Building Better NICU Infection Prevention

Premature babies and the neonatal intensive care units (NICUs) where they often require care, are uniquely susceptible to infectious disease threats, making infection prevention efforts vital. The Centers for Disease Control and Prevention (CDC) reportedthat in 2018, one in ten babies were born early in the United States. Researchers have found that since the first NICU opened in the United States more than 55 years ago, the neonatal mortality rate has fallen by more than four-fold and that there are roughly 78 NICU admissions per 1,000 live births.

Outbreaks in NICUs are particularly challenging in that not only are the patients vulnerable to infections, but often the design and layout of these units (often a pin-wheel configuration) coupled with family visits bring about inherent challenges. Hundreds of outbreaks have been reported in NICUs and in 2007, a study noted that Enterobacteriaceae tended to be the most common culprit. In one 1997 outbreak, an outbreak of drug-resistant Enterobacter cloacae occurred in a NICU that resulted in the closing of the NICU to new admissions. Ultimately, screening efforts found that ready-to-use “disinfected” thermometers and problems were colonized and likely the cause as rushed disinfection practices had led to such contamination.

From the infection prevention perspective, there have been several things that made NICU infection control efforts challenging. NICUs are one of the few healthcare environments that allow for an open configuration, versus single-family room. The ability to use the pinwheel configuration and have multiple babies in several pods within a larger room is common and unique to the NICU environment. This set up though means that there is often more shared space and family/visitors are more likely to come into contact with surfaces/objects that are shared across babies. Studies have shown that those single-family rooms though, despite being more costly, are more conducive to family-centered care and enhanced medical progress through reduced nosocomial sepsis and mortality. Ultimately, a single-family room is not only preferable, but helps reduce the risk that a sick visitor or healthcare worker would expose multiple babies. 

For many infection preventionists with a NICU in their purview, a single case of a respiratory infection in the NICU can be alarming. NICUs can be especially vulnerable to those like respiratory syncytial virus (RSV) and influenza. Analysis of an outbreak involving eight ill infants (resulting in one death), found that the attack rate was higher in preterm infants born at lower gestational ages, resulting in higher morbidity and mortality. Often these respiratory viruses are spread by the close contact they have with the infants and the contamination of high-touch surfaces. While it is critical for healthcare workers to stay home while sick, it is also critical to stress the importance of family/visitors staying home while sick. Too often a parent or family member, with good intention in an obligatory visit, does not realize the implications of transmitting these infections to the vulnerability population that stays within the NICU. 

Infection prevention efforts are critical in this environment, but also must consider the layout of the unit and how best to consider human factors and work processes that might put patients at risk. Educating and working with family/visitors to ensure hand hygiene and basic infection prevention efforts can make a huge difference. Moreover, rounding in these areas to observe if disinfection practices are being done appropriately, as well as other infection control measures, can help break the chain of infection.