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Relationship of nosocomial infections with the development of necrotizing enterocolitis in preterm infants.
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PMID:  24757392     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: The aim of this study was to determine the association between the number of nosocomial infections prior to necrotizing enterocolitis (NEC) diagnosis as well as to evaluated how it contributed to development of NEC in premature infants.
MATERIAL AND METHODS: The study included 51 preterm infants diagnosed with NEC and 71 preterm infants without NEC hospitalized in the neonatal intensive care unit (NICU) of Clinical Center University of Sarajevo. We evaluated the correlation of the number of nosocomial infections prior to NEC diagnosis with the development of NEC.
RESULTS: There was a statistically significant association of the number of nosocomial infections prior NEC diagnosis with the development of NEC (odds ratio, 3.32; 95% confidence interval, 1.09-10.01).
CONCLUSION: Increased number of nosocomial infections prior to NEC diagnosis is associated with increased risk of necrotizing enterocolitis.
Authors:
Zlatan Zvizdic; Suada Heljic; Alena Firdus; Asmir Jonuzi; Denisa Zvizdic
Publication Detail:
Type:  Journal Article     Date:  2014-02-20
Journal Detail:
Title:  Materia socio-medica     Volume:  26     ISSN:  1512-7680     ISO Abbreviation:  Mater Sociomed     Publication Date:  2014 Feb 
Date Detail:
Created Date:  2014-04-23     Completed Date:  2014-04-23     Revised Date:  2014-04-25    
Medline Journal Info:
Nlm Unique ID:  101281595     Medline TA:  Mater Sociomed     Country:  Bosnia and Hercegovina    
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Languages:  eng     Pagination:  4-6     Citation Subset:  -    
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Journal ID (nlm-ta): Mater Sociomed
Journal ID (iso-abbrev): Mater Sociomed
Journal ID (publisher-id): MSM
ISSN: 1512-7680
ISSN: 1986-597X
Publisher: AVICENA, d.o.o., Sarajevo, Bosnia and Herzegovina
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Received Day: 11 Month: 12 Year: 2013
Accepted Day: 25 Month: 1 Year: 2014
Electronic publication date: Day: 20 Month: 2 Year: 2014
Print publication date: Month: 2 Year: 2014
Volume: 26 Issue: 1
First Page: 4 Last Page: 6
PubMed Id: 24757392
ID: 3990399
Publisher Id: MSM-26-4
DOI: 10.5455/msm.2014.26.4-6

Relationship of Nosocomial Infections with the Development of Necrotizing Enterocolitis in Preterm Infants
Zlatan Zvizdic1
Suada Heljic2
Alena Firdus1
Asmir Jonuzi1
Denisa Zvizdic3
1Clinic of Pediatric Surgery, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
2Pediatric Clinic, Neonatal Intensive Care Unit, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
3Eye Clinic, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Correspondence: Corresponding author: Zlatan Zvizdic, MD, PhD, Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina. Phone: +387 33 297 142; Email: zlatan.zvizdic@gmail.com

1. INTRODUCTION

Necrotizing enterocolitis (NEC) is an acquired inflammatory disease of the gastrointestinal tract (GIT) characterized by coagulation necrosis and inflammation of the intestine in a neonate (1). The incidence of NEC is 0.5-3.5 per 1000 live births (2, 3). NEC affects mostly preterm infants (2). NEC in term infants is usually associated with conditions such as congenital anomalies, sepsis, or hypotension (4). It has documented that the incidence of NEC increases with decreasing birth weight (BW) and gestational age (GA) (3). The age of onset is highly variable and inversely correlated with GA (3). The mortality rate associated with NEC ranges between 20 to 30%, with the highest rate in infants who had undergone surgery (5). Approximately 27–63% of affected infants require surgery (6). Prematurity (with immature GIT and host defenses) is the primary risk factor (7). In addition, various studies have identified other risk factors for the development of NEC (8, 9); however, the definite aetiology still eludes modern medical research.

In this study, we retrospectively determined the association between the number of nosocomial infections prior to NEC diagnosis as well as evaluated how it contributed to development of NEC in preterm infants admitted in the NICU of Clinical Center University of Sarajevo.


2. PATIENTS AND METHODS

In accordance with the Helsinki declaration, the Institutional Review Board (IRB), and the Independent Ethics Committee of Clinical Center University of Sarajevo (CCUS) approved all aspects of this study. This retrospective study was performed on all preterm infants (<37 weeks gestation at birth) admitted in the NICU of CCUS during a period of 5 years, from 2008 to 2012. Gestational age was determined by early ultrasound and recorded as completed weeks. This study examined the number of nosocomial infections prior to NEC diagnosis.

