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NICU Environment and Principles of Infection Control


  • 1.

    What are some general measures that can reduce or minimize the risk of nosocomial infections?

Nosocomial infections are a serious concern in the NICU setting. The extremely small and immunologically compromised status of the patients makes them particularly vulnerable. Success in preventing nosocomial infections depends largely on a team approach, with the full commitment of frontline staff. The most effective measures are strict hand-washing and hand hygiene. Elimination of overcrowding and understaffing, strict adherence to central line maintenance and removal guidelines, careful preparation and storage of infant formulas, increasing breastfeeding rates, decreasing the number of heel sticks and attempts at venipuncture, using single-dose administration of medications when possible, avoiding drugs associated with an increased risk of nosocomial infection (histamine 2 blockers and corticosteroids), and use of sterile suctioning techniques have all been shown to be important factors in reducing nosocomial infection rates.

  • 2.

    What are best practices for hand hygiene?

Hand-washing and “degerming” remain the simplest and most effective methods of preventing transmission of infectious agents from clinicians to infants and from infants to infants. The Centers for Disease Control and Prevention (CDC) recommend the following practices in health care settings:

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    A 15-second wash with soap and water before initial patient care or when hands are visibly dirty or contaminated with blood or body fluids

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    Degerming (using an alcohol-based hand rub with emollient) immediately before and after all direct patient contact. This approach is effective in reducing the number of bacterial, fungal, and viral pathogens.

In addition, the American Academy of Pediatrics (AAP) Guidelines for Perinatal Care, 4th edition, has the following recommendations for all staff members coming in contact with neonates:

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    Personnel should remove rings, watches, and bracelets before entering nursery or obstetric areas.

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    Fingernails should be trimmed short, and no artificial fingernails or nail polish should be permitted.

  • 3.

    What is a CLABSI?

A CLABSI or a central line–associated blood stream infection is a primary bloodstream infection in a patient who had a central line within a 48-hour period of developing the infection.

  • 4.

    Is there a minimum time duration in which the central line must be in place before an infection can be categorized as a CLABSI?

No, according to the CDC, there is no minimum time duration that a central line needs to be in place before an infection is categorized as a CLABSI.

  • 5.

    How can ventilator-associated pneumonias be prevented?

A ventilator-associated pneumonia (VAP) is a pneumonia that develops in a ventilated patient starting at 48 hours after the initiation of mechanical ventilation. Very-low and extremely-low-birth-weight babies who are intubated are at particularly high risk. Preventive strategies include strict hand hygiene, elevating the head of the bed 30 to 60 degrees, in-line suctioning, oral hygiene, and the use of non-invasive ventilation when possible. ∗

∗ Foglia E, Meier MD, Elward A. Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients. Clin Microbiol Rev 2007;20:409–25.

  • 6.

    What are some of the multidrug-resistant organisms encountered in a NICU?

Table 5-1 lists some of the multidrug-resistant organisms found in the NICU.

TABLE 5-1
MULTIDRUG RESISTANT ORGANISMS ENCOUNTERED IN AN NICU
Modified from Cipolla D, Giuffrè M, Mammina C, Corsello G: Prevention of nosocomial infections and surveillance of emerging resistances in NICU. J Mater Fetal Neonatal Med 2011;24; 23–26.
Methicillin-resistant Staphylococcus aureus (MRSA) Frequent colonization and outbreaks. Frequent involvement of colonized health care workers (HCWs) in the transmission chains. High frequency of MRSA late-onset infections. Efficacy of decolonization and active surveillance.
Vancomycin-resistant enterococci (VRE) Very different prevalence rates depending on geographical area and antibiotic policy. Enteric reservoir. Episodic but dangerous spread. Long-term survival on environmental surfaces.
Multidrug-resistant gram-negatives (MDRGN) (Enterobacteriaceae , glucose nonfermenting gram negatives, resistant Pseudomonas strains) Selected by broad spectrum antibiotics (mostly by third-generation cephalosporins). Enteric reservoir, but for some species possible environmental reservoir. Epidemic spread driven by cross-transmission via caregiver’s hands. Production of extended spectrum beta-lactamases (ESBLs).
Carbapenem-resistant microorganisms (Enterobacteriaceae, Acinetobacter baumannii) Only sporadically reported in NICU. Extensively drug-resistant strains. The most serious threat to the available antimicrobial therapeutic options from both the clinical and public health points of view.

NICU Environment: Parental Responses to the NICU

  • 7.

    What are some of the stresses experienced by parents whose infant is being cared for in the NICU?

Parental reactions to a severe, life-altering event run the entire gamut of emotional response, including shock, denial, grief, fear, sadness, anger, and guilt. The following are typical parental concerns:

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    Infant appearance, comfort, health, course of hospitalization

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    Separation from infant; not feeling like a parent

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    Disruption of family life, family routines, time, household tasks, spousal communication

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    Concerns for siblings

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    Own health and well-being

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    Difficulties with breastfeeding and pumping

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    Communications with or actions of medical staff

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    Postdischarge expectations

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    NICU environment

It is important to remember that mothers and fathers may prioritize these concerns differently, and this discordance alone may be a source of severe family distress. As one family member put it, “There is no such thing as a good NICU experience.” The physician and nurse, however, can have a positive impact on a family’s NICU experience simply by acknowledging and assisting the family in dealing with these stresses.

