Efficacy of interventions to improve hand hygiene compliance in neonatal units: a systematic review and meta-analysis.

Healthcare-associated infections (HCAIs) cause significant morbidity and mortality in neonatal intensive care units (NICUs). Meticulous hand hygiene is the most effective strategy to prevent HCAI. However, hand hygiene compliance (HHC) is low, especially in ICUs. Hence, we aimed to evaluate the efficacy of strategies for improving HHC in NICUs. A systematic review of the literature and meta-analysis were carried out. PubMed, EMBASE, Cochrane CENTRAL and CINAHL were searched in October 2013. PRISMA guidelines were followed. The quality of included studies was assessed by the Newcastle-Ottawa scale (NOS). Sixteen eligible non-randomised studies were included. A total of 27,155 hand hygiene moments were observed. Meta-analysis using a random effects model indicated that a range of strategies, such as educational campaigns, musical parodies, reminders, easy access to hand hygiene sanitisers, UV sensors and performance feedback, improved HHC [odds ratio (OR) 2.04; 95 % confidence interval (CI) 1.40, 2.97]. Significant statistical heterogeneity was noted. Studies which specifically provided performance feedback at either the individual or group levels reported a more significant improvement in HHC compared to those that did not (OR 2.81; 95 % CI 1.32, 5.96 vs. OR 1.55; 95 % CI 1.13-2.11). Strategies to improve HHC in NICUs seem to be more effective when they include performance feedback at the personal or group levels. Randomised controlled trials (RCTs) specifically assessing the benefits of performance feedback in improving HHC are needed.

Probiotics for preterm neonates: what will it take to change clinical practice?

Necrotizing enterocolitis (NEC) is a major cause of mortality (25%) and morbidity including recurrent sepsis, dependence on parenteral nutrition, need for surgery, and survival with short bowel syndrome in preterm very low birth weight infants. Mortality (45-100%) and morbidity including the risk of long-term neurodevelopmental impairment are higher in extremely preterm infants needing surgery for NEC. Systematic reviews of randomized controlled trials (RCT) indicate that probiotics significantly reduce the risk of NEC (RR 0.39; 95% CI 0.29-0.52; p < 0.00001) and all-cause mortality (RR 0.52; 95% CI 0.40-0.69; p < 0.00001) while facilitating enteral feeds in preterm infants. At present, data from 25 RCT (∼5,000 neonates) and reports on routine use (∼3,000 neonates) indicates that significant adverse effects of probiotics are rare. Despite the robust evidence, there is still reluctance in incorporating routine probiotic prophylaxis in clinical practice. If the goal is to have zero tolerance for NEC, then probiotic prophylaxis must be adopted as soon as possible. Current gaps in knowledge can be addressed by continued research while providing routine probiotic supplementation. We believe that the concept of evidence-based practice of medicine has been stretched too far in this case. Trial sequential analysis has already shown that the evidence for probiotic supplementation was conclusive after 10 trials. Results of the ongoing trials are unlikely to change the conclusions of the systematic reviews significantly. Currently we are at trial number 25; how many more trials do we need? What will it take to change clinical practice?

Clinical outcome of umbilical artery catheter-related thrombosis - a cohort study.

OBJECTIVE: To reveal the incidence of umbilical artery catheter-related thrombosis (UACRT), the associated risk factors and the natural history of clot formation and regression. STUDY DESIGN: A prospective cohort study. An umbilical artery catheter was inserted in 61 infants, who were evaluated and followed by serial duplex ultrasound studies for the development of UACRT, renal artery resistance index (RI) and clot resolution. Maternal and infant clinical variables were correlated with the characteristics of thrombi. RESULT: Nineteen infants developed UACRT, all resolved spontaneously without sequella; most had maximal length at the first evaluation. No correlation was found between the thrombus length and time to resolution. The RI did not differ between the infants with and without UACRT. After adjusting for possible confounding, catheter days was the only covariate associated with UACRT. CONCLUSION: Asymptomatic UACRT in our cohort was a self-resolving disease; it was associated with catheter days and did not necessitate medical treatment.

Gastrointestinal colonization with ESBL-producing Klebsiella in preterm babies--is vancomycin to blame?

In this study, we examine the possible association between treatment with vancomycin and colonization with extended-spectrum beta-lactamase (ESBL)-producing Klebsiella in our neonatal intensive care unit (NICU). Variables compared between newborns which developed rectal colonization and those who did not include: gestational age, birth weight, gender, and total length of hospital stay until positive stool culture or discharge, treatment with vancomycin, and positive blood culture for coagulase-negative Staphylococcus. We found that lower birth weight, younger gestational age, and treatment with vancomycin were statistically significant risk factors for gastrointestinal colonization with ESBL-producing Klebsiella. When applying a multivariate model, treatment with vancomycin, both for a full 10-day course and for a short 3-day empirical treatment, remained statistically significant. Treatment with vancomycin is a risk factor for gastrointestinal colonization with ESBL-producing Klebsiella in premature babies.