- Email: [email protected]
Strategies for the prevention of hospital-acquired infections in the neonatal intensive care unit
Letters to the Editor serum urea levels, impaired functional capacity ( class 2) was also found to be an independent variable significantly associated with mortality (B ¼ 0.3304; ExpB ¼ 1.3915; Wald ¼ 8.395; 95% CI ¼ 1.080e1.680; P ¼ 0.0038).2 Our findings were in agreement with other researchers, who reported functional impairment as a predictor of increased mortality in patients with CDAD.7,8 Functional capacity can be easily assessed and was graded as follows: class 1, patient is independent; class 2, patient requires assistance in daily activities; and class 3, patient is bedridden. This variable, for unexplained reasons, was ignored by the authors and not included in the model. Further, large-scale, prospective interventional studies, taking into account functional capacity status and, possibly, age in addition to white cell count, serum albumin and urea levels, are warranted. This might improve the performance of the proposed RUWA model. Early identification of patients who will progress to severe CDAD would provide clinicians with an opportunity to expedite intervention aggressively and may improve outcome. Therefore, the proposed RUWA scoring is an important step in the right direction; however, I believe that it can and should be further improved upon.
95 7. Kyne L, Merry C, O’Connell B, Kelly A, Keane C, O’Neill D. Factors associated with prolonged symptoms and severe disease due to Clostridium difficile. Age Ageing 1999;28: 107e13. 8. Anand A, Bashey B, Mir T, Glatt A. Epidemiology, clinical manifestations and outcome of Clostridium difficile-associated diarrhoea. Am J Gastroenterol 1994;89:519e23.
J. Bishara* Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel E-mail address: [email protected] Available online 28 November 2008 * Tel.: þ972 3 9377511; fax: þ972 3 9377513. ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.10.014
Strategies for the prevention of hospitalacquired infections in the neonatal intensive care unit
Conflict of interest statement None declared. Madam, Funding sources None.
References 1. Drew RJ, Boyle B. RUWA scoring system: a novel predictive tool for the identification of patients at high risk for complications from Clostridium difficile infection. J Hosp Infect 2008;71:93e4. 2. Bishara J, Peled N, Pitlik S, Samra Z. Mortality of patients with antibiotic-associated diarrhea: the impact of Clostridium difficile. J Hosp Infect 2008;68:308e14. 3. Moshkowitz M, Ben-Barouch E, Kline Z, Shimoni Z, Niven M, Konikoff F. Risk factors for severity and relapse of pseudomembranous colitis in an elderly population. Colorectal Dis 2007;9:173e7. 4. Blossom DB, McDonald LC. The challenges posed by reemerging Clostridium difficile infection. Clin Infect Dis 2007;45: 222e7. 5. Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002;235: 363e72. 6. Andrews CN, Raboud J, Kassen BO, Enns R. Clostridium difficile-associated diarrhea: predictors of severity in patients presenting to the emergency department. Can J Gastroenterol 2003;17:369e73.
I read with interest the review article by Borghesi and Stronati regarding strategies for the prevention of hospital-acquired infections in the neonatal intensive care unit (NICU).1 In the discussion on prevention of central venous catheter (CVC)related infections the authors state that 2% aqueous chlorhexidine should be considered the agent of choice for skin disinfection before vascular access. The reference for this is the 2002 Centers for Disease Control and Prevention guideline for the prevention of intravascular catheter-related infections.2 However, this guideline specifically singles out the neonatal patient as an unresolved issue, stating that ‘no recommendation can be made for the use of chlorhexidine in infants aged <2 months’. In my experience, the optimal skin disinfectant for use in neonates, particularly very low birthweight infants, is unknown. Skin disinfectants found to be safe and effective in adult and older paediatric patients do not necessarily apply to neonates. A neonate’s skin is thinner and more sensitive than that of most other patients and is damaged easily. Specific concerns relate primarily
96
Letters to the Editor
to skin burns and systemic absorption including thyroid toxicity (with iodine-based products). NICUs currently use a variety of products including 70% alcohol, 10% povidone-iodine, 0.05% chlorhexidine, 0.5% chlorhexidine with 70% alcohol and combinations of the above. However, it is my understanding that no consensus has been agreed on the optimal product at present. Conflict of interest statement None declared. Funding sources None.
