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1.  Etiology of Neonatal Blood Stream Infections in Tbilisi, Republic of Georgia 
Neonatal blood stream infections (BSI) are major cause of morbidity and mortality in developing countries. It is crucial to continuously monitor the local epidemiology of neonatal BSI to detect any changes in patterns of infection and susceptibility to various antibiotics.
To examine the etiology of BSI in two neonatal intensive care units (NICU) in the Republic of Georgia, a resource-poor country, and to determine antibiotic susceptibility of the isolated organisms.
Cross-sectional study among all septic infants was conducted in NICU of two pediatric hospitals in Tbilisi between 09/2003-09/2004.
A total of 200 infants with clinical signs of sepsis were admitted in two NICUs. Of these, 126 (63%) had confirmed bacteremia. Mortality rate was 34%. A total of 98 (78%) of 126 recovered isolates were Gram-negative organisms, and 28 (22%) were Gram-positive. Klebsiella pneumoniae was the most common pathogen, accounting for 36 (29%) of 126 isolates, followed by Enterobacter cloacae – 19 (15%), and S. aureus – 15 (12%). The gram-negative organisms showed high degree of resistance to commonly used antibiotics such as ampicillin, amoxicillin/clavulanate, and comparatively low resistance to amikacin, ciprofloxacin, carbapenems, and gentamicin; 40% of S. aureus isolates were methicillin resistant (MRSA). In multivariate analysis only umbilical discharge was a significant risk factor for having positive blood culture at admission to NICU (PR=2.25, 95% CI 1.82-2.77).
Neonatal BSI was mainly caused by gram-negative organisms, which are developing resistance to commonly used antibiotics. Understanding the local epidemiology of neonatal BSI can lead to the development of better medical practices, especially more appropriate choices for empiric antibiotic therapy, and may contribute to improvement of infection control practices.
PMCID: PMC2695829  PMID: 19058989
blood stream infections; Republic of Georgia; neonatal
2.  Pattern of Blood Stream Infections within Neonatal Intensive Care Unit, Suez Canal University Hospital, Ismailia, Egypt 
Introduction. Blood stream infection (BSI) is a common problem of newborn in neonatal intensive care units (NICUs). Monitoring neonatal infections is increasingly regarded as an important contributor to safe and high-quality healthcare. It results in high mortality rate and serious complications. So, our aim was to determine the incidence and the pattern of BSIs in the NICU of Suez Canal University Hospital, Egypt, and to determine its impact on hospitalization, mortality, and morbidity. Methods. This study was a prospective one in which all neonates admitted to the NICUs in Suez Canal University hospital between January, 2013 and June 2013 were enrolled. Blood stream infections were monitored prospectively. The health care associated infection rate, mortality rate, causative organism, and risk factors were studied. Results. A total of 317 neonates were admitted to the NICU with a mortality rate of 36.0%. During this study period, 115/317 (36.3%) developed clinical signs of sepsis and were confirmed as BSIs by blood culture in only 90 neonates with 97 isolates. The total mean length of stay was significantly longer among infected than noninfected neonates (34.5 ± 18.3 and 10.8 ± 9.9 days, resp., P value < 0.001). The overall mortality rates among infected and noninfected neonates were 38.9% and 34.8%, respectively, with a significant difference. Klebsiella spp. were the most common pathogen (27.8%) followed by Pseudomonas (21.6%) and Staphylococcus aureus (15.4%). Conclusion. The rate of BSIs in NICU at Suez Canal University Hospital was relatively high with high mortality rate (36.0%).
PMCID: PMC4217241  PMID: 25389439
3.  Variation in the use of alternative levels of hospital care for newborns in a managed care organization. 
Health Services Research  2000;34(7):1535-1553.
OBJECTIVE(S): To assess the extent to which variation in the use of neonatal intensive care resources in a managed care organization is a consequence of variation in neonatal health risks and/or variation in the organization and delivery of medical care to newborns. STUDY DESIGN: Data were collected on a cohort of all births from four sites in Kaiser Permanente by retrospective medical chart abstraction of the birth admission. Likelihood of admission into a neonatal intensive care unit (NICU) is estimated by logistic regression. Durations of NICU stays and of hospital stay following birth are estimated by Cox proportional hazards regression. RESULTS: The likelihood of admission into NICU and the duration of both NICU care and hospital stay are proportional to the degree of illness and complexity of diagnosis. Adjusting for variation in health risks across sites, however, does not fully account for observed variation in NICU admission rates or for length of hospital stay. One site has a distinct pattern of high rates of NICU admissions; another site has a distinct pattern of low rates of NICU admission but long durations of hospital stay for full-term newborns following NICU admission as well as for all newborns managed in normal care nurseries. CONCLUSIONS: Substantial variations exist among sites in the risk-adjusted likelihood of NICU admission and in durations of NICU stay and hospital stay. Hospital and NICU affiliation (Kaiser Permanente versus contract) or affiliation of the neonatologists (Kaiser Permanente versus contract) could not explain the variation in use of alternative levels of hospital care. The best explanation for these variations in neonatal resource use appears to be the extent to which neonatology and pediatric practices differ in their policies with respect to the management of newborns of minimal to moderate illness.
PMCID: PMC1975663  PMID: 10737452
4.  Risk Factors for Post-NICU Discharge Mortality Among Extremely Low Birth Weight Infants 
The Journal of Pediatrics  2012;161(1):70-74.e2.
To evaluate maternal and neonatal risk factors associated with post-neonatal intensive care unit (NICU) discharge mortality among ELBW infants.
Study design
This is a retrospective analysis of extremely low birth weight (<1,000 g) and <27 weeks' gestational age infants born in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network sites from January 2000 to June 2007. Infants were tracked until death or 18–22 months corrected age. Infants who died between NICU discharge and the 18–22 month follow-up visit were classified as post-NICU discharge mortality. Association of maternal and infant risk factors with post-NICU discharge mortality was determined using logistic regression analysis. A prediction model with six significant predictors was developed and validated.
5,364 infants survived to NICU discharge. 557 (10%) infants were lost to follow-up, and 107 infants died following NICU discharge. Post-NICU discharge mortality rate was 22.3 per 1000 ELBW infants. In the prediction model, African-American race, unknown maternal health insurance, and hospital stay ≥120 days significantly increased risk, and maternal exposure to intra-partum antibiotics was associated with decreased risk of post-NICU discharge mortality.
