The prevention of nosocomial infection

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Controversies in managing neonatal infections

• David Isaacs
• Childrens Hospital at Westmead
• Sydney Australia

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Controversies in managing neonatal infections

• Should I start antibiotics?
• Should I do a lumbar puncture first?
• Which antibiotics?
• Reluctance to stop antibiotics.
• How can I prevent fungal infections?
• How can I prevent coagulase negative
  staphylococcal infection?

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Should I start antibiotics?

• Maternal risk factors in early sepsis
• Clinical examination
• Laboratory blood count, acute phase reactants
• If in doubt, start them

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Should I do a lumbar puncture first?

• Delayed
• Respiratory compromise
• Trauma
• Cerebral herniation
• Rare

• Immediate
• Biopsy alters treatment in 25 (Ecoli)
• 15-40 with meningitis have negative blood
  cultures
• Avoids confusion

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LP and possible early sepsis

• Baby with RDS
• 0.3 have meningitis
• 1500 LPs to find one meningitis
• Indications for Selective LP
• Clinical suspicion
• Risk factors (greatly prolonged rupture)
• Wiswell, 1995
• 169,000 babies Selective LP would mean delay
  or missed diagnosis in 16 of 43 babies (37)

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LP and late sepsis

• Traditional data up to 10 of babies with late
  sepsis have meningitis
• Recent data 50-60 of late sepsis is with
  coagulase negative staphylococci
• Inclination
• take blood culture, urine but not CSF (unless
  very sick)
• start antibiotics
• LP only if blood growing likely meningitis
  pathogen

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Which antibiotics?

• Narrowest spectrum possible
• Penicillin and gentamicin
• Flucloxacillin and gentamicin
• Vancomycin and gentamicin
• Not third generation cephalosporins
• Not imipenem or carbapenem

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Antibiotic abuse

• Paper to review
• European country
• Thanksgiving
• 30 babies treated for Pseudomonas infection
  with ciprofloxacin
• Used ciprofloxacin because had run out of
  other options
• Only 4 had sepsis 26 had endotracheal tube
  isolates
• Treated for 8 to 30 days

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Antibiotics abuse (cont)

• Treating colonisation not sepsis
• Treating for long periods of time
• Using very broad spectrum (and expensive)
  antibiotics

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Good antibiotic practise

• Use narrowest spectrum antibiotics possible
• Treat sepsis, not colonisation
• Stop antibiotics if cultures negative

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Reasons given for continuing antibiotics

• Baby looked sick
• Acute phase reactants elevated
• Cultures might be false negatives
• Cultures unreliable
• Culture results not back

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Antibiotic use, Oxford 1984-6 (ADC 1987
62 727-8)

• 1984 1986
• Mean duration of antibiotics 5.5 days 3.6 days
• Weight of antibiotics (g) 202.7 122.1
• treated 50 42
• Late sepsis 12 16
• No. after stopping antibiotics 0 0

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Reasons for stopping antibiotics

• Baby looked sick
• Courage, other causes
• Raised CRP
• Stop measuring it
• False negative cultures
• Rare in late sepsis
• Results not back
• Go to the lab and ask

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How do I prevent fungal infections?

• Reduce duration of antibiotics
• Reduce duration of parenteral feeding
• Prophylactic antifungals

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Fluconazole prophylaxis

• (Kaufman et al, NESM 2001 345 1660-6)
• 100 babies lt 1000g BW over 30 month period
• 50 IV fluconazole for 6 weeks
• 50 placebo

Fluconazole Placebo Colonisation 11
30 Infection (urine, blood, CSF) 0 10
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Prophylactic oral nystatin

• Preterm babies, birthweight lt1250g
• Oral nystatin 1mL (100,000U) 8-hourly until one
  week after extubation.
• Outcome colonisation (oropharynx, rectum)
• sepsis (blood, urine)
• (Sims M et al. Am J Perinatol 1988 533-6)

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Prophylactic nystatin for low birthweight babies

• Nystatin Control P
• (n 33) (n 34)
• Colonised 4 (14) 15 (44) lt0.01
• Systemic
• infection 2 (6) 11 (32) lt0.001
• UTI 2 (6) 10 (30) lt0.01
• Pneumonia 0 1 (died)
• Candidaemia 0 2
• (Sims ME. 1988)

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How can we prevent coagulase negative
staphylococcal sepsis?

• Change question
• Should we try to prevent CoNS sepsis?

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Coagulase negative staphylococcal neonatal
infection

• (Australasia 1991 - 2000)
• 1,281 episodes
• 57 of late sepsis
• Meningitis 5 (0.4)
• Mortality 4 (0.3)

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Conclusions

• Antibiotics are an extremely valuable resource
• Use them wisely
• Use them sparingly
• Prevention important
• Over-vigorous prevention not always wise

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