References 1. Borghesi A, Stronati M. Strategies for the prevention of hospital-acquired infections in the neonatal intensive care unit. J Hosp Infect 2008;68:293e300. 2. Garland JS, Henrickson K, Maki DG. Hospital Infection Control Practices Advisory Committee Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. Pediatrics 2002; 110:1009e13.
S.J. Knowles* National Maternity Hospital, Dublin, Ireland E-mail address: [email protected] Available online 14 November 2008 * Address: National Maternity Hospital, Holles Street, Dublin 2, Ireland. Tel.: þ35316373578; fax: þ35316765048.
ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.09.019
Strategies for the prevention of hospitalacquired infections in the neonatal intensive care unit
Madam, We thank Dr Knowles for permitting us to clarify this issue. We agree that no consensus has been reached on the optimal product to be used for skin disinfection before vascular access during central venous catheter (CVC) placement in neonates.1
The antiseptic effectiveness of chlorhexidine has been well demonstrated in several studies. In one prospective randomised trial of adult patients, use of 2% aqueous chlorhexidine before placement of CVCs or arterial catheters was associated with the lowest incidence of local catheter-related infection and catheter-related bacteraemia compared with 10% povidone-iodine and 70% alcohol.2 In a subsequent multicentre, non-randomised prospective study in a tertiary neonatal intensive care setting, the use of 0.5% chlorhexidine gluconate in 70% isopropyl alcohol before peripheral catheter placement reduced catheter colonisation and catheter-related bloodstream infections compared with 10% povidone-iodine.3 Major concerns about the use of alcoholic chlorhexidine are for the high risk of skin burns in extremely premature infants during the first days of life, when the skin is thin and not fully keratinised. Aqueous chlorhexidine could be less irritant when used in very and extremely low birthweight infants and thus could represent a good option. A recent prospective trial of adult patients, published subsequently to our review, showed similar effectiveness of alcoholic and aqueous solutions of chlorhexidine.4 However, to date no study evaluated whether the aqueous formulation is less harmful and as effective as the alcoholic formulation in neonatal infants. The lack of evidence for neonatal patients prompts urgent need for large randomised controlled trials comparing effectiveness and safety of different skin disinfectants before CVC placement in neonates and particularly in very low birthweight infants. Conflict of interest statement None declared. Funding sources None.
References 1. Upadhyayula S, Kambalapalli M, Harrison CJ. Safety of antiinfective agents for skin preparation in premature infants. Arch Dis Child 2007;92:646e7. 2. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 1991;338:339e43. 3. Garland JS, Buck RK, Maloney P, et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial. Pediatr Infect Dis J 1995;14:510e6.
95 7. Kyne L, Merry C, O’Connell B, Kelly A, Keane C, O’Neill D. Factors associated with prolonged symptoms and severe disease due to Clostridium difficile. Age Ageing 1999;28: 107e13. 8. Anand A, Bashey B, Mir T, Glatt A. Epidemiology, clinical manifestations and outcome of Clostridium difficile-associated diarrhoea. Am J Gastroenterol 1994;89:519e23.
J. Bishara* Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel E-mail address: [email protected] Available online 28 November 2008 * Tel.: þ972 3 9377511; fax: þ972 3 9377513. ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.10.014
Strategies for the prevention of hospitalacquired infections in the neonatal intensive care unit
Conflict of interest statement None declared. Madam, Funding sources None.
References 1. Drew RJ, Boyle B. RUWA scoring system: a novel predictive tool for the identification of patients at high risk for complications from Clostridium difficile infection. J Hosp Infect 2008;71:93e4. 2. Bishara J, Peled N, Pitlik S, Samra Z. Mortality of patients with antibiotic-associated diarrhea: the impact of Clostridium difficile. J Hosp Infect 2008;68:308e14. 3. Moshkowitz M, Ben-Barouch E, Kline Z, Shimoni Z, Niven M, Konikoff F. Risk factors for severity and relapse of pseudomembranous colitis in an elderly population. Colorectal Dis 2007;9:173e7. 4. Blossom DB, McDonald LC. The challenges posed by reemerging Clostridium difficile infection. Clin Infect Dis 2007;45: 222e7. 5. Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002;235: 363e72. 6. Andrews CN, Raboud J, Kassen BO, Enns R. Clostridium difficile-associated diarrhea: predictors of severity in patients presenting to the emergency department. Can J Gastroenterol 2003;17:369e73.