We identified African-American race, unknown medical insurance and prolonged NICU stay as risk factors associated with post-NICU discharge mortality among ELBW infants.
PMCID: PMC3366175  PMID: 22325187
extremely preterm infants; discharge; mortality; predictive model
5.  The Main Etiologies of Acute Kidney Injury in the Newborns Hospitalized in the Neonatal Intensive Care Unit 
Acute kidney injury (AKI) is one of the most common diseases among the newborns hospitalized in the neonatal intensive care units (NICUs), which is usually resulted from predisposing factors including sepsis, hypovolemia, asphyxia, respiratory distress syndrome (RDS), and heart failure. The goal of this study was to assess main etiologies, relevant risk factors, and early outcome of neonatal AKI.
Materials and Methods:
In a cross- sectional study, 49 consecutive neonates hospitalized in NICU of Besat hospital with diagnosis of AKI from October 2009 to October 2011 were investigated through census sampling method. AKI was diagnosed based on urine output and serum creatinine levels.
The prevalence of AKI was 1.54% (49 out of 3166 newborns hospitalized in NICU) with the female: male was 7:1. Thirty-nine patients (79.5%) were full-term neonates. Oliguria was observed in 38 (77.5%) patients. Sepsis was the most common predisposing factor for AKI in 77.5% of patients (n = 38) accompanied with the highest mortality rate among other factors (30.5%). Other leading causes of AKI included hypovolemia secondary to dehydration, followed by hypoxia secondary to RDS, patent ductus arteriosus, posterior urethral valve, asphyxia, and renal venous thrombosis. A positive relationship was observed between neonates' age, sex, urine output, and also between serum creatinine levels with initiation of dialysis. The mortality rate among the newborns hospitalized with AKI was 36.7%. Eighteen (36.7%) newborns were treated with peritoneal dialysis (PD) of whom 10 patients (55.6%) died, 31 patients were managed conservatively of whom five neonate died (25.9%).
Prognosis of AKI in the oliguric neonates requiring PD is very poor. It is thus recommended to prevent AKI by predicting and rapid diagnosis of AKI in patients with potential risk factors and also by early and effective treatment of such factors in individuals with AKI.
PMCID: PMC4089136  PMID: 25024976
Acute kidney injury; newborns; outcomes
6.  High Mortality among Patients with Positive Blood Cultures at a Children's Hospital in Tbilisi, Georgia 
The etiology and outcomes of blood stream infections (BSI) among pediatric patients is not well described in resource-limited countries including Georgia.
Patients with positive blood cultures at the largest pediatric hospital in the country of Georgia were identified by review of medical and laboratory records for patients who had blood cultures obtained between 01/2004-06/2006.
Of 1,693 blood cultures obtained during the study period, 338 (20%) were positive; 299 were included in our analysis. The median age was 14 days (range 2 days -14 years) and 178 (60%) were male; 53% of patients with a positive culture were admitted to Neonatal Intensive Care Unit (NICU). Gram-negative bacilli (GNB) were representing 165 (55%) of 299 cultures. Further speciation of 135 (82%) of 165 GNR was not possible because of lack of laboratory capacity. Overall mortality was 30% (90 of 299). Among the 90 children who died, 80 (89%) were neonates and 68 (76%) had BSI caused by Gram-negative organism. In multivariate analysis, independent risk factors for in-hospital mortality included age <30 days (OR=4.00, 95% CI 1.89-8.46) and having a positive blood culture for a Gram-negative BSI (OR=2.38, 95% CI 1.32-4.29).
A high mortality was seen among children, particularly neonates, with positive blood cultures at the largest pediatric hospital in Georgia. Because of limited laboratory capacity microbiological identification of common organisms known to cause BSI in children was not possible and susceptibility testing was not performed. Improving the infrastructure of diagnostic microbiology laboratories in resource limited countries is critical in order to improve patient care and clinical outcomes and from a public health standpoint to improve surveillance activities.
PMCID: PMC2864639  PMID: 19759489
BSI; mortality; children; Georgia
7.  Risk adjusted and population based studies of the outcome for high risk infants in Scotland and Australia 
OBJECTIVES—To compare outcomes of care in selected neonatal intensive care units (NICUs) for very low birthweight (VLBW) or preterm infants in Scotland and Australia (study 1) and perinatal care for all VLBW infants in both countries (study 2).
DESIGN—Study 1: risk adjusted cohort study; study 2: population based cohort study.
SUBJECTS—Study 1: all 2621 infants of < 1500 g birth weight or < 31 weeks' gestation admitted to a volunteer sample of hospitals comprising eight of all 17 Scottish NICUs and six of all 12 tertiary NICUs in New South Wales and Queensland in 1993-1994; study 2: all 5986infants of 500-1499 g birth weight registered as live born in Scotland and Australia in 1993-1994.
MAIN OUTCOMES—Study 1: (a) hospital death; (b) death or cerebral damage, each adjusted for gestation and CRIB (clinical risk index for babies); study 2: neonatal (28 day) mortality.
RESULTS—Study 1. Data were obtained for 1628 admissions in six Australian NICUs, 775 in five Scottish tertiary NICUs, and 148 in three Scottish non-tertiary NICUs. Crude hospital death rates were 13%, 22%, and 22% respectively. Risk adjusted hospital mortality was about 50% higher in Scottish than in Australian NICUs (adjusted mortality ratio 1.46, 95% confidence interval (CI) 1.29 to 1.63,p < 0.001). There was no difference in risk adjusted outcomes between Scottish tertiary and non-tertiary NICUs. After risk adjustment, death or cerebral damage was more common in Scottish than Australian NICUs (odds ratio 1.9, 95% CI 1.5 to 2.5). Both these risk adjusted adverse outcomes remained more common in Scottish than Australian NICUs after excluding all infants < 28 weeks' gestation from the comparison. Study 2. Population based neonatal mortality in infants of 500-1499 g was higher in Scotland (20.3%) than Australia (16.6%) (relative risk 1.22, 95% CI 1.08 to 1.39, p = 0.002). In a post hoc analysis, neonatal mortality was also higher in England and Wales than in Australia.