Nosocomial infection was defined and categorized in accordance with the NNIS/CDC, Atlanta criteria (10, 11). Definition of nosocomial infection (NI): NI infection is defined as an infection that occurs after 48 hours of hospitalization, resulting in a positive blood, cerebrospinal fluid (CSF), or urine culture with clinical manifestations such as hospital-acquired bloodstream infections, nosocomial pneumonia, sepsis, urinary tract infection and meningitis.

For the purposes of this analysis, a diagnosis of NEC was made based on the presence of clinical, radiological and/or histopathological evidence that fulfilled the criteria of Bell’s (12) as well as Walsh’s modification of these criteria (13). Definition of necrotizing enterocolitis:

Medical NEC was defined as the presence of radiological signs of pneumatosis intestinalis and when the disease is treated with antibiotics for more than two days. Surgical NEC was defined as any surgical treatment. Of all 830 premature infants, 51 preterm infants met the criteria for NEC in this analysis. The control group consisted of 71 randomly selected preterm infants that were not significantly different by BW and GA from premature infants with NEC.

A standardised format was used for data collection. The infants’s medical records were reviewed daily for medical course informations until hospital discharge or death of infant.


3. STATISTIC ANALYSIS

Statistical analysis was performed using SPSS 16.0 (SPSS Inc, Chicago, IL, USA). The number of nosocomial infections was compared between infants with and without NEC. Categorical variables were compared using the χ2 test. The means of continuous variables were compared using Student’s t test, and the data are presented as mean (SD). The influence of relevant confounding variables, identified by univariate analysis, was assessed using multivariate logistic regression analysis. Confidence intervals presented for odds ratios are adjusted for the clustering of infants within participating nurseries (14). Statistical level of 95% (p<0.05) was considered as significant for all performed tests.


4. RESULTS

During the study period, 830 preterm infants were admitted in the NICU; 51 (6,1%) got NEC. In the group of patients with NEC, based on the diagnostic criteria (12, 13), established the existence of the medical NEC in 30 patients (58,8%) while the surgical NEC was found in 21 patients (41,2%).

The frequency of nosocomial infections prior NEC diagnosis is presented in Figure 1.

There are presented the frequency of NI in the collective group of patients with NEC (n=51), in medical NEC group (NEC I-II) (n=30), in surgical NEC group (NEC III) (n=21) and in the control group (Z) (n=71), p <–probability

Results presented in Figure 1. showed that 56.9% (29/51) of premature infants with NEC had at least one or more of NI prior to NEC diagnosis. Further analysis showed that 46.7% (14/30) preterm infants with medical NEC and 71.4% (15/21) preterm infants with surgical NEC had at least one or more NI prior to diagnosis of NEC. In the control group of patients, NI’s were present in 23.9% (17/71). Chi square test of independence (with Yates’ correction for continuity) showed a significant correlation between the frequency of NI and the development of NEC in the collective group of patients with NEC compared to the control group. A statistically significant difference was observed between the NEC group of patients compared to the control group χ2 (1, N = 122) = 12.328, p = 0.0004, between the medical NEC group (NEC I-II) compared to the control group χ2 (1, N = 101) = 4.106, p = 0.0427, and between the surgical NEC group (NEC III) compared to the control group χ2 (1, n = 92) = 14.084, p=0.0002. This test showed no significant correlation between the frequency of NI in collective group of patients with NEC compared to patients with medical or surgical NEC.

Logistic regression analysis of six continuous variables (number of days of on mechanical ventilation, number of nosocomial infection, number of days of prescribed H2 blockers, morphine sulfate, inotropes, number of received red blood cell transfusions) prior to NEC diagnosis was deemed statistically significant.

Logistic regression analysis of risk factor (nosocomial infections) associated with the development of necrotizing enterocolitis is presented in Table 2.

Logistic regression analysis showed that there was a statistically significant association of the number of nosocomial infections prior NEC diagnosis with the development of NEC (odds ratio, 3.32; 95% confidence interval, 1.09-10.01). Based on the result of logistic regression analysis, it can be concluded that each additional infection increased the odds of developing NEC by 3 times. No relationship was identified between the number of nosocomial infections and gender.


