Article infectious diseases

Infection Control Practices in the NICU:

What is Evidence-based?
Judith A. Guzman-
Cottrill, DO* Abstract
Nosocomial infections cause significant morbidity and mortality in neonatal intensive
care unit (NICU) patients. Neonates, particularly those who are preterm and low
Author Disclosure birthweight, are at higher risk of acquiring infections compared with term and older
Dr Guzman-Cottrill infants. As a result, many interventions have been established in the NICU to attempt
to decrease the infants’ risk of acquiring infection. Over time, various interventions
has disclosed that she
have been adopted as “standard of care,” but other practices vary substantially from
is a member of the
one unit to another. This review examines several infection prevention strategies used
speakers’ bureau for in the NICU and reviews the literature related to such practices. Evidence-based
Sanofi Pasteur. This recommendations are made when supportive scientific evidence is available for this
commentary does not specific patient population.
contain a discussion
of an unapproved/ Objectives After completing this article, readers should be able to:
investigative use of a
1. Review evidence-based recommendations related to hand hygiene practices in the
commercial
NICU.
product/device.
2. Describe the appropriate use of personal protective equipment to protect the health-
care worker and infant from infectious pathogens.
3. Review evidence related to neonatal skin antisepsis for central venous catheter
insertion.
4. Review the evidence supporting routine influenza and pertussis vaccination for NICU
clinicians.

Introduction
Nosocomial infection is defined as an infection acquired in the hospital that was neither
present nor incubating at the time of hospital admission. (1) Neonates, especially those
requiring NICU care, are more susceptible to nosocomial infections. Multiple factors
contribute to this population’s high risk for infection, including prematurity and the
related relative immunodeficiency, use of central venous catheters, ventilator support, use
of urinary catheters, receipt of parenteral nutrition and lipids, and exposure to broad-
spectrum antimicrobials. Lower birthweight is directly related to a higher risk of develop-
ing device-associated infections, including central line-associated bloodstream infection
(CLABSI). (2) Surveillance from 2006 to 2008 by the Centers for Disease Control and
Prevention reports the mean infection rate in infants whose birthweights are 750 g or less is
4.9% for CLABSI and 5.7% for umbilical catheter-associated
bloodstream infections. (2) In comparison, the respective
mean infection rates in NICU patients whose birthweights
Abbreviations
are more than 2,500 g is 1.2% for CLABSI and 1.0% for
CHG: chlorhexidine gluconate umbilical catheter-associated bloodstream infections. (2)
CLABSI: central line-associated bloodstream infection Although this patient population is at risk for nosocomial
HCW: health-care worker infection, all NICUs should maintain a belief that such
NICU: neonatal intensive care unit infections are preventable and unacceptable; a “zero toler-
PI: povidone-iodine ance unit culture” is the first step toward a sustained reduc-
PPE: personal protective equipment tion. Various interventions have been developed in the
NICU in efforts to decrease the risk of nosocomial infection.

*Assistant Professor, Pediatrics, Division of Infectious Diseases, Oregon Health and Science University, Doernbecher Children’s
Hospital, Portland, Ore.

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infectious diseases infection control