CONCLUSIONS—Study 1: outcome was better in the Australian NICUs. Study 2: perinatal outcome was better in Australia. Both results may be consistent, at least in part, with differences in the organisation and implementation of neonatal care.

PMCID: PMC1721047  PMID: 10685984
8.  Mode of delivery and other risk factors for Escherichia coli infections in very low birth weight infants 
BMC Pediatrics  2014;14(1):274.
Infections in newborns remain one of the most significant problems in modern medicine. Escherichia coli is an important cause of neonatal bloodstream and respiratory tract infections and is associated with high mortality. The aim of our study was to investigate the epidemiology of E. coli infection in Polish neonatal intensive care units (NICUs) and resistance to antibiotics, with particular reference to the safety of very low birth weight infants.
Continuous prospective infection surveillance was conducted in 2009–2012 in five NICUs, including 1,768 newborns whose birth weight was <1.5 kg. Escherichia coli isolates from different diagnostic specimens including blood, tracheal/bronchial secretions and others were collected. All isolates were tested using disk diffusion antimicrobial susceptibility methods. Pulsed-field gel electrophoresis was used to determine the possible horizontal transfer of E. coli among patients.
The incidence of E. coli infections was 5.4% and 2.0/1,000 patient-days. The occurrence of E. coli infections depended significantly on the NICU and varied between 3.9% and 17.9%. Multivariate analysis that took into account the combined effect of demographic data (gender, gestational age and birth weight) and place of birth showed that only the place of hospitalisation had a significant effect on the E. coli infection risk. The highest levels of resistance among all E. coli isolates were observed against ampicillin (88.8%) and amoxicillin/clavulanic acid (62.2%). Among E. coli isolates, 17.7% were classified as multidrug resistant. Escherichia coli isolates showed different pulsotypes and dominant epidemic clones were not detected.
Our data indicate that antibiotic prophylaxis in the presence of symptoms such as chorioamnionitis and premature rupture of membranes did not help reduce the risk of E. coli infection. Multivariate analysis demonstrated only one significant risk factor for E. coli infection among infants with a birth weight <1.5 kg, that is, the impact of the NICU, it means that both neonatal care and care during pregnancy and labour were found to be significant.
PMCID: PMC4287582  PMID: 25326700
Very low birth weight; Infections; Escherichia coli; Surveillance
9.  Variations in mortality rates among Canadian neonatal intensive care units 
Most previous reports of variations in mortality rates for infants admitted to neonatal intensive care units (NICUs) have involved small groups of subpopulations, such as infants with very low birth weight. Our aim was to examine the incidence and causes of death and the risk-adjusted variation in mortality rates for a large group of infants of all birth weights admitted to Canadian NICUs.
We examined the deaths that occurred among all 19 265 infants admitted to 17 tertiary-level Canadian NICUs from January 1996 to October 1997. We used multivariate analysis to examine the risk factors associated with death and the variations in mortality rates, adjusting for risks in the baseline population, severity of illness on admission and whether the infant was outborn (born at a different hospital from the one where the NICU was located).
The overall mortality rate was 4% (795 infants died). Forty percent of the deaths (n = 318) occurred within 2 days of NICU admission, 50% (n = 397) within 3 days and 75% (n = 596) within 12 days. The major conditions associated with death were gestational age less than 24 weeks (59 deaths [7%]), gestational age 24–28 weeks (325 deaths [41%]), outborn status (340 deaths [42%]), congenital anomalies (270 deaths [34%]), surgery (141 deaths [18%]), infection (108 deaths [14%]), hypoxic–ischemic encephalopathy (128 deaths [16%]) and small for gestational age (i.e., less than the third percentile) (77 deaths [10%]). There was significant variation in the risk-adjusted mortality rates (range 1.6% to 5.5%) among the 17 NICUs.
Most NICU deaths occurred within the first few days after admission. Preterm birth, outborn status and congenital anomalies were the conditions most frequently associated with death in the NICU. The significant variation in risk-adjusted mortality rates emphasizes the importance of risk adjustment for valid comparison of NICU outcomes.
PMCID: PMC99269  PMID: 11826939
10.  The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates – results of nation-wide cohort study in Germany 
Very low birthweight (VLBW) newborns on neonatal intensive care units (NICU) are at increased risk for developing central venous catheter-associated bloodstream infections (CVC BSI). In addition to the established intrinsic risk factors of VLBW newborns, it is still not clear which process and structure parameters within NICUs influence the prevalence of CVC BSI.
The study population consisted of VLBW newborns from NICUs that participated in the German nosocomial infection surveillance system for preterm infants (NEO-KISS) from January 2008 to June 2009. Structure and process parameters of NICUs were obtained by a questionnaire-based enquiry. Patient based date and the occurrence of BSI derived from the NEO-KISS database. The association between the requested parameters and the occurrance of CVC BSI and laboratory-confirmed BSI was analyzed by generalized estimating equations.
We analyzed data on 5,586 VLBW infants from 108 NICUs and found 954 BSI cases in 847 infants. Of all BSI cases, 414 (43%) were CVC-associated. The pooled incidence density of CVC BSI was 8.3 per 1,000 CVC days. The pooled CVC utilization ratio was 24.3 CVC-days per 100 patient days. A low realized staffing rate lead to an increased risk of CVC BSI (OR 1.47; p=0.008) and also of laboratory-confirmed CVC BSI (OR 1.78; p=0.028).
Our findings show that low levels of realized staffing are associated with increased rates of CVC BSI on NICUs. Further studies are necessary to determine a threshold that should not be undercut.
PMCID: PMC3643825  PMID: 23557510
Staffing; CVC; BSI; NICU; VLBW
11.  Correlation of Neonatal Intensive Care Unit Performance Across Multiple Measures of Quality of Care 
JAMA pediatrics  2013;167(1):47-54.
To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance.
We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations.
Twenty-two regional NICUs in California.
In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007.
Main Outcomes Measures
Pneumothorax, growth velocity, health care–associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk.