5. DISCUSSION

Result of our study of 6.1% preterm infants with NEC among the total percentage of hospitalized preterm infants in the NICU of CCUS is in accordance with the results of studies that recorded the frequency of these patients in the total percentage of admission to the NICU from 1-7.7% (15).

Preterm infants are at increased risk of infectious diseases due to the immaturity of their immune system and prolonged hospital stay (16). Nosocomial infections (NI) cause a huge burden of morbidity and mortality and include bloodstream, urine, cerebrospinal, peritoneal, and lung infections as well as infections starting from burns and wounds, or from any other usually sterile sites (17). Bloodstream infection is the most common nosocomial infection in the NICU setting (18). NI’s are responsible for almost 50% of the infants mortality rate in the first two weeks of life (19).

Numerous studies that looked at association of the increased number of nosocomial infections with the development of NEC found that the increased number of nosocomial infections prior to NEC diagnosis correlated with an increase in the development of NEC (19). Extremely low BW infants with NEC were found to have more culture-proven sepsis than infants without NEC (20). It was also observed that preterm infants with predisposing clinical conditions, when exposed to an infectious agent, could experience intestinal ischemia leading to the development of NEC (21). Although it is not yet known the exact reason for the connection between of nosocomial infections with the development of NEC, it is assumed that the reason also might lie in the increased length of the utilization of total parenteral nutrition in these preterm infants, which has resulted in an immunosuppressive effect by reducing the degree of phagocytosis and consequent inability of neutralizing the coagulase-negative staphylococci (22).

Results of our study found that the number of nosocomial infections prior to NEC diagnosis in the group of patient with NEC was statistically significantly higher correlated to the control group (p = 0.0004). Also the exposure of nosocomial infections was significantly higher in the medical NEC group (p = 0.0427) as well as in the surgical NEC group (p = 0.0002) correlated with the control group. In logistic regression analysis with six independent variables (nosocomial infections, mechanical ventilation, morphine sulfate, inotropes, red blood cell transfusion and H2-blocker therapy), applied to assess the influence of these multiple factors on probability of developing NEC, the number of nosocomial infection prior to NEC diagnosis has significantly contributed to the model, suggesting that the increased number of nosocomial infections in preterm infants increases probability of developing NEC three times. Our results are in accordance with the results of studies that found a significant effect of nosocomial infections on the development of NEC (16, 19, 22, 23).

Furthermore, the results of our research showed that preterm infants with lower GA and BW had a significantly higher number of nosocomial infections and more serious stage of NEC compared with premature infants born at later gestational ages and with higher BW. This difference may be due to the fact that infants who are of lower GA and BW being at higher risk for infection than infants weighing more than 1500 grams because of several factors associated with NICU admission such as poor handwashing techniques, central venous catheters, mechanical ventilation and poor skin cleansing prior to invasive techniques. Our results are in accordance with the results of other studies that have found that preterm infants with lower GA and BW have a higher sensitivity for the development of nosocomial infections and more serious stages of NEC (24, 25).


6. CONCLUSION

Preterm infants who developed NEC had significantly higher number of nosocomial infections prior to developing NEC than those who did not develop NEC. Identifying risk factors for NEC, through the findings that the number of nosocomial infections strongly correlated with the development of NEC, could lead to clinical applications of crucial infection control practices in the healthcare settings to minimize risk of NEC in preterm infants.


Notes

CONFLICT OF INTEREST: NONE DECLARED.