Some interventions have become “standard of care” tricians and Gynecologists Guidelines for Perinatal Care
without supportive evidence. Other infection strategies recommend that “personnel should scrub their hands
have sound scientific support in the adult literature but and arms to a point above the elbow with an antiseptic
have not been well-studied in neonates. Comprehensive soap. Disposable sponges are as effective as brushes. . . .”
infection prevention staff education can significantly de- (14) However, no scientific evidence indicates that a
crease rates of nosocomial infection in the NICU. After routine surgical scrub on unit entry decreases nosocomial
implementing best practice education, sharing infection infections in the NICU. Moreover, infection preven-
rates, and implementing a specialty team for venous and tion guidelines for other highly immunocompromised
arterial catheter care, one center noted a 29% reduction groups, such as bone marrow transplant recipients, (15)
in nosocomial infections. (3) A good understanding of do not recommend surgical scrubbing prior to unit en-
basic infection prevention strategies is the most impor- try. Instead, efforts should focus on routine, meticulous
tant step toward decreasing nosocomial infections in the hand hygiene before and after every patient contact.
NICU. Techniques for preventing nosocomial infection Sinks and alcohol-based hand hygiene product dispens-
by altering the newborn’s immune function have been ers should be numerous and conveniently located
discussed previously in this journal. (4) This article con- throughout the unit for easy HCW access. Fingernails
centrates on infection control practices in the NICU. should be natural, trimmed short, and free of artificial
nails or wraps; previous P aeruginosa outbreak investiga-
Hand Hygiene Practices tions have demonstrated significantly increased transmis-
The most common mode of pathogen transmission from sion risk from HCWs who have either long or artificial
one individual to another is via contact and can occur fingernails. (9)(10)
directly or indirectly. (1) Direct contact transmission is Many NICUs recommend that all jewelry (eg, rings,
defined as the transfer of microorganisms from one in- bracelets, wrist watches) be removed distal to the elbows
fected person to another person without a contaminated because multiple studies have proven that ring-wearing
intermediate object or person. An example of direct increases the bacterial colonization of hands. (16)(17)(18)
contact transmission is the physician who develops a One study found a high risk of colonization regardless
staphylococcal abscess on a finger after direct, ungloved of ring type (including plain, flat wedding bands). (17)
contact with a patient’s staphylococcal wound. Indirect Fagerenes and associates (18) attempted to determine
contact transmission occurs when an infectious agent is the impact of finger rings on transmission of bacteria.
transferred through a contaminated intermediate person They found the prevalence of gram-negative organism
or item. Indirect contact transmission in the NICU contamination was higher on the hands of those wearing
setting is well-documented in the literature. Examples rings, but they were unable to demonstrate an increased
include thermometers colonized with Enterobacter cloa- risk of direct contact transmission in their study model,
cae; (5) Stenotrophomonas maltophilia outbreak associ- which was not specific to the NICU setting.
ated with tap water; (6) and Pseudomonas aeruginosa
outbreaks related to contaminated feeding bottles, (7) Personal Protective Equipment and Universal
hand lotion, (8) and artificial fingernails (9)(10) Con- Gloving
taminated hands of health-care workers (HCWs) trans- Personal protective equipment (PPE) refers to the vari-
mitting organisms if adequate hand hygiene is not per- ous barriers used alone or in combination to protect the
formed has been documented in bacterial, candidal, and HCW from contact with infectious microorganisms.
respiratory syncytial virus outbreaks. (10)(11)(12) PPE includes gloves, isolation gowns, masks, goggles,
Meticulous, routine hand hygiene effectively inter- and face shields. Precautions to prevent transmission of
rupts both direct and indirect contact transmission. infectious pathogens include standard, contact, droplet,
Thus, hand hygiene is the single most important inter- or airborne precautions (Table). In some situations, a
vention to prevent nosocomial infection. Despite this combination of precaution categories is required (eg,
well-known fact, HCWs consistently demonstrate sub- contact plus droplet precautions for adenovirus bronchi-
optimal hand hygiene compliance, with an overall aver- olitis). (19)
age 40% compliance rate. (13) For many years, hand Standard precautions should be followed with every
hygiene in the NICU has been identified as an important single patient encounter; HCWs should assume that all
infection prevention strategy, with a surgical scrub on patients are potentially infected or colonized with patho-
unit entry considered standard of care. The American gens that may be transmitted in the health-care setting.
Academy of Pediatrics and American College of Obste- Thus, the HCW should wear the appropriate PPE to

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 infectious diseases infection control

