0021-7557/01/77-Supl.1/S81 Jornal de Pediatria - Vol. 77, Supl.

1 , 2001 S81
Jornal de Pediatria
Copyright © 2001 by Sociedade Brasileira de Pediatria

REVIEW ARTICLE

Neonatal nosocomial infections

Marisa Márcia Mussi-Pinhata,1 Suely Dornellas do Nascimento2

Abstract
Objective: to review the current medical literature on neonatal nosocomial infections, emphasizing
aspects of neonatal colonization, immune system and infection mechanisms, modes of transmission,
epidemiology, surveillance and prevention of these infections, in addition to assessing peculiarities about
etiologic agents and prophylactic recommendations.
Sources: electronic search in the Medline and Lilacs databases, with selection of the most relevant
articles published within the last ten years.
Summary of the findings: the several peculiarities that cause greater susceptibility to infection in
newborns, and the survival of preterm infants due to the invasive procedures and treatment with broad
spectrum antibiotics at intensive care units are responsible for prevalence rates of neonatal nosocomial
infections between 9.3 and 25.6%. Neonatal nosocomial infections affect at least 50% of newborns who
weigh less than 1500 g, which ends up increasing mortality rates. Full-term newborns frequently have skin
and soft tissue lesions caused by gram-positive organisms. In neonatal intensive care units, sepsis and
pneumonia are frequently diagnosed (especially those caused by S. aureus, S. epidermidis, E. coli, K.
pneumoniae, and E. cloacae). An increasing frequency of resistance to several antimicrobial drugs has been
observed. A nosocomial infection surveillance program tailored to the characteristics of the neonatal unit
allows the identification of infection outbreaks, the rational use of antibiotics and the application of
preventive measures.
Conclusions: neonatal nosocomial infections are a relevant problem. Their control can only be
achieved if adequate measures concerning pregnant women, hospital environment, nursing staff, and
newborns are adopted. Although new prophylactic measures are being proposed for preterm infants, they
are costly and do not preclude continued epidemiological surveillance and control in neonatal units.

J Pediatr (Rio J) 2001; 77 (Supl.1): S81-S96: epidemiology, immune system, transmission, infection/
control, prevention.

Introduction
Reports of infections acquired in places where patients
are treated data back to the middle ages. The inherent risks
of hospital assistance as to what concerns morbidity and
mortality are also known since the origin of hospitals in the
1. Ph.D. Professor, Department of Puericulture and Pediatrics, School of
Medicine of Ribeirão Preto, Universidade de São Paulo. Member of the
Department of Neonatology.
2. Master. Assistant Professor of the Discipline of Neonatal Pediatrics,
Paulista School of Medicine, Universidade Federal de São Paulo. Doctor,
Neonatal ICU, Hospital and Maternity Santa Joana.
18th century.1 Important milestones for the understanding
of factors involved in transmission of hospital infections are
represented in the observations of Holmes2 and of
Semmelweis,3 who verified a relation between occurrence
of puerperal infection and inadequate washing of the hands
by the staff who assisted the parturients.
Currently, the cumulative knowledge on the incidence,
presentation, associated factors, consequences, and
prevention of infections acquired in the hospital or up to 73