The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations only 6 were significant (P < .05). Correlations between pairs of quality measures were strong (ρ > .5) for 1 pair, moderate (.3 < |ρ| <
.5) for 8 pairs, weak (.1 < |ρ| < .3) for 5 pairs and negligible (|ρ| < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care–associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4.
In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.
PMCID: PMC4028032  PMID: 23403539
infant; newborn; quality of care; performance measurement
12.  Change in Pathogens Causing Late-onset Sepsis in Neonatal Intensive Care Unit in Izmir, Turkey 
Iranian Journal of Pediatrics  2010;20(4):451-458.
Neonatal sepsis is a common cause of morbidity and mortality among newborns in the developing world. We have investigated the causative agents and their antimicrobial susceptibility of late-onset sepsis (>72 h post-delivery), and determined the possible association between various risk factors and the mortality due to neonatal sepsis in 2008. To view the changes in years, we compared them with the data which we gained in 2004.
Medical records of all neonates with late-onset sepsis were reviewed for demographic characteristics (birth weight, gestational age, gender, type of delivery, and mortality rate), positive cultures and risk factors of mortality.
One hundred and forty-seven and 227 neonates had been diagnosed as late-onset sepsis in 2004 and 2008, respectively. Coagulase-negative staphylococcus was the most frequent microorganisms. Gram-negative bacilli, particularly Pseudomonas aeruginosa showed a significant increase in years. The mortality rate was 11.5% and 19% in 2004 and 2008, respectively. Birth weight, gestational age, and infection with Klebsiella spp. isolates were found to have significant association with sepsis mortality in our neonatal intensive care unit (NICU).
The present study emphasizes the importance of periodic surveys of sepsis encountered in particular neonatal setting to recognize the trend. Increased Gram-negative bacilli rate was possibly related to the widespread use of antibiotics in our NICU.
PMCID: PMC3446087  PMID: 23056745
Sepsis; Risk factors; Neonatal intensive care unit; Neonate; Infection; Antibiotics
13.  Polycythemia in Neonatal Intensive Care Unit, Risk Factors, Symptoms, Pattern, and Management Controversy 
Polycythemia (PC) is defined as venous hematocrit (hct) ≥65%.  Its incidence is high among certain risk factors (RFs). Its management is controversy.
To determine: (1) The incidence of PC in our neonatal intensive care unit (NICU). (2) Most common RF, symptoms, and laboratory abnormalities (LA) associated with PC and their effect on the length of hospital stay (LOS). (3) Whether noninvasive interventions are effective in reducing hct. (4) Hct pattern of PC neonates.
Retrospective cohort study.
NICU at a maternity and children hospital.
Materials and Methods:
Records review of all neonates from March 2011 to August 2013. Inclusions criteria were: (1) Venous hct ≥65%. (2) Neonates born in our institution. (3) Early umbilical cord clamping. (4) Gestational age ≥34 weeks.
Statistical Analysis:
Chi-square and multiple regression analysis.
One hundred and one PC neonates were eligible. Incidence of PC in our NICU is 14.5%. The most common RF, symptoms, and LA were: Small for gestational age, jaundice and hypoglycemia respectively. Tachypnea (  P - 0.04) and oliguria (P - 0.03) significantly prolonged LOS. Noninvasive interventions or observation could not reduce the hct significantly (P - 0.24). The hcts mean peaked maximally at a mean of 2.8 h of age.
PC incidence in our NICU is higher than the reported incidence in healthy newborns. Most of the PC neonates were either symptomatic or having LA. Noninvasive interventions or observation were not effective in reducing hct in polycythemic neonates. Hct in both healthy and PC neonates peaked at the same pattern.
PMCID: PMC4089135  PMID: 25024975
Hematocrit; length of hospital stay; neonatal intensive care unit; neonate; noninvasive; observation; overhydration; pattern; polycythemia
14.  Molecular epidemiology of coagulase-negative Staphylococcus carriage in neonates admitted to an intensive care unit in Brazil 
BMC Infectious Diseases  2013;13:572.
Nasal colonization with coagulase-negative Staphylococcus (CoNS) has been described as a risk factor for subsequent systemic infection. In this study, we evaluated the genetic profile of CoNS isolates colonizing the nares of children admitted to a neonatal intensive care unit (NICU).
We assessed CoNS carriage at admittance and discharge among newborns admitted to a NICU from July 2007 through May 2008 in one of the major municipalities of Brazil. Isolates were screened on mannitol salt agar and tryptic soy broth and tested for susceptibility to antimicrobials using the disc diffusion method. Polymerase chain reaction (PCR) was used to determine the species, the presence of the mecA gene, and to perform SCCmec typing. S. epidermidis and S. haemolyticus isolated from the same child at both admission and discharge were characterized by PFGE.
Among 429 neonates admitted to the NICU, 392 (91.4%) had nasal swabs collected at both admission and discharge. The incidence of CoNS during the hospitalization period was 55.9% (95% confidence interval [CI]: 50.9-60.7). The most frequently isolated species were S. haemolyticus (38.3%) and S.epidermidis (38.0%). Multidrug resistance (MDR) was detected in 2.2% and 29.9% of the CoNS isolates, respectively at admittance and discharge (p = 0.053). The mecA gene was more prevalent among strains isolated at discharge (83.6%) than those isolated at admission (60%); overall, SCCmec type I was isolated most frequently. The length of hospitalization was associated with colonization by MDR isolates (p < 0.005). Great genetic diversity was observed among S. epidermidis and S. haemolyticus.
NICU represents an environment of risk for colonization by MDR CoNS. Neonates admitted to the NICU can become a reservoir of CoNS strains with the potential to spread MDR strains into the community.
PMCID: PMC4028975  PMID: 24308773
Coagulase-negative Staphylococcus; mecA; SCCmec; Neonatal intensive care units; Neonates
15.  Infant Neurobehavioral Development 
Seminars in perinatology  2011;35(1):8-19.
