rats from each of the age groups received normal saline as a control. The concentration of each SCFA solution was 300 mM, and the pH of all solutions was adjusted to 4.0. The volume of administered solution was 0.1 mL/10 g of body weight. After 24 h, all rats were killed and the daily weight change was recorded and proximal colon was collected for histologic examination. A histologic injury score was used to quantify the severity of mucosal injury. The severity of mucosal injury induced by luminal SCFAs administration decreased as the rats matured; by postnatal day 23, the injury caused by SCFAs was minimal. Thus, the severity of the colonic mucosal injury induced by luminal SCFAs is maturation dependent; the immature state of the mucosal defense in early postnatal age in newborn rat may explain its greater vulnerability to luminal SCFAs.

Variable effects of short chain fatty acids and lactic acid in inducing intestinal mucosal injury in newborn rats.

Background Short chain fatty acids and lactic acid are colonic bacterial fermentation products. Methods To evaluate the effects of these organic acids on the intestinal mucosa, a total of 72 newborn Sprague-Dawley rats (10 days old) were studied. A 3.5F catheter was inserted per rectum 4.0 cm deep into the proximal colon for organic acid administration at a volume of 0.1 ml/10 g body weight. The pH of organic acid solutions and normal saline was adjusted to 4.0. Group 1 (n = 10) received normal saline as a control. Group 2 (n = 11) received 150 mM acetic acid. Group 3 (n = 11) received 300 mM acetic acid. Group 4 (n = 10) received 150 mM butyric acid. Group 5 (n = 11) received 300 mM butyric acid. Group 6 (n = 7) received 150 mM lactic acid, and group 7 (n = 12) received 300 mM lactic acid. Animals were killed 24 hours after colonic installation of test solutions. Results Both 300 mM acetic acid and 300 mM butyric acid were associated with impaired weight gain, increased colon wet weight, and increased histologic injury scores in the colon and distal ileum (P < 0.05, analysis of variance). Both 150 mM acetic acid and butyric acid at 150 mmol/L induced minimal injury in the colon and distal ileum. Neither 150 mM nor 300 mM lactic acid induced any identifiable gross or microscopic intestinal mucosal injury. Conclusion Luminal short chain fatty acids can induce dose-dependent intestinal mucosal injury in newborn rats, resembling the pathology seen in neonatal necrotizing enterocolitis. Overproduction/accumulation of short chain fatty acids, but not lactic acid, in the proximal colon and/or distal ileum may play a role in the pathogenesis of necrotizing enterocolitis in premature infants.

A trial of vitamin a therapy to facilitate ductal closure in premature infants

OBJECTIVE To determine whether postnatal vitamin A therapy increased ductal closure rate in premature infants. STUDY DESIGN This was a prospective, double-blind, placebo-controlled trial. Subjects (n=40) were recruited on day of life 1. Inclusion criteria were premature neonates weighing 500 to 1500 g with an indwelling umbilical line. Vitamin A was administered intramuscularly on days 1, 3, and 7. Blood vitamin A and retinol binding protein levels were obtained on days 1 and 3. Echocardiography was performed on days 1, 3, 7, and 14. Failure of ductal closure was defined as the presence of a moderate to large patent ductus arteriosus on day 14, indomethacin therapy, or surgical ligation. RESULTS Comparison between the treatment and placebo groups revealed no differences in gestational age, weight, or oxygenation index. Vitamin A and retinol binding protein levels did not differ between the groups at entry but increased significantly after vitamin A treatment. Failure of ductal closure occurred in 22 of 40 babies without any difference between the groups (12/22 vs 10/18, P=NS). Four infants required surgical ligation, all in the treatment group (P=.04). Clinical outcome did not vary between groups. CONCLUSION Postnatal vitamin A therapy did not improve ductal closure rates in premature infants.

Vitamin A supplementation ameliorates butyric acid-induced intestinal mucosal injury in newborn rats.

Abstract Vitamin A (vit A) plays an important role in wound healing and therefore may help in repairing of intestinal mucosal injury. The purpose of this study was to determine if vit A supplementation could promote healing in intestinal mucosal injury as commonly seen in neonatal necrotizing enterocolitis (NEC). Mild intestinal mucosal injury was induced in 10-day-old Sprague-Dawley rats by luminal administration of 1.5% butyric acid (BA) at pH 4.0. Normal saline at the same pH was administered as control. Immediately after administrations of BA or normal saline, animals were randomly assigned to receive high dose vit A (20,000 IU/kg for one dose, i.p.), low dose vit A (5,000 IU/kg for two doses) or vehicle. Animals were followed for 48 hours and then sacrificed for histological examination. Rats with BA-induced intestinal mucosal injury had a reduction in daily weight gain (p < 0.05). Vit A supplementation significantly improved the daily weight gain in the rats with BA-induced intestinal mucosal injury and the effect is dose dependent. At sacrifice, the colon wet weight was significantly heavier and the histological injury scores from both ileum and proximal colon higher in the rats with BA-induced intestinal mucosal injury. All of those parameters were improved with vit A supplementation. We conclude that vit A supplementation ameliorates BA induced-intestinal mucosal injury in newborn rats.

Duodenal atresia: not always a double bubble

A newborn infant with a prenatal diagnosis of duodenal atresia and abdominal radiographs demonstrating air in distal bowel is presented. An upper gastrointestinal series revealed complete duodenal obstruction and duodenal atresia was confirmed at surgery. The significance of distal bowel gas and the embryological development of this unusual entity is discussed.