Table. Transmission-based Precautions

Personal Protective
Transmission Precaution Definition Equipment (PPE) Example
Standard Precautions Prevents potential transmission Dependent on anticipated HCW wearing goggles and
of pathogens in various exposure(s) during mask during aerosol-
situations, dependent on the patient care generating procedure or
HCW-patient interaction. HCW wearing gloves
Before each patient when handling blood
encounter, the HCW should and body fluids.
consider what potential
exposure may occur.
Contact Precautions Prevents transmission of Disposable gloves or Multidrug-resistant
pathogens that are spread gown organisms (eg,
by direct or indirect contact methicillin-resistant
with the patient or his/her Staphylococcus aureus,
environment. vancomycin-resistant
enterococcus,
respiratory syncytial
virus)
Droplet Precautions Prevents transmission of Mask Pertussis
pathogens spread via close
contact with respiratory
secretions within short
distance (<3 feet).
Airborne Precautions Prevents transmission of Fit-tested N-95 Measles, varicella virus,
pathogens that are capable respirator or powered pulmonary tuberculosis
of travel over long distances air-purifying respirator
when suspended in air. (PAPR), private special
airflow room
Combination: Contact ⴙ See above Disposable gloves, gown, Adenovirus bronchiolitis
Droplet Precautions mask
HCW⫽health-care worker

prevent potential occupational exposures. PPE recom- become contaminated during glove manipulation, hand
mendations may differ based on the anticipated extent of hygiene always is required after glove removal. (13)
exposure (eg, wearing gloves while changing a wound One NICU reported a significant decrease in late-
dressing, regardless of culture results) and the potential onset infection in very low-birthweight infants after im-
(or known) pathogens with which the patient is colo- plementing a universal alcohol hand rub and glove com-
nized or infected (eg, wearing a mask when entering the bination regimen. (21) This protocol included: 1) hand
room of a coughing infant who has possible pertussis). washing up to the elbows on unit entry; 2) hand hygiene
When the etiologic agent of an infant’s infection is un- with alcohol-based rub; 3) donning disposable, clean
known, HCWs should choose PPE based on the differ- latex gloves after handrubbing; 4) application of alcohol-
ential diagnosis of possible pathogens, until diagnostic based rub onto the gloves before touching an infant;
test results are available. 5) reapplication of alcohol-based rub onto gloves after
Some NICUs have adopted a “universal gloving pol- touching surrounding environment; 6) removal of gloves
icy” for all patient contact, with the presumed rationale after patient contact; and 7) hand hygiene with alcohol-
that the gloves prevent transmission of pathogens from based rub after glove removal. In addition, the hospital’s
HCW hands to the infant. No strong scientific evidence infection control program provided educational work-
routinely supports this practice; in fact, one study found shops and feedback on a monthly basis. This interven-
that universal gloving may lead to diminished hand hy- tion led to an impressive 2.8-fold reduction in the inci-
giene compliance in between glove use. (20) HCWs may dence of late-onset infection. Unfortunately, this was not
be misled to think that hand hygiene is not required if a a randomized, controlled trial; instead, the authors used
universal gloving policy is followed. Because hands may retrospective data for baseline comparison. It is highly

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infectious diseases infection control

