gram negative resistance bact*

[sSnjezana]

Hi,

could you help me? We have in my NICU gram neg res. bact ( kl pneum and E. coli) and last year we have 24 VLBW infants with sepsis. Almost all blood culture were negative, however tubus aspirate in the babies on MV and gastric fluids were positive on one of those bacteria. I know that was colonisation, but in the case of sepsis (oliguria/anuria, low blood pressure, impaired perfusion, apnea, need for MV...lab signs- high CRP, leukopenia, thrombocitopenia..) we gave the babies meropenem. And now we have more infections, despite all epidemiogical investigations were negative.

1. I'm considered because meropenem is the second line of antibiotics

2. What do you think about probiotics (as in prehipp)

3. some oral antibiotics for "sterilisation" of gut, which I'm not cheerfull about?

4 or more nurses in Nicu ( 3 nurses on 13 children!!!!)

[Francesco Cardona]

I understand your concerns and also our hospital had to deal with higher rates of infections. I agree about being worried of constantly having to use meropenem in these patients. So far in premature infants using probiotics has only shown to reduce incidence of NEC, but not sepsis in general. So I am not sure you would achieve your aim through these measures.

The final verdict on oral antibiotics is not yet out, so I would not recommend this as a first line either.

More nurses is always beneficial I feel and burden of workload can be a strong predictor on rates of infection.

One common successful route in reducing infections is educating the staff on hygienic measures and being strict about enforcing those measures.

Have a look at these articles (there are a lot more out there..)

http://www.ncbi.nlm.nih.gov/pubmed/20570396 (on controlling MRSA transmission)

http://www.ncbi.nlm.nih.gov/pubmed/20970881 hand hygiene is one of the most cost effective and protective measures out there, but probably also one that is the hardest to comply to

Edited March 9, 2011 by fcardona
typo

[salameh101]

a. Suspicion of sepsis could have been anticipated earlier on view of reduction of platelet count and the progressive metabolic acidosis.

b. Ventilatory devises are a potential source of organisms

c. The insidious onset is a common pathophysiologic feature of some organism and could reflect on a lack of early interpretation of infant septic behavior.

d. All positive cultures are to be taken seriously and infants (particularly prematures) treated empirically until further support to discontinue medications becomes available.

e. CRP as part of sepsis work-up, should be performed more than once to be utilized as a reliable indicator.

f. CBC picture with leukopenia and neutropenia with feeding intolerance and upper GIT bleeding are all potential signs of sepsis.

g. Placental histopathology and culture should be requested in cases where maternal infection may be the source of neonatal sepsis.

h. HVS should be requested in infants where GBS is suspected but not proven.

Use of antibiotics:

a. Highly potent antibiotics such as meropinum should not be used until discussed with team leaders or infectious disease personnel.

b. Targocid use for Staph hemolyticus sepsis should be observed closely as the organism is understood to change it’s sensitivity pattern in vivo. In this scenario switching to vancomycin may be appropriate.

c. The proper time interval between ampicillin and gentamicin IV infusion is > 1 hour.

[Stefan Johansson]

This comment was posted on our Facebook page (http://www.facebook.com/99nicu

3 nurses for 13 neonates who are tubed is certainly a risk for infection, maybe you need to check how strict they are with their hand washing ,the more neonates you care for the more likely you can cross- contaminate if you don't clean hands between neonates & doing multiple thing for one baby .

[sSnjezana]

Thank you Francesco on the articles and answer. It will help to me.

sincerely Snjezana

[sSnjezana]

dear salameh 101

d. All positive cultures are to be taken seriously and infants (particularly prematures) treated empirically until further support to discontinue medications becomes available. - what do you mean- on all positive cultures , blood cultures or other wich can be positive from colonisation? The most my prematures have positive gastric aspirate on 5 th day and E tube aspirate if they are on long MV. Do you think that we must them treated without any signs of sepsis? I think that opinion can worse the situation on NICU. And CRP become high usually 48 hours from onset of sepsis. The first sign can be only tachycardia. I agree with you about meropenem, but we are in some " circulus vitiosus". Anyway, thanks a lot Snjezana

[salameh101]

dear salameh 101

d. All positive cultures are to be taken seriously and infants (particularly prematures) treated empirically until further support to discontinue medications becomes available. - what do you mean- on all positive cultures , blood cultures or other wich can be positive from colonisation? The most my prematures have positive gastric aspirate on 5 th day and E tube aspirate if they are on long MV. Do you think that we must them treated without any signs of sepsis? I think that opinion can worse the situation on NICU. And CRP become high usually 48 hours from onset of sepsis. The first sign can be only tachycardia. I agree with you about meropenem, but we are in some " circulus vitiosus". Anyway, thanks a lot Snjezana

[salameh101]

.ETT c&s within first 12-24 , Eye swab c&s especially for gram negative.

any blood c&s should be treated until proved otherwise.

CRP SINGLE READING IS NOT SIGNIFICANT RATHER THAN THE TREND