I read with interest the review article by Borghesi and Stronati regarding strategies for the prevention of hospital-acquired infections in the neonatal intensive care unit (NICU).1 In the discussion on prevention of central venous catheter (CVC)related infections the authors state that 2% aqueous chlorhexidine should be considered the agent of choice for skin disinfection before vascular access. The reference for this is the 2002 Centers for Disease Control and Prevention guideline for the prevention of intravascular catheter-related infections.2 However, this guideline specifically singles out the neonatal patient as an unresolved issue, stating that ‘no recommendation can be made for the use of chlorhexidine in infants aged <2 months’. In my experience, the optimal skin disinfectant for use in neonates, particularly very low birthweight infants, is unknown. Skin disinfectants found to be safe and effective in adult and older paediatric patients do not necessarily apply to neonates. A neonate’s skin is thinner and more sensitive than that of most other patients and is damaged easily. Specific concerns relate primarily
96
Letters to the Editor
to skin burns and systemic absorption including thyroid toxicity (with iodine-based products). NICUs currently use a variety of products including 70% alcohol, 10% povidone-iodine, 0.05% chlorhexidine, 0.5% chlorhexidine with 70% alcohol and combinations of the above. However, it is my understanding that no consensus has been agreed on the optimal product at present. Conflict of interest statement None declared. Funding sources None.
References 1. Borghesi A, Stronati M. Strategies for the prevention of hospital-acquired infections in the neonatal intensive care unit. J Hosp Infect 2008;68:293e300. 2. Garland JS, Henrickson K, Maki DG. Hospital Infection Control Practices Advisory Committee Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. Pediatrics 2002; 110:1009e13.
S.J. Knowles* National Maternity Hospital, Dublin, Ireland E-mail address: [email protected] Available online 14 November 2008 * Address: National Maternity Hospital, Holles Street, Dublin 2, Ireland. Tel.: þ35316373578; fax: þ35316765048.
ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.09.019
Strategies for the prevention of hospitalacquired infections in the neonatal intensive care unit
Madam, We thank Dr Knowles for permitting us to clarify this issue. We agree that no consensus has been reached on the optimal product to be used for skin disinfection before vascular access during central venous catheter (CVC) placement in neonates.1
The antiseptic effectiveness of chlorhexidine has been well demonstrated in several studies. In one prospective randomised trial of adult patients, use of 2% aqueous chlorhexidine before placement of CVCs or arterial catheters was associated with the lowest incidence of local catheter-related infection and catheter-related bacteraemia compared with 10% povidone-iodine and 70% alcohol.2 In a subsequent multicentre, non-randomised prospective study in a tertiary neonatal intensive care setting, the use of 0.5% chlorhexidine gluconate in 70% isopropyl alcohol before peripheral catheter placement reduced catheter colonisation and catheter-related bloodstream infections compared with 10% povidone-iodine.3 Major concerns about the use of alcoholic chlorhexidine are for the high risk of skin burns in extremely premature infants during the first days of life, when the skin is thin and not fully keratinised. Aqueous chlorhexidine could be less irritant when used in very and extremely low birthweight infants and thus could represent a good option. A recent prospective trial of adult patients, published subsequently to our review, showed similar effectiveness of alcoholic and aqueous solutions of chlorhexidine.4 However, to date no study evaluated whether the aqueous formulation is less harmful and as effective as the alcoholic formulation in neonatal infants. The lack of evidence for neonatal patients prompts urgent need for large randomised controlled trials comparing effectiveness and safety of different skin disinfectants before CVC placement in neonates and particularly in very low birthweight infants. Conflict of interest statement None declared. Funding sources None.
References 1. Upadhyayula S, Kambalapalli M, Harrison CJ. Safety of antiinfective agents for skin preparation in premature infants. Arch Dis Child 2007;92:646e7. 2. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 1991;338:339e43. 3. Garland JS, Buck RK, Maloney P, et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial. Pediatr Infect Dis J 1995;14:510e6.