likely that a similar infection reduction would have been paring a 10% PI skin scrub to a 70% alcohol scrub
achieved by implementing the infection prevention edu- followed by placement of a CHG-impregnated dressing
cation campaign with the meticulous hand hygiene pro- for preventing catheter-associated infections. (25) Dur-
tocol (without glove use). In addition, the authors did ing the first 15 months of the study, several extremely
not comment about the effect of repeated application low-birthweight neonates developed severe contact der-
of an alcohol-based agent on the permeability of latex matitis under the CHG dressing. The mean birthweight
gloves. Certain petroleum-based creams or hand lotions was 720 g (range, 560 to 880 g) and mean gestational
may affect the integrity of latex gloves. (13) Before age of affected neonates was 24.5 weeks (range, 22.5 to
recommending routine, repeated application of alcohol- 26.5 weeks). During the entire study period, 15 of 98
based products directly onto disposable gloves, it should neonates (15%) who weighed less than 1,000 g and 4 of
be established that the gloves can continue to protect the 237 neonates (1.5%) who weighed 1,000 g or more and
HCW from exposure to infectious pathogens. received the CHG dressing developed related contact
With the exception of sterile procedures, disposable dermatitis. It must be emphasized that this significant
gloves should be used as a means to protect the HCW. finding was associated with CHG-impregnated foam,
Gloves should be used to prevent contamination of which allows for continuous release of CHG onto the
HCW hands when: 1) anticipating direct contact with underlying skin. Such a severe degree of dermatitis may
mucous membranes, blood or body fluids, or nonintact not be associated with the transient use of CGH for skin
skin; 2) having direct contact with infants who are in- antisepsis before central catheter insertion.
fected or colonized with pathogens transmitted by con- A recent pilot study reviewed the effectiveness and
tact route; or 3) touching visibly soiled or potentially tolerability of 2% CHG versus 10% PI skin preparation
contaminated surfaces or equipment. (1) Rather than a for 48 neonates during insertion of peripherally inserted
universal gloving policy, HCWs should follow these central catheters. (26) Neonates who were younger than
guidelines in conjunction with routine hand hygiene 7 days of age or who weighed less than 1,500 g were
before and after each patient contact. excluded. The authors found no significant difference in
dermatitis in the CHG group compared with the PI
Antisepsis for Central Catheter Insertion group. They also found no statistically significant differ-
Extensive evidence-based guidelines exist for the preven- ence in catheter tip colonization or bloodstream infec-
tion of intravascular catheter-associated infections in the tions, although the study likely was not large enough to
non-neonatal population. Hand hygiene, aseptic tech- detect such benefit. Larger randomized trials are needed
nique, maximal sterile barrier precautions, standardiza- in this special population to determine the best skin
tion of catheter insertion kits, and chlorhexidine glu- antisepsis for the various birthweight categories.
conate (CHG)-based products for skin antisepsis have
become standard of care when inserting a central venous Health-care Worker Vaccination
catheter in adults and children. (22) Studies in adults Routine immunization of HCWs is a critical component
have proven that skin antisepsis with CHG is superior to of patient safety in the NICU. Nosocomial outbreaks of
povodine-iodine (PI) in decreasing intravascular catheter- vaccine-preventable disease have been documented ex-
associated infection. (23) To date, no randomized trial tensively in the literature. Influenza virus is an easily
has demonstrated that CHG is more effective that PI in transmissible pathogen known to be associated with
preventing CLABSIs in neonates. In addition, no CHG- higher morbidity and mortality in the very young popu-
containing skin preparation has been approved by the lation. In addition, HCWs may shed (and transmit) virus
United States Food and Drug Administration for use in for 1 to 2 days before the onset of symptoms. A level III
neonates, and no standard recommendation exists about NICU experienced a severe influenza A virus outbreak in
its use in this age group. The National Association of 1998 (27) in which 19 of 54 infants (35%) in the unit
Neonatal Nurses Peripherally Inserted Central Catheters during the 18-day long outbreak became infected, in-
Guideline for Practice, 2nd edition, recommends to cluding one fatal case of a 27-week gestation twin who
“prep the insertion site and surrounding skin with chlo- became ill at 7 days of age.
rhexidine gluconate (CHG) or povidone iodine (PI) per An epidemiologic outbreak investigation revealed
facility protocol.” (24) that of 86 NICU staff who responded to the question-
CHG use in neonates may be associated with contact naire, only 13 (15%) had been immunized against influ-
dermatitis, including severe skin blisters and burns. This enza that season. The medical staff had a higher vaccina-
risk was demonstrated in a 2001 randomized trial com- tion rate (67%) compared with nursing staff (9%). In