The trend toward single-room neonatal intensive care units (NICUs) is increasing; however scientific evidence is, at this point, mostly anecdotal. This is a critical time to assess the impact of the single-room NICU on improving medical and neurobehavioral outcomes of the preterm infant. We have developed a theoretical model that may be useful in studying how the change from an open-bay NICU to a single-room NICU could affect infant medical and neurobehavioral outcome. The model identifies mediating factors that are likely to accompany the change to a single-room NICU. These mediating factors include family centered care, developmental care, parenting and family factors, staff behavior and attitudes, and medical practices. Medical outcomes that plan to be measured are sepsis, length of stay, gestational age at discharge, weight gain, illness severity, gestational age at enteral feeding, and necrotizing enterocolitis (NEC). Neurobehavioral outcomes include the NICU Network Neurobehavioral Scale (NNNS) scores, sleep state organization and sleep physiology, infant mother feeding interaction scores, and pain scores. Preliminary findings on the sample of 150 patients in the open-bay NICU showed a “baseline” of effects of family centered care, developmental care, parent satisfaction, maternal depression, and parenting stress on the neurobehavioral outcomes of the newborn. The single-room NICU has the potential to improve the neurobehavioral status of the infant at discharge. Neurobehavioral assessment can assist with early detection and therefore preventative intervention to maximize developmental outcome. We also present an epigenetic model of the potential effects of maternal care on improving infant neurobehavioral status.
PMCID: PMC3168949  PMID: 21255702
preterm; neurobehavior; NNNS; NICU; very-low-birthweight infants; single-room NICU design; epigenetics
16.  Prevalence of Hearing Loss in Newborns Admitted to Neonatal Intensive Care Unit 
Hearing is essential for humans to communicate with one another. Early diagnosis of hearing loss and intervention in neonates and infants can reduce developmental problems. The aim of the present study was to assess the prevalence of hearing impairment in newborns admitted to a neonatal intensive care unit (NICU) and analyze the associated risk factors.
Materials and Methods:
This cross-sectional study was conducted to assess the prevalence of hearing loss in neonates who were admitted to the NICU at Nemazee Hospital, Shiraz University of Medical Sciences between January 2006 and January 2007. Auditory function was examined using otoacoustic emission (OAE) followed by auditory brainstem response (ABR) tests. Relevant potential risk factors were considered and neonates with a family history of hearing loss and craniofacial abnormality were excluded. For statistical analysis logistic regression, the chi-squared test, and Fisher’s exact test were used.
Among the 124 neonates included in the study, 17 (13.7%) showed hearing loss in the short term. There was a significant statistical relationship between gestational age of less than 36 weeks (P=0.013), antibiotic therapy (P= 0.033), oxygen therapy (P=0.04), and hearing loss. On the contrary, there was no significant relationship between hearing loss and use of a ventilator, or the presence of sepsis, hyperbilirubinemia, congenial heart disease, transient tachypnea of newborn, congenital pneumonia, or respiratory distress syndrome.
Auditory function in neonates who are admitted to a NICU, especially those treated with oxygen or antibiotics and those born prematurely, should be assessed during their stay in hospital. The importance of early diagnosis of hearing loss and intervention in these neonates and avoidance of any unnecessary oxygen or antibiotic therapy needs to be further promoted.
PMCID: PMC3846223  PMID: 24303398
Auditory brainstem response; Hearing loss; Newborn; Neonatal intensive care unit; Otoacoustic emission
17.  Drug Use and HIV Risk Outcomes in Opioid-Injecting Men in the Republic of Georgia: Behavioral Treatment + Naltrexone compared to Usual Care 
Drug and Alcohol Dependence  2011;120(1-3):14-21.
To test the initial feasibility of a novel 22-week comprehensive intervention pairing behavioral treatment with naltrexone that aimed at engaging, retaining, and treating opioid-injecting men in the Republic of Georgia.
Forty opioid-injecting males and their drug-free female partners participated in a two-group randomized clinical trial at the field site of the Union Alternative Georgia, in Tbilisi, Republic of Georgia. The comprehensive intervention that paired behavioral treatment with naltrexone for the male participants (n=20) included counseling sessions using Motivational Interviewing for both the male participant and the couple, monetary incentives for drug abstinence, and research-supported detoxification followed by naltrexone treatment. Male participants in the usual care condition (n=20) had the opportunity to attend once-a-week individualized education sessions and upon request receive referrals to detoxification programs and aftercare that could or could not have included naltrexone. Outcome measures included entry into inpatient detoxification and naltrexone treatment, urine drug screening, reduction in illicit substance use, use of benzodiazepines, injection of buprenorphine, and needle and syringe sharing.
The comprehensive intervention condition showed significantly more weekly urine samples negative for illicit opioids during weeks 1 through 22 (7.0 v. 1.4; p<.001) and reported significant declines in use of benzodiazepines and injection of buprenorphine (both ps<.004).
The first behavioral treatment randomized clinical trial in the Republic of Georgia found that the use of tailored behavioral therapy paired with naltrexone is both feasible and efficacious for treating drug use and reducing HIV drug-risk behavior in Georgian men.
PMCID: PMC3377370  PMID: 21742445
opioid dependence; injection drug use; behavioral treatment; naltrexone; Republic of Georgia
18.  Variations in rates of nosocomial infection among Canadian neonatal intensive care units may be practice-related 
BMC Pediatrics  2005;5:22.
Nosocomial infection (NI), particularly with positive blood or cerebrospinal fluid bacterial cultures, is a major cause of morbidity in neonatal intensive care units (NICUs). Rates of NI appear to vary substantially between NICUs. The aim of this study was to determine risk factors for NI, as well as the risk-adjusted variations in NI rates among Canadian NICUs.
From January 1996 to October 1997, data on demographics, intervention, illness severity and NI rates were submitted from 17 Canadian NICUs. Infants admitted at <4 days of age were included. NI was defined as a positive blood or cerebrospinal fluid culture after > 48 hrs in hospital.
765 (23.5%) of 3253 infants <1500 g and 328 (2.5%) of 13228 infants ≥1500 g developed at least one episode of NI. Over 95% of episodes were due to nosocomial bacteremia. Major morbidity was more common amongst those with NI versus those without. Mortality was more strongly associated with NI versus those without for infants ≥1500 g, but not for infants <1500 g. Multiple logistic regression analysis showed that for infants <1500 g, risk factors for NI included gestation <29 weeks, outborn status, increased acuity on day 1, mechanical ventilation and parenteral nutrition. When NICUs were compared for babies <1500 g, the odds ratios for NI ranged from 0.2 (95% confidence interval [CI] 0.1 to 0.4) to 8.6 (95% CI 4.1 to 18.2) when compared to a reference site. This trend persisted after adjustment for risk factors, and was also found in larger babies.
