Infection Prevention in the NICU: A Changing Landscape

Premature infants in the neonatal intensive care unit (NICU) require special care and attention, especially regarding infection prevention. Infection control practices in the NICU have evolved significantly, resulting in improved outcomes and best practices. It is crucial to acknowledge the importance of using up-to-date and efficient techniques to guarantee the safety and health of these delicate patients.

According to recent studies, implementing infection prevention measures in the NICU has significantly reduced health care–associated infections (HAIs).¹ Moreover, studies have shown that by implementing comprehensive infection control programs, NICUs have achieved up to a 60% reduction in health care–associated bloodstream infections.^1,2 These impressive statistics demonstrate the impact of dedicated infection prevention efforts in the NICU.

In the past, infection prevention in the NICU was primarily focused on hand hygiene and basic isolation measures. Although these steps were important, they did not address premature infants’ unique challenges. Neonates have fragile immune systems and are highly susceptible to infections. Recognizing this, health care professionals began to develop a more comprehensive approach to infection prevention in the NICU.

Medical technology and scientific research have played a critical role in shaping how infection prevention is practiced in the NICU. Following are some notable advancements in this field.

Neonatal Infection Surveillance Programs

Implementing neonatal infection surveillance programs has revolutionized how infection prevention is practiced in NICUs.³ These programs allow health care providers to track infection rates in real time, identify outbreaks, analyze trends, and implement targeted infection prevention strategies. This has enabled early detection and prevention of infections, thereby minimizing their impact on premature infants. It has also helped to improve the care provided in NICUs by enhancing the quality of data collected on infections, leading to a better understanding of best practices for infection prevention.

Following are some specific neonatal infection surveillance programs and how experts in the field utilize them.

a. National Healthcare Safety Network (NHSN) Neonatal Component:

The NHSN Neonatal Component, run by the CDC in the United States, focuses on tracking HAIs in NICUs and special care nurseries. Experts in this program utilize standardized definitions and reporting methods to collect data on infections, including bloodstream infections, pneumonia, and urinary tract infections. The data are analyzed to identify trends, patterns, and risk factors associated with neonatal infections. This information is then used to develop evidence-based infection prevention and control strategies, optimize antimicrobial use, and improve patient outcomes.

b. Canadian Neonatal Network (CNN)

The CNN is a collaborative network of NICUs across Canada that collects and analyzes data on neonatal infections and outcomes. Experts utilize the pooled data from participating NICUs to compare infection rates, treatment approaches, and outcomes. This information helps identify best practices for neonatal care, including infection prevention measures, antibiotic stewardship, and supportive interventions. The network also facilitates research to improve the quality of neonatal care and reduce infection-related morbidity and mortality.

c. European Neonatal Infection Surveillance Network (EuroNeoNet)

EuroNeoNet is a consortium of European neonatal units that monitors and benchmarks neonatal infections, antimicrobial resistance, and perinatal epidemiology. Experts in EuroNeoNet collect and share data on neonatal infections and antimicrobial resistance, enabling cross-national comparisons and identification of regional variations. This effort helps to increase understanding of the impact of different health care systems, policies, and practices on neonatal infection rates and resistance patterns. By learning from collaboration, experts can work toward implementing effective infection control strategies and improving neonatal outcomes across Europe.

Enhanced Hand Hygiene Programs

Effective hand hygiene is essential for infection prevention in NICUs.⁴ Alcohol-based hand sanitizers, stricter guidelines, and continuous education have significantly improved hand hygiene practices. Health care professionals have been trained to practice hand hygiene regularly, especially before and after patient contact, to reduce the risk of HAIs. Improvements in hand hygiene have led to a reduction in the incidence of infections in NICUs, contributing significantly to better patient outcomes.

Strict Isolation Precautions

One of the most effective ways of preventing the spread of infections is implementing strict isolation precautions in NICUs. Such precautions include placing neonates with contagious infections in single-patient rooms and using barrier precautions such as gloves, gowns, and masks when handling them. Isolation precautions have proven effective in minimizing cross-contamination and lowering the risk of infection transmission, thereby reducing the incidence of HAIs in NICUs.

Antibiotic Stewardship Programs

The overuse and misuse of antibiotics have led to the emergence of drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant S aureus, and extended-spectrum b-lactamase–producing Enterobacteriaceae, posing a significant threat to health care systems.⁵ To combat this, antibiotic stewardship programs have been introduced in NICUs. These programs emphasize the appropriate use of antibiotics, proper dosage, and duration, reducing the chances of antibiotic resistance. By ensuring that neonates receive antibiotics only when necessary, antibiotic stewardship programs have contributed to reducing the incidence of infections in NICUs, improving patient outcomes, and reducing the emergence of drug-resistant bacteria.

Improvement in Medical Device Safety

Medical devices, such as central venous catheters, endotracheal tubes, and urinary catheters, are commonly used in NICUs. However, these devices can increase the risk of HAIs, such as central line–associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections, if not appropriately managed.

Recently, there have been significant improvements in the design and maintenance of these devices, reducing the likelihood of infections. Innovations in device design have led to the development of catheters with antimicrobial coatings, which can prevent bacterial colonization and reduce the risk of infections. For instance, a study published in Nano Research showed that zinc-doped copper oxide nanoparticle–coated catheters reduced Escherichia coli, S aureus, and Proteus mirabilis biofilm formation by more than 90% under flow conditions for 24 hours.⁶ Additionally, frequent monitoring and maintenance of medical devices can help ensure proper functioning, minimizing the risk of device-associated infections.

