Risk Factors for Health Care-Associated Bloodstream Infections in NICUs

Abstract

Importance: Neonates requiring intensive care are at high risk of health care-associated infections. In neonatal intensive care units (NICUs) in low-resource settings, the identification of modifiable risk factors can inform targeted prevention strategies to reduce the global burden of neonatal morbidity and mortality.

Objective: To describe the incidence of and the risk factors associated with health care-associated bloodstream infections (BSIs) in NICUs in Pune, India.

Design, setting, and participants: This multicenter prospective cohort study enrolled all neonates admitted to 3 NICUs in Pune, India, from May 1, 2017, to July 31, 2019. Neonates were followed up from admission until discharge, transfer, or death. This secondary data analysis included neonates admitted for 3 days or more and was completed on January 31, 2024.

Main outcomes and measures: The primary outcome was health care-associated BSIs, defined as a positive blood culture on or after admission day 3. Summary statistics, incidence of health care-associated BSIs, and hazard rate by characteristics of interest were generated. Among neonates admitted for 7 days or longer, the association between antibiotic exposure and infection risk was assessed.

Results: A total of 6410 neonates were admitted for 3 days or longer. The median gestational age was 34 weeks (IQR, 32-37 weeks), and 3560 (55.5%) were male. The incidence of health care-associated BSIs was 6.09 per 1000 patient-days. Most isolates were gram-negative organisms (n = 273 [66.3%]), of which 85.5% (202 of 236 isolates tested) were resistant to third- or fourth-generation cephalosporins and 44.8% (117 of 261 isolates tested) were resistant to carbapenems. The hazard rate of health care-associated BSIs was higher among neonates with central venous catheters, respiratory support, or urinary catheters within 3 days preceding infection. Of 3229 neonates admitted for 7 days or longer, 190 (5.8%) had health care-associated BSIs on or after hospital day 7, with an incidence of 3.22 per 1000 patient-days. Antibiotic exposure during the first week of admission was associated with a nearly 3-fold increase in the risk of health care-associated BSIs (adjusted hazard ratio, 2.82 [95% CI, 1.26-6.32]).

Conclusions and relevance: In this cohort study of 6410 neonates admitted to 3 NICUs in Pune, India, the risk of health care-associated BSIs was associated with the presence of indwelling devices and prior antibiotic exposure. Future efforts should focus on mitigating the risks associated with indwelling devices and strengthening infection prevention and control and antimicrobial stewardship programs to prevent health care-associated infections.

Figure 1.. Study Flow Diagram for Analytic Cohort of Neonates Admitted to 3 Tertiary Care Neonatal Intensive Care Units (NICUs) in Pune, India, From May 1, 2017, to July 31, 2019

BSI indicates health care–associated bloodstream infection.

Figure 2.. Epidemic Curve of Health Care–Associated Bloodstream Infection (BSI) Events by Hospital Day Among Neonates Admitted for 3 Days or Longer to 3 Tertiary Care Neonatal Intensive Care Units in Pune, India, From May 1, 2017, to July 31, 2019

Bars indicate the number of health care–associated BSI events per hospital day. The plot points indicate the rate of infection per 1000 patient-days for each individual hospital day. The blue curve indicates the locally weighted scatterplot smoothing rate of infection per 1000 patient-days for each hospital day.