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Background.Nosocomial infections are still a major cause of morbidity and mortality among neonates admitted to neonatal intensive care units (NICUs).Objective.To describe the epidemiology of nosocomial infections in NICUs and to assess the risk of nosocomial infection related to the therapeutic procedures performed and to the clinical characteristics of the neonates at birth and at admission to the NICU, taking into account the time between the exposure and the onset of infection.Design.A multicenter, prospective cohort study.Patients and Setting.A total of 1,692 neonates admitted to 6 NICUs in Italy were observed and monitored for the development of nosocomial infection during their hospital stay.Methods.Data were collected on the clinical characteristics of the neonates admitted to the NICUs, their therapeutic interventions and treatments, their infections, and their mortality rate. The cumulative probability of having at least 1 infection and the cumulative probability of having at least 1 infection or dying were estimated. The hazard ratio (HR) for the first infection and the HR for the first infection or death were also estimated.Results.A total of 255 episodes of nosocomial infection were diagnosed in 217 neonates, yielding an incidence density of 6.9 episodes per 1,000 patient-days. The risk factors related to nosocomial infection in very-low-birth-weight neonates were receipt of continuous positive airway pressure (HR, 3.8 [95% confidence interval {CI}, 1.7-8.1]), a Clinical Risk Index for Babies score of 4 or greater (HR, 2.2 [95% CI, 1.4-3.4]), and a gestational age of less than 28 weeks (HR, 2.1 [95% CI, 1.2-3.8]). Among heavier neonates, the risk factors for nosocomial infection were receipt of parenteral nutrition (HR, 8.1 [95% CI, 3.2-20.5]) and presence of malformations (HR, 2.3 [95% CI, 1.5-3.5]).Conclusions.Patterns of risk factors for nosocomial infection differ between very-low-birth-weight neonates and heavier neonates. Therapeutic procedures appear to be strong determinants of nosocomial infection in both groups of neonates, after controlling for clinical characteristics.

Objective To investigate the accuracy of procalcitonin (PCT) as a diagnostic marker of nosocomial sepsis (NS) and define the most accurate cut-off to distinguish infected from uninfected neonates. Setting Six neonatal intensive care units (NICUs). Patients 762 neonates admitted to six NICUs during a 28-month observational study for whom at least one serum sample was taken on admission. Main outcome measures Positive and negative predictive values at different PCT cut-off levels. Results The overall probability of an NS was doubled or more if PCT was >0.5 ng/ml. In very-low-birth-weight (VLBW) infants, a cut-off of >2.4 ng/ml gave a positive predictive value of NS near to 50% with a probability of a false-positive diagnosis of NS in about 10% of the patients. Conclusions In VLBW neonates, a serum PCT value >2.4 ng/ml prompts early empirical antibiotic therapy, while in normal-birth-weight infants, a PCT value ≤2.4 ng/ml carries a low risk of missing an NS.

As care improves many neonates with life-threatening disorders now survive. Nonetheless Nosocomial Infections (NI) are still a major cause of morbidity and mortality in NICUs. A prospective multicentric surveillance study was conducted in six Italian NICUs to describe the epidemiologic profile and determinants of NI in NICU. 1692 neonates, consecutively admitted to the NICUs from July 2000 to October 2002 and monitored for the development of NI were enrolled into the study. The standard definition criteria for NI formulated by the Centers for Disease Control in Atlanta were used. The cumulative probability and hazard ratios (HR) for the first episode of infection were estimated by the Kaplan-Meier method and the Cox model. A total of 217 neonates had 255 episodes of NI. The incidence rate of NI was 7 per 1000 patient-days. The cumulative probability of first infection was 20% (95% CI, 7.50–23.30) and 27.6% (95 CI, 23.20–32.80) at 30 and 60 days after admission to the NICU. After adjustment for the severity of illness, the main risk factors related to NI in very-low-birth-weight neonates (VLBW) were surgical procedures (HR 2.69;95% CI 0.60–12.08), nasal ventilation (CPAP) (HR, 2.51; 95% CI, 0.93–6.76), continuous enteral feeding (HR 1.89; 95% CI, 0.20–17.50), mechanical ventilation (HR, 1.70; 95%CI, 0.72–4.00) and intravenous infusions (HR 1.46; 95% CI, 0.32–6.52). Among neonates with a birth weight over 1500 g, risk factors for NI were parenteral nutrition with lipid emulsion (HR, 12.41; 95% CI, 4.19–36.78), surgical procedures (HR 2.78; 95% CI, 0.82–9.44), and intravenous infusions (HR, 2.63; 95% CI, 0.27–25.53). Risk factors for NI were related more to the severity of illness than to healthcare procedures in VLBW babies and more to medications among neonates weighing more than 1500 g at birth.