Despite the progress made in infection prevention, there is still room for improvement. Here are some potential developments.

Advanced Molecular Techniques

Advancements in molecular techniques, such as rapid diagnostic tests and polymerase chain reaction (PCR)-based assays, hold promise in the early detection of infections. These techniques can help identify pathogens quickly, allowing for prompt treatment and limiting the spread of infections.

Here are some examples of brands or infections associated with these techniques:

a. PCR-Based Assays

• Roche Diagnostics: Roche produces PCR-based assays for various infectious diseases. For example, the cobas series includes assays for detecting infections like HIV, and various respiratory viruses.
• Abbott Laboratories: Abbott offers PCR-based assays for detecting infections such as influenza virus, COVID-19, and other
  respiratory pathogens.

b. Rapid Diagnostic Tests

• BD Veritor System: BD (Becton, Dickinson and Company)
  manufactures the Veritor System, a rapid diagnostic test platform. It has been used to detect infections like influenza A virus and influenza B virus, respiratory syncytial virus (RSV), and strep throat.
• Sofia 2 by Quidel: Sofia 2 is a rapid immunoassay system for detecting various infections, including influenza virus, strep throat, and RSV.

c. COVID-19 Detection:

The COVID-19 pandemic has rapidly developed and deployed molecular diagnostic tests, especially PCR-based assays. Numerous companies, including Roche, Abbott, Thermo Fisher Scientific, and Cepheid, have developed and distributed PCR tests for COVID-19 detection. Antigen-based rapid tests, such as those produced by Abbott (BinaxNOW) and
QuidelOrtho (QuickVue), have also played an essential role in detecting COVID-19 infections quickly.

Improved Vaccination Strategies

Vaccination plays a vital role in preventing infectious diseases. In the future, there may be an increased focus on developing specific
vaccines for neonates and
implementing immunization strategies to protect premature infants against common pathogens.⁷

Available vaccines (as of 2023):

• Hepatitis B vaccine
• Rotavirus vaccine
• Diphtheria and tetanus toxoids and acellular pertussis vaccine
• Pneumococcal conjugate vaccine
• Haemophilus influenzae type b vaccine
• Inactivated polio vaccine
• RSV vaccine
• Measles-mumps-rubella vaccine

Vaccines that were in the works or being researched
(as of 2023):

• Group B Streptococcus vaccine
• Universal influenza vaccine
• Malaria vaccine
• Enhanced Infection
  Prevention Education
• Continued education and training for health care professionals regarding infection prevention practices in the NICU will be important. This will ensure they stay up-to-date with the latest guidelines and best practices, enhancing patient safety.⁸

Efforts to improve environmental disinfection in the NICU will continue. Novel technologies, such as UV germicidal irradiation and robotic disinfection systems, may be implemented to further reduce the risk of infections.

Infection prevention in the NICU has come a long way, thanks to advances in medical knowledge, technology, and dedicated efforts of health care professionals. Continued research, improved surveillance programs, and innovative strategies will further enhance the prevention and control of infections in the NICU. As we observe NICU Awareness Month, let us recognize the critical role infection prevention plays in safeguarding the health and well-being of premature infants.

References

1. Johnson J, Akinboyo IC, Schaffzin JK. Infection prevention in the neonatal intensive care unit. Clin Perinatol. 2021;48(2):413-429. doi:10.1016/j.clp.2021.03.011
2. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(5):553-569. doi:10.1017/ice.2022.87
3. Fitzgerald FC, Zingg W, Chimhini G, et al. The impact of interventions to prevent neonatal healthcare-associated infections in low- and middle-income countries: a systematic review. Pediatr Infect Dis J. 2022;41(3S):S26-S35. doi:10.1097/INF.0000000000003320
4. Kuti BP, Ogunlesi TA, Oduwole O, et al. Hand hygiene for the prevention of infections in neonates. Cochrane Database Syst Rev. 2023;6(6):CD013326. Published 2023 Jun 6. doi:10.1002/14651858.CD013326.pub4
5. Ventola CL. The antibiotic resistance crisis, part 1: causes and threats. P T. 2015;40(4):277-283. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378521/
6. Shalom Y, Perelshtein I, Perkas N, Gedanken A, Banin E. Catheters coated with Zn-doped CuO nanoparticles delay the onset of catheter-associated urinary tract infections. Nano Res. 2017;10:520-533. doi:10.1007/s12274-016-1310-8
7. The state of the world’s children 2023. Unicef. April 1, 2023. Accessed July 24, 2023. https://www.unicef.org/reports/state-worlds-children-2023?gclid=Cj0KCQjwn_OlBhDhARIsAG2y6zOZZopnIUqK3-v-cvH9pj9dQVa74jo9rVOA2_W7W5ZcXBmtHVGgwWsaAlu2EALw_wcB
8. Dramowski A, Aucamp M, Beales E, et al. Healthcare-associated infection prevention interventions for neonates in resource-limited settings. Front Pediatr. 2022;10:919403. doi:10.3389/fped.2022.919403