Rates of nosocomial infection in Canadian NICUs vary considerably, even after adjustment for known risk factors. The implication is that this variation is due to differences in clinical practices and therefore may be amenable to interventions that alter practice.
PMCID: PMC1182378  PMID: 16004613
19.  Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities 
PLoS Medicine  2011;8(8):e1001080.
Mikkel Oestergaard and colleagues develop annual estimates for neonatal mortality rates and neonatal deaths for 193 countries for 1990 to 2009, and forecasts into the future.
Historically, the main focus of studies of childhood mortality has been the infant and under-five mortality rates. Neonatal mortality (deaths <28 days of age) has received limited attention, although such deaths account for about 41% of all child deaths. To better assess progress, we developed annual estimates for neonatal mortality rates (NMRs) and neonatal deaths for 193 countries for the period 1990–2009 with forecasts into the future.
Methods and Findings
We compiled a database of mortality in neonates and children (<5 years) comprising 3,551 country-years of information. Reliable civil registration data from 1990 to 2009 were available for 38 countries. A statistical model was developed to estimate NMRs for the remaining 155 countries, 17 of which had no national data. Country consultation was undertaken to identify data inputs and review estimates. In 2009, an estimated 3.3 million babies died in the first month of life—compared with 4.6 million neonatal deaths in 1990—and more than half of all neonatal deaths occurred in five countries of the world (44% of global livebirths): India 27.8% (19.6% of global livebirths), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%). Between 1990 and 2009, the global NMR declined by 28% from 33.2 deaths per 1,000 livebirths to 23.9. The proportion of child deaths that are in the neonatal period increased in all regions of the world, and globally is now 41%. While NMRs were halved in some regions of the world, Africa's NMR only dropped 17.6% (43.6 to 35.9).
Neonatal mortality has declined in all world regions. Progress has been slowest in the regions with high NMRs. Global health programs need to address neonatal deaths more effectively if Millennium Development Goal 4 (two-thirds reduction in child mortality) is to be achieved.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, more than 8 million children die before their fifth birthday. Most of these deaths occur in developing countries and most are caused by preventable or treatable diseases. In 2000, world leaders set a target of reducing child mortality to one-third of its 1990 level by 2015 as Millennium Development Goal 4 (MDG4). This goal, together with seven others, is designed to help improve the social, economic, and health conditions in the world's poorest countries. In recent years, progress towards reducing child mortality has accelerated but remains insufficient to achieve MDG4. In particular, progress towards reducing neonatal deaths—deaths during the first 28 days of life—has been slow and neonatal deaths now account for a greater proportion of global child deaths than in 1990. Currently, nearly 41% of all deaths among children under the age of 5 years occur during the neonatal period. The major causes of neonatal deaths are complications of preterm delivery, breathing problems during or after delivery (birth asphyxia), and infections of the blood (sepsis) and lungs (pneumonia). Simple interventions such as improved hygiene at birth and advice on breastfeeding can substantially reduce neonatal deaths.
Why Was This Study Done?
If MDG4 is to be met, more must be done to prevent deaths among newborn babies. To improve survival rates and to monitor the effects of public-health interventions in this vulnerable group, accurate, up-to-date estimates of national neonatal mortality rates (NMRs, the number of neonatal deaths per 1,000 live births) are essential. Although infant (under-one) and under-five mortality rates are estimated annually for individual countries by the United Nations Interagency Group for Child Mortality Estimation, annual NMR trend estimates have not been produced before. In many developed countries, child mortality rates can be calculated directly from vital civil registration data—records of all births and deaths. But many developing countries lack vital registration systems and child mortality has to be estimated using data collected in household surveys such as the Demographic and Health Surveys (a project that helps developing countries collect data on health and population trends). In this study, the researchers estimate annual national NMRs and numbers of neonatal deaths for the past 20 years using the available data.
What Did the Researchers Do and Find?
The researchers used civil registration systems, household surveys, and other sources to compile a database of deaths among neonates and children under 5 years old for 193 countries between 1990 and 2009. They estimated NMRs for 38 countries from reliable vital registration data and developed a statistical model to estimate NMRs for the remaining 155 countries (in which 92% of global live births occurred). In 2009, 3.3 million babies died during their first month of life compared to 4.6 million in 1990. More than half the neonatal deaths in 2009 occurred in five countries—India, Nigeria, Pakistan, China, and the Democratic Republic of Congo. India had the largest number of neonatal deaths throughout the study. Between 1990 and 2009, although the global NMR decreased from 33.2 to 23.9 deaths per 1,000 live births (a decrease of 28%), NMRs increased in eight countries, five of which were in Africa. Moreover, in Africa as a whole, the NMR only decreased by 17.6%, from 43.6 per 1,000 live births in 1990 to 35.9 per 1,000 live births in 2009.
What Do These Findings Mean?
These and other findings suggest that neonatal mortality has declined in all world regions since 1990 but that progress has been slowest in the regions with high NMRs such as Africa. Although there is considerable uncertainty around the estimates calculated by the researchers, these findings nevertheless highlight the slow progress in reducing the neonatal mortality risk over the past 20 years and suggest that the relative contribution of neonatal deaths to child deaths will increase into the future. Thus, if MDG4 is to be achieved, it is essential that national governments and international health bodies invest in improved methods for the measurement of neonatal deaths and stillbirths and increase their investment in the provision of care at birth and during the first few weeks of life.
Additional Information
Please access these Web sites via the online version of this summary at
The United Nations Children's Fund (UNICEF) works for children's rights, survival, development, and protection around the world; it provides information on Millennium Development Goal 4, and its Childinfo Web site provides detailed statistics about child survival and health, including a description of the United Nations Interagency Group for Child Mortality Estimation and a link to its database, and information on newborn care (some information in several languages)
The World Health Organization also has information about the Millennium Development Goal 4, provides information on newborn mortality, and provides the latest estimates of child mortality
Further information about the Millennium Development Goals is available
Information is also available about the Demographic and Health Surveys
PMCID: PMC3168874  PMID: 21918640
20.  A comparison of Wisconsin Neonatal Intensive Care Units with National data on outcomes and practices 
Improvements in neonatal care over the past three decades have resulted in increased survival of infants at lower birthweights and gestational ages. However, outcomes and practices vary considerably between hospitals.
