Objective: to assess the impact of a hospital-wide combined strategy to prevent late-onset neonatal sepsis in preterm newborns delivered at less than 32 weeks’ gestation.
Design: non-randomised experimental study with historical controls to assess the efficacy of a series of preventive measures implemented during the study period (lasting 5 years).
Setting: tertiary care level hospital in the United Kingdom.
Study population: 979 patients born at less than 32 weeks of gestational age (GA) admitted to the neonatal care unit between January 2007 and December 2012.
Intervention: the initial intervention consisted of the introduction of audits of central venous catheter practices, the appointment of a specialist hospital vascular device nurse, the change in policy recommendations from 0.5% to 2% chlorhexidine for catheter hub disinfection, the introduction of a venous infusion phlebitis scoring system and a change in the mode of administration of vancomycin to continuous infusion to treat late-onset sepsis (LOS) in newborns with percutaneously-inserted central catheters or surgical catheters; measures implemented later on included the standardisation of skin disinfection policy, a second hospital-wide audit, moving the Neonatal Intensive Care Unit (NICU) to a new building, and the updating and reinforcement of hospital-wide blood culture guidelines.
Outcome assessment: the NICU activity for each month was calculated based on the number of intensive care days, high dependency days and special care days as defined by the British Association of Perinatal Medicine, and the number of central line days was obtained from the retrospective review of the neonatal unit database. In addition, the number of blood cultures taken from peripheral or central venous catheters was obtained from the laboratory database. The authors estimated the risk of central line associated blood stream infection (CLA-BSI) and LOS based on the pre- and post-intervention days of exposure using Poisson regression.
Main results: the percentage of newborns delivered before 32 weeks’ gestation that had at least one episode of infection decreased from 38% in 2007 to 12.1% in 2012, with a reduction in the incidence of LOS from 26.1 to 2.9 per 1000 high dependency days and a decrease in CLA-BIS from 31.6 to 4.3 per 1000 catheter days. The authors estimated a reduction in incidence associated to the initial interventions of 55% (95% confidence interval [95 CI]: 40 to 74) for LOS and of 45% (95 CI: 33 to 61) for CLA-BSI. The estimated reduction in LOS associated with the standardization of skin disinfection policy was of 64% (95 CI: 47 to 87), and the reduction associated to moving to a new building was estimated at 54% (95 CI: 34 to 88). The implementation of an aseptic no-touch technique for infusion access was associated with a reduction in CLA-BSI of 53% (95 CI: 37 to 75).
Conclusion: this intervention produced a significant reduction in the rate of LOS in preterm infants, and the most important factors identified were the changes in skin disinfection, the administration of antimicrobials through catheters, the training of nurses responsible for intravascular catheter management and regular surveillance.
Conflicts of interest: none.
Funding source: none reported.