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addition, although 14 HCWs admitted to having an HCWs who may transmit pertussis to infants in the
influenzalike illness during the outbreak period, only hospital. Persons who have pertussis are contagious be-
four reported taking time off of work. Similarly low fore developing the classic paroxysmal cough. In fact, the
influenza immunization rates among HCWs were re- period of highest infectivity begins during the catarrhal
ported (45% of physicians and 5% of nurses) from an- stage of illness, when symptoms are similar to the com-
other outbreak investigation in a 20-bed NICU where mon cold (19) (and HCWs often continue to work
four infants became ill. (28) After this outbreak, 100% of despite mild upper respiratory tract illness). Routine
NICU staff was immunized against influenza within 2 vaccination of NICU staff may be effective in decreasing
months. the risk of nosocomial pertussis. In addition, education
Policies mandating seasonal influenza immunization about pertussis vaccination should be provided to NICU
of HCWs have been implemented by several large med- parents and other close contacts of these vulnerable
ical centers in the United States as a condition for em- patients (eg, older siblings, extended family, childcare
ployment, (29) resulting in vaccination rates as high as providers).
98.4%. (30) In 2009, the New York State Health Depart-
ment mandated influenza vaccination for HCWs as a Summary
component of their 2009 H1N1 pandemic prepared- Neonates in the NICU are at high risk of nosocomial
ness. (31) In institutions where immunization is not infections. The risk of infection and the associated com-
mandatory, NICU leadership (both physicians and nurs- plications increase with the degree of prematurity and
ing representatives) should implement an annual sea- low birthweight. NICU staff should regard nosocomial
sonal influenza employee immunization campaign. Rou- infections as preventable and unacceptable, maintaining
tine HCW influenza immunization should be regarded a “zero tolerance unit culture.” Basic infection control
as standard practice for the protection of vulnerable practices, such as excellent hand hygiene compliance,
patients, fellow HCWs, and HCW families and to de- appropriate use of PPE, and routine HCW vaccination,
crease the risk of occupational exposure to influenza can decrease the risk of nosocomial infection in this
virus. patient population. Staff education and continued rein-
In the 1980s, Bordetella pertussis re-emerged as a forcement of these strategies must be a part of every
significant infectious disease, in part due to waning im- NICU’s infection prevention and control plan.
munity in the general population. Because most related
morbidity and mortality occurs in infants, an outbreak in
the NICU setting poses a major threat. Transmission of American Board of Pediatrics Neonatal-Perinatal
this highly contagious pathogen from HCW to neonate Medicine Content Specification
has been described, including a 2003 outbreak in a • Know the effective techniques for control
neonatal intermediate care nursery. (32) A 26-week ges- of nosocomial infection in the nursery,
tation infant who had been hospitalized since birth neonatal intensive care unit, and
obstetrical unit.
developed cough and apnea at 2 months of age. The
primary source of infection was a 36-year-old nurse who
had a 3-week coughing illness, and three additional
nurses were diagnosed with pertussis during the out-
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 infectious diseases infection control

NeoReviews Quiz
5. Nosocomial infection is defined as an infection acquired in the hospital setting that was neither present
nor incubating at the time of hospital admission. Several strategies are proposed to prevent nosocomial
infection in the neonatal intensive care unit. Of the following, the single most important preventive
intervention is:
A. Hand hygiene before and after every patient contact.
B. Removal of all jewelry distal to the elbows.
C. Surgical scrubbing before entry into the unit.
D. Universal gloving for all patient contact.
E. Wearing masks to avoid contact with respiratory secretions.

6. Personal protective equipment refers to various barriers used alone or in combination to protect the health-
care worker from contact with infectious microorganisms. Personal protective equipment includes gloves,
isolation gowns, masks, goggles, and face shields. Of the following, the personal protective equipment of a
powered air-purifying respirator (PAPR) is recommended for preventing transmission of:
A. Adenovirus.
B. Bordetella pertussis.
C. Methicillin-resistant Staphylococcus aureus.
D. Respiratory syncytial virus.
E. Varicella-zoster virus.

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 Infection Control Practices in the NICU: What is Evidence-based?
Judith A. Guzman-Cottrill
NeoReviews 2010;11;e419
DOI: 10.1542/neo.11-8-e419

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 Infection Control Practices in the NICU: What is Evidence-based?
Judith A. Guzman-Cottrill
NeoReviews 2010;11;e419
DOI: 10.1542/neo.11-8-e419

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