To describe maternal and infant characteristics, NICU practices, morbidity, and mortality in Wisconsin neonatal intensive care units (NICU) and to compare outcomes in Wisconsin to the National Institute of Child Health and Human Development network of large academic medical center NICUs.
Design and Setting:
The Newborn Lung Project Statewide Cohort is a prospective observational study of all very low birthweight (≤ 1500 grams) infants admitted during 2003 and 2004 to the 16 level III NICUs in Wisconsin. Anonymous data were collected for all admitted infants (N=1463).
Main outcome measures:
Major neonatal morbidities, including bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity were evaluated.
The overall incidence of bronchopulmonary dysplasia was 24% (range 8-56% between NICUs); intraventricular hemorrhage incidence was 23% (9-41%); the incidence of necrotizing enterocolitis was 7% (0-21%); and the incidence of grade III or higher retinopathy of prematurity was 10% (0-35%).
The incidence rates of major neonatal morbidities in Wisconsin were similar to those of a national network of academic NICUs.
PMCID: PMC2650395  PMID: 19180870
21.  Neonatal health of infants born to mothers with asthma 
The Journal of allergy and clinical immunology  2013;133(1):10.1016/j.jaci.2013.06.012.
Maternal asthma is associated with serious pregnancy complications but newborn morbidity is understudied.
To determine if infants of asthmatic mothers have more neonatal complications.
The Consortium on Safe Labor (2002–2008), a retrospective cohort, included 223,512 singleton deliveries at ≥ 23 weeks’ gestation. Newborns of mothers with asthma (n=17,044) were compared to newborns of non-asthmatic women using logistic regression models with generalized estimating equations to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI). Electronic medical record data included gestational week at delivery, birthweight, resuscitation, neonatal intensive care unit (NICU) admission, NICU length of stay, hyperbilirubinemia, respiratory distress syndrome, apnea, sepsis, anemia, transient tachypnea of the newborn, infective pneumonia, asphyxia, intracerebral hemorrhage, seizure, cardiomyopathy, peri- or intraventricular hemorrhage, necrotizing enterocolitis, aspiration, retinopathy of prematurity and perinatal mortality.
Preterm delivery was associated with maternal asthma for each week after 33 completed weeks of gestation and not earlier. Maternal asthma also increased the adjusted odds of small for gestational age (SGA, OR=1.10, CI:1.05–1.16), NICU admission (OR=1.12, CI:1.07–1.17), hyperbilirubinemia (OR=1.09, CI:1.04–1.14), respiratory distress syndrome (OR=1.09, CI:1.01–1.19), transient tachypnea of the newborn (OR=1.10, CI:1.02–1.19), and asphyxia (OR=1.34, CI:1.03–1.75). Findings persisted for term infants (≥ 37 weeks) who had additional increased odds of intracerebral hemorrhage (OR=1.84, CI: 1.11–3.03) and anemia (OR=1.30, CI: 1.04–1.62).
Maternal asthma was associated with prematurity and SGA. Adverse neonatal outcomes including respiratory complications, hyperbilirubinemia, and NICU admission were increased in association with maternal asthma even among term deliveries.
PMCID: PMC3874245  PMID: 23916153
neonatal health; maternal asthma; respiratory distress syndrome; transient tachypnea of the newborn; neonatal jaundice; preterm birth
22.  Comparison of broad range 16S rDNA PCR and conventional blood culture for diagnosis of sepsis in the newborn: a case control study 
BMC Pediatrics  2009;9:5.
Early onset bacterial sepsis is a feared complication of the newborn. A large proportion of infants admitted to the Neonatal Intensive Care Unit (NICU) for suspected sepsis receive treatment with potent systemic antibiotics while a diagnostic workup is in progress. The gold standard for detecting bacterial sepsis is blood culture. However, as pathogens in blood cultures are only detected in approximately 25% of patients, the sensitivity of blood culture is suspected to be low. Therefore, the diagnosis of sepsis is often based on the development of clinical signs, in combination with laboratory tests such as a rise in C – reactive protein (CRP). Molecular assays for the detection of bacterial DNA in the blood represent possible new diagnostic tools for early identification of a bacterial cause.
A broad range 16S rDNA polymerase chain reaction (PCR) without preincubation was compared to conventional diagnostic work up for clinical sepsis, including BACTEC blood culture, for early determination of bacterial sepsis in the newborn. In addition, the relationship between known risk factors, clinical signs, and laboratory parameters considered in clinical sepsis in the newborn were explored.
Forty-eight infants with suspected sepsis were included in this study. Thirty-one patients were diagnosed with sepsis, only 6 of these had a positive blood culture. 16S rDNA PCR analysis of blinded blood samples from the 48 infants revealed 10 samples positive for the presence of bacterial DNA. PCR failed to be positive in 2 samples from blood culture positive infants, and was positive in 1 sample where a diagnosis of a non-septic condition was established. Compared to blood culture the diagnosis of bacterial proven sepsis by PCR revealed a 66.7% sensitivity, 87.5% specificity, 95.4% positive and 75% negative predictive value. PCR combined with blood culture revealed bacteria in 35.1% of the patients diagnosed with sepsis. Irritability and feeding difficulties were the clinical signs most often observed in sepsis. CRP increased in the presence of bacterial infection.
There is a need for PCR as a method to quickly point out the infants with sepsis. However, uncertainty about a bacterial cause of sepsis was not reduced by the PCR result, reflecting that methodological improvements are required in order for DNA detection to replace or supplement traditional blood culture in diagnosis of bacterial sepsis.
PMCID: PMC2635358  PMID: 19152691
23.  Maternal and neonatal separation and mortality associated with concurrent admissions to intensive care units 
Concurrent admission of a mother and her newborn to separate intensive care units (herein referred to as co-ICU admission), possibly in different centres, can magnify family discord and stress. We examined the prevalence and predictors of mother–infant separation and mortality associated with co-ICU admissions.