  • 8.

    What are some of the stresses experienced by the family of a preterm infant after hospital discharge?

The stresses are more dramatic for families of infants with ongoing medical issues and home care needs than for families of healthy preterm infants. The following are some common stresses:

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    Insecurity about parenting abilities

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    Marital stress and possible discord

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    Bonding and attachment issues caused by prolonged hospitalization

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    Financial stress, especially when there is a loss of income because one parent needs to remain home with the infant

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    Inadequate or lack of insurance coverage for home care needs (e.g., nursing, equipment, special formulas and therapies)

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    Isolation, reduced contact with family and friends owing to concerns about exposure to infection (especially during winter months)

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    Resentment felt by siblings because of parents’ attention and time spent with new infant ∗

    ∗ Hughes MA, McCollum J, Sheftel D, et al. How parents cope with the experience of neonatal intensive care. Child Health Care 1994;23:1–14.

NICU Environmental Condition

  • 9.

    What is the optimal intensity and pattern of ambient light exposure for a preterm infant?

Although the answer is not definitively known, current data suggest that relatively dim ambient light (180 to 200 lux, or typical indoor lighting), cycled to an even dimmer level at night, may be preferable to lighting of unvaried intensity or chaotically varied lighting. The evidence for this is as follows:

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    Cycled dim light entrains circadian rhythm in newborn primates.

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    Day/night differences in activity are observed during the first 10 days after discharge in preterm infants exposed to diurnal-cycled dim ambient light (i.e., the babies are more likely to sleep at night and be awake during the day). These characteristics develop later in infants exposed to continuous dim lighting.

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    Day/night light cycling in the NICU may improve postdischarge weight gain compared with chaotic light cycling.

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    There is little evidence that neonates born before 35 weeks’ gestation establish circadian variations in behavior, temperature, and activity in response to day/night light variation. However, such effects are well documented at term and thereafter. ∗

    ∗ Rivkees S. Emergence and influences of circadian rhythmicity in infants. Clin Perinatol 2004;31:217–28.

  • 10.

    What are the effects of high noise levels on preterm babies in a neonatal ICU?

By 26 to 28 weeks gestational age, the preterm infant’s auditory system is sufficiently mature for loud noise to produce changes in heart rate, blood pressure, respiration, and oxygenation. The possible impact of high noise exposure on the long-term neurodevelopmental outcomes of these high-risk preterm neonates is also a concern. The NICU can be an unpredictably noisy place as a result of the alarms, ventilators, phones, and staff conversations. Also, the baby’s own crying can be a significant source of noise because loud sounds tend to be amplified within the incubator. In 1997 the AAP determined that safe sound levels in the NICU should not exceed an hourly level of 45 decibels on an A-weighted scale (dBA). It is well established that noise levels in the NICU often exceed these recommended levels. ∗

∗ Wachman EM, Lahav A. The effects of noise on preterm infants in the NICU. Arch Dis Child Fetal Neonatal Ed 2011;96:F305–F309.

  • 11.

    What are the major etiologies of deafness in the newborn?

Hearing loss is the most common congenital condition in the United States. Universal newborn hearing screening has been endorsed by multiple organizations, including the AAP, National Institutes of Health (NIH), and the CDC and is now mandatory in most states. Early intervention can be critical and assists in the development of speech and improved learning. Infants with the following risk factors have higher rates of hearing deficits:

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    Low birth weight

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    Congenital infections (e.g., rubella, toxoplasmosis, cytomegalovirus, syphilis, herpes)

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    Exposure to toxins (including ototoxic antibiotics and loop diuretics)

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    Exposure to assisted ventilation

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    Exposure to extracorporeal membrane oxygenation

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    Hyperbilirubinemia requiring exchange transfusion

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    Hypoxic-ischemic encephalopathy

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    Craniofacial anomalies

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    Family history of deafness ∗

    ∗ Graziani LJ, Desai S, Baumgart S, et al. Clinical antecedents of neurologic and audiologic abnormalities in survivors of neonatal ECMO—a group comparison study. J Child Neurol 1997;12:415–22.

  • 12.

    What is the estimate of visual acuity of a term infant? When does color vision develop?

At birth the newborn has at least 20/150 vision, and color vision develops at 2 months of age.

  • 13.

    What are the four modes of heat loss in a neonate?

Table 5-2 lists the four modes of heat loss.

TABLE 5-2
MODES OF HEAT LOSS IN A NEONATE
Modified from Allen F. Heat loss prevention in neonates. J Perinatol 2008;28:S57–S59.
Conduction Heat loss that occurs from contact of the baby’s skin with a colder object. This loss can be prevented by placing the baby on warmed blankets or mattress and ensuring that the provider’s hands are warm.
Convection Heat loss that takes place when heat is transferred to the cooler air surrounding the infant. This phenomenon can be prevented by increasing the room temperature in delivery rooms and closing doors and windows to minimize drafts.
Evaporation Heat loss that occurs when water molecules move to the air from wet skin. Evaporative loss can be prevented by promptly drying the baby after birth, and, in the case of very-low-birth-weight babies, covering them with a plastic wrap.
Radiation Heat loss caused by heat transfer to cooler objects that are not in direct contact with the neonate. This can be prevented by having double-walled incubators and placing incubators far from walls and windows.

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