REFERENCES
1. Jesse N,Neu J. Necrotizing enterocolitis relationship to innate immunity, clinical features, and strategies for preventionNeo ReviewsYear: 20067e143e149
2. Chandler JC,Hebra A. Necrotizing enterocolitis in infants with very low birth weightSemin Pediatr SurgYear: 20009637210807226
3. Yee WH,Soraisham AS,Shah VS,Aziz K,Yoon W,Lee SK. Canadian Neonatal Network. Incidence and timing of presentation of necrotizing enterocolitis in preterm infantsPediatricsYear: 20121292e29830422271701
4. Zvizdić Z,Hadžimuratović A,Dizdarević S,Karavdić K,Džiho N,Heljić S,et al. Necrotizing enterocolitis after staged gastroschisis repairMedical JournalYear: 2010161-26769
5. Fitzgibbons SC,Ching Y,Yu D,Carpenter J,Kenny M,Weldon C,et al. Mortality of necrotizing enterocolitis expressed by birth weight categoriesJ Pediatr SurgYear: 2009441072107519524719
6. Lee JS,Polin RA. Treatment and prevention of necrotizing enterocolitisSeminars in NeonatologyYear: 2003844945915001117
7. Neu J,Walker WA. Necrotizing enterocolitisN Engl J MedYear: 201136425526421247316
8. Carter BM,Holditch-Davis D. Risk factors for necrotizing enterocolitis in pre-term infants: how race, gender, and health status contributeAdv Neonatal CareYear: 20088528529018827518
9. Carter BM,Holditch-Davis D,Tanaka D,Schwartz TA. Relationship of neonatal treatments with the development of necrotizing enterocolitis in preterm infantsNurs ResYear: 20126129610222282155
10. Emori TG,Culver DH,Horan TC,Jarvis WR,White JW,Olson DR,et al. National nosocomial infections surveillance system (NNIS): description of surveillance methodsAm J Infect ControlYear: 199119119351850582
11. Garner JS,Jarvis WR,Emori TG,Horan TC,Hughes JM. CDC definitions for nosocomial infections 1988America J Infect ControlYear: 1988163128140
12. Bell MJ,Ternberg JL,Feigin RD,Keating JP,Marshall R,Barton L,et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical stagingAnn SurgYear: 1978187117413500
13. Walsh MC,Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteriaPediatr Clin North AmYear: 1986331792013081865
14. Liang KY,Zeiger SI. Longitudinal data analysis using generalized linear modelsBiometrikaYear: 1986731322
15. Holman RC,Stoll BJ,Curns AT,Yorita KL,Steiner CA,Schonberger LB. Necrotizing enterocolitis hospitalizations among neonates in the United StatesPaediatr Perinat EpidemiolYear: 200620649850617052286
16. Rojas MA,Lozano JM,Rojas MX,Rodriguez VA,Rondon MA,Bastidas JA,et al. Prophylactic probiotics to prevent death and nosocomial infection in preterm infantsPediatricsYear: 20121305e1113112023071204
17. Manzoni P,De Luca D,Stronati M,Jacqz-Aigrain E,Ruffinazzi G,Luparia M,et al. Prevention of nosocomial infections in neonatal intensive care unitsAm J PerinatolYear: 2013302818823292914
18. Wei SH,Chiu HH,Hung KC,Wang JH,Su BH,Lin HC,et al. Epidemiologic trends in nosocomial bacteremia in a neonatal intensive care unitJ Microbiol Immunol InfectYear: 20053828328816118677
19. Bartels DB,Schwab F,Geffers C,Poets CF,Gastmeier P. Nosocomial infection in small for gestational age newborns with birth weight <1500 g: a multicentre analysisArch Dis Child Fetal Neonatal EdYear: 2007926F44945317460021
20. Salhab WA,Perlman JM,Silver L,Sue Broyles R. Necrotizing enterocolitis and neurodevelopmental outcome in extremely low birth weight infants <1000 gJ PerinatolYear: 200424953454015254558
21. Boccia D,Stolfi I,Lana S,Moro ML. Nosocomial necrotising enterocolitis outbreaks: epidemiology and control measuresEur J PediatrYear: 2001160638539111421422
22. Flidel-Rimon O,Friedman S,Lev E,Juster-Reicher A,Amitay M,Shinwell ES. Early enteral feeding and nosocomial sepsis in very low birthweight infantsArch Dis Child Fetal Neonatal EdYear: 2004894F28929215210657
23. Tom-Revzon C. Strategic use of antibiotics in the neonatal intensive care unitJ Perinat Neonatal NursYear: 200418324125815478475
24. Geffers C,Bearwolff S,Schwab F,Gastmeier P. Incidence of healthcare-associated infections in high-risk neonates: results from the German surveillance system for very-low-birthweight infantsJ Hosp InfectYear: 200868321422118289725
25. Adams-Chapman I,Stoll BJ. Prevention of nosocomial infections in the neonatal intensive care unitCurr Opin PediatrYear: 200214215716411981284

Figures

[Figure ID: F1]
Figure 1 

The frequency of nosocomial infections prior to NEC diagnosis.



Tables
[TableWrap ID: T1] Table 1 

Definition of NEC



[TableWrap ID: T2] Table 2 

Logistic regression analysis of risk factor (nosocomial infections) associated with the development of necrotizing enterocolitis.




Article Categories:
  • Original Paper

Keywords: Nosocomial infections, Necrotizing enterocolitis, Preterm infants.

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