We completed a population-based study of all 1 023 978 singleton live births in Ontario between Apr. 1, 2002, and Mar. 31, 2010. We included data for maternal–infant pairs that had co-ICU admission (n = 1216), maternal ICU admission only (n = 897), neonatal ICU (NICU) admission only (n = 123 236) or no ICU admission (n = 898 629). The primary outcome measure was mother–infant separation because of interfacility transfer.
The prevalence of co-ICU admissions was 1.2 per 1000 live births and was higher than maternal ICU admissions (0.9 per 1000). Maternal–newborn separation due to interfacility transfer was 30.8 (95% confidence interval [CI] 26.9–35.3) times more common in the co-ICU group than in the no-ICU group and exceeded the prevalence in the maternal ICU group and NICU group. Short-term infant mortality (< 28 days after birth) was higher in the co-ICU group (18.1 per 1000 live births; maternal age–adjusted hazard ratio [HR] 27.8, 95% CI 18.2–42.6) than in the NICU group (7.6 per 1000; age-adjusted HR 11.5, 95% CI 10.4–12.7), relative to 0.7 per 1000 in the no-ICU group. Short-term maternal mortality (< 42 days after delivery) was also higher in the co-ICU group (15.6 per 1000; age-adjusted HR 328.7, 95% CI 191.2–565.2) than in the maternal ICU group (6.7 per 1000; age-adjusted HR 140.0, 95% CI 59.5–329.2) or the NICU group (0.2 per 1000; age-adjusted HR 4.6, 95% CI 2.8–7.4).
Mother–infant pairs in the co-ICU group had the highest prevalence of separation due to interfacility transfer and the highest mortality compared with those in the maternal ICU and NICU groups.
PMCID: PMC3519169  PMID: 23091180
24.  Respiratory Morbidity in Late Preterm Births 
Late preterm births (LPTB, 34 0/7-36 6/7 weeks) account for a growing proportion of prematurity-associated short term morbidities, particularly respiratory, that require specialized care and prolonged neonatal hospital stays.
To assess short-term respiratory morbidity in LPTB compared to term births in a contemporary cohort of deliveries in the United States.
Design, Setting, and Participants
Retrospective collection of electronic data from 12 institutions (19 hospitals) across the United States on 233,844 deliveries between 2002 and 2008. Charts were abstracted for all neonates with respiratory compromise admitted to a neonatal intensive care unit (NICU) and LPTB were compared to term births in regard to resuscitation, respiratory support and respiratory diagnoses. A multivariate logistic regression analysis compared infants at each gestational week controlling for factors that influence respiratory outcomes.
Main outcome measures
Respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), pneumonia, respiratory failure, standard and oscillatory ventilator support.
Of 19,334 LPTB, 7,055 were admitted to a NICU and 2,032 had respiratory compromise. Of 165,993 term infants, 11,980 were admitted to a NICU, 1,874 with respiratory morbidity.
Respiratory distress syndrome decreased from 10.5% (390/3700) at 34 weeks to 0.3% (140/41,764) at 38 weeks. Similarly, TTN decreased from 6.4% (n=236) to 0.4% (n=155), pneumonia from 1.5% (n=55) to 0.1% (n=62), and respiratory failure from 1.6% (n=61) to 0.2% (n=63). Standard and oscillatory ventilator support had similar patterns. Odds of RDS decreased with each advancing week until 38 weeks compared to 39-40 weeks (adjusted OR at 34 weeks 40.1 [95% CI 32.0-50.3] and at 38 weeks 1.1 [95% CI, 0.9-1.4]). At 37 weeks odds for RDS were greater than 39-40 weeks (3.1 [95% CI, 2.5-3.7]), but the odds at 38 weeks did not differ from 39-40 weeks. Similar patterns were noted for TTN (adjusted OR at 34 weeks 14.7 [95% CI, 11.7-18.4] and at 38 weeks 1.0 [95% CI 0.8-1.2]); pneumonia (adjusted OR at 34 weeks 7.6 [95% CI, 5.2-11.2] and at 38 weeks 0.9 [95% CI, 0.6-1.2]), and respiratory failure (adjusted OR at 34 weeks 10.5 [95% CI, 6.9-16.1] and at 38 weeks 1.4 [95% CI, 1.0-1.9]).
In a contemporary cohort, late preterm birth, compared with term delivery, was associated with increased risk for respiratory distress syndrome and other respiratory morbidity.
PMCID: PMC4146396  PMID: 20664042
25.  Impact of enhanced infection control at two neonatal intensive care units in the Philippines 
The growing burden of neonatal mortality due to hospital acquired neonatal sepsis in the developing world creates an urgent need for low cost effective infection control measures in low resource settings.
Using a pre/post comparison design, we measured how rates of staff hand hygiene compliance, colonization with resistant pathogens (defined as ceftazidime- and/or gentamicin-resistant gram-negative rods (GNRs) and resistant gram-positive cocci), bacteremia, and overall mortality changed following the introduction of a simplified package of infection control measures at two neonatal intensive care units (NICUs) in Manila, the Philippines.
Of 1828 NICU neonates admitted, 45.6% became newly colonized with resistant bacteria, 19.6% became bacteremic (78.2% from GNRs), and 33.6% died. 2903 resistant colonizing bacteria were identified of which 85% were resistant GNRs (predominantly Klebsiella spp., Pseudomonas spp., and Acinetobacter spp.) and 14% were Methicillin-resistant Staphylococcus aureus. Contrasting control vs. intervention periods at each NICU, staff hand hygiene compliance improved (At NICU 1 RR=1.3, 95% CI 1.1–1.5; At NICU 2 RR=1.6, 95% CI 1.4–2.0) and overall mortality declined (NICU 1 RR=0.5, 95%CI 0.4–0.6; NICU 2 RR=0.8, 95% CI 0.7–0.9). However, colonization with resistant pathogens and sepsis rates did not change significantly at either NICU.
Nosocomial transmission of resistant pathogens was intense at these two Philippines NICUs and dominated by resistant GNRs. Infection control interventions are feasible and possibly effective in resource limited hospital settings.
PMCID: PMC3866590  PMID: 19025496
Infection Control; Philippines; NICU; Drug Resistance; Hand Hygiene

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