S81
S82 Jornal de Pediatria - Vol. 77, Supl.1, 2001
hours after discharge allows for identification, surveillance,
and control of nosocomial infections.
Hospital infections are more frequent and, generally,
more severe in newborn infants than in older children or
adults. The peculiar characteristics of this period of life
allow for greater susceptibility to infections. In addition,
another factor responsible for infections being more severe
in these patients is the increased survival of premature
newborn infants, following prolonged neonatal ICU stay,
use of invasive procedures and of wide spectrum
antimicrobials.
The prevention and control of neonatal bacterial
infections represent a challenge for all professionals involved
in hospital care of newborns. Infection outbreaks in nurseries
and that result in deaths have been widely reported by the
Brazilian press. In other countries, hospital infections are
associated with 7 to 73% of neonatal mortality.4 Neonatal
hospital infections, in addition to being the cause of a
significant number of perinatal, neonatal, and postnatal
deaths, are also associated with increased healthcare costs.
This is because hospitalization of infected children is up to
threefold longer than that of noninfected children.4 It is our
objective to review the main aspects of this broad theme.
Colonization, infection, and mechanisms of defense in
newborn infants
Colonization is the presence of a microorganism in or on
a host, with growth and multiplication but without any overt
clinical expression or detected immune response in the host
at the time it is isolated.5 A developing fetus is protected
from the microbial flora of the genital tract of the mother.
Normal colonization in newborns and of the placenta begins
during the birth process, after rupture of the amniotic
membrane and through subsequent contacts with the
inanimate or animate environments until a delicately
balanced normal flora is established; subsequently, the
precise components of a neonatal endogenous flora evolve.
Many factors can influence the acquisition of neonatal
flora: maternal genital flora; type of nutrition of the newborn;6
hospital staff and people in direct contact with the newborn;
and environment, including the flora of objects and other
newborns.7
In general, newborns that remain in contact with the
mother and are naturally breastfed can be colonized on the
skin and mucous surfaces (nasopharynx, oropharynx,
conjunctive, umbilical chord, external genitalia) several
days after birth. The main microorganisms, in this sense, are
alpha-hemolytic Streptococcus, negative-coagulase
Staphylococcus (skin, upper respiratory mucosa, umbilical
stump), lactobacillus, other anaerobic microorganisms, and
E. Coli (gastrointestinal tract). Other common bacteria are
Candida albicans (gastrointestinal tract, vagina, perineal
area) and Staphylococcus aureus (skin and mucous
surfaces).5
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
The presence of normal flora and of mildly virulent
microorganisms protects the newborn from potentially
pathogenic microorganisms, such as gram-negative bacillus.
That is because the microorganisms in the normal flora
spread to different sites and compete with pathogenic
organisms, but rarely causing disease.
Infections, which are the invasion by a microorganism
that multiplies and causes lesions, usually occur as a direct
extension of the sites of colonization or of bloodstream
infection with the resulting dissemination of the infection.
Infections also depend on the virulence of the microorganism,
of the inoculum, and of the pathogen-host interaction. In
most cases, the pathogens invade the newborn through the
conjunctive, the respiratory and gastrointestinal tracts, and
the skin.
The decreased production and function of local and
systemic defense (of both innate and specific responses)
depend on the antigen and contribute to greater susceptibility
to infection during the neonatal period.8
That is the reason for local natural barriers against
bacterial infections being compromised in newborn infants.
The skin, and especially that of preterm newborn infants, is
immature and has increased permeability, which is partially
caused by the production of free fatty acids and alkaline pH.
Moreover, skin integrity can be affected by environmental
aggressions. The umbilical chord can be another source of
infection due to is proximity to the bloodstream, to the
increased permeability, and to the potential colonization by
pathogens.9 Also, the production of secretory immunoglobin
A is absent during the first days of life; thus, the respiratory
and gastrointestinal epithelium are more vulnerable.10
The lack of innate immune response (granulocytes,
mononuclear phagocytes, and humoral factors such as the
complement, fibronectin, and colectin), which is activated
in the first hours or days of contact with microbes, plays a
critical role in the susceptibility to infection by pyogenic
bacteria and fungi. The antigen-specific response, in turn,
does not develop until 5 to 7 days after the initial exposure
to microorganisms.
In general, in newborn infants, the ability to accelerate
production of neutrophils as a response to infection is
restricted, the chemotaxy of neutrophils is decreased as a
response to a variety of stimuli, and these cells are less
adherent, deformable, and survive less.11 As to what concerns
the mononuclear phagocytes, despite the delayed and
attenuated inflow of these cells to the site of inflammation,
some studies have suggested that newborns present
microbicidal activity against certain bacteria that is similar
to that of adults. In turn, in term newborns, the production
of mediators that contribute to the recruitment of neutrophils
to the site of infection differs 25 to 50% in relation to that
of adults (GM-CSF, TNF, IL-8, leukotriene B4); whereas
the production of C-CSF and of IL-1 is similar to that of
adult life.9 Also, newborn infants and especially preterm
newborn infants present deficiencies in both pathways of
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
the complement system and in fibronectins. In this sense,
the fractions of the alternative pathway of the complement
present smaller concentrations than those of the classical
pathway.12 Consequently, there is a deterioration of the lyse
of bacteria (complement factor 9 - C9), especially of those
that are gram-negative, and a reduction of opsonization
(C3b), especially of those that are capsulated. 12
The immature innate response of newborns is partially
compensated by transplacental transfer of immunoglobin G
from the mother. The specific antibodies acquired from the
mother, in this sense, can promote more efficient
opsonization and phagocytosis.9,10 However, the absence
of type-specific antibodies acquired from the mother can be
a predisposing factor to infection by certain agents
independently of the production of antibodies by the newborn
infant.13
The ability to respond to specific antigens develops
chronologically and in a distinct manner provided that the
response occurs independently of the help of T lymphocytes,
or that this help is necessary. With the exception of
polysaccharide antigens, the response to most specific
antigens is dependent on T cells. In newborn infants, the
production of antibodies by the lymphocytes B and thymus-
dependent antigens is similar to that of adults.14 Considering
that many pyogenic bacteria are capsulated and,
consequently, the response is thymus-independent, the
production of antibodies by newborns will be limited and
contribute to greater susceptibility.
Despite the fact that the causes of increased susceptibility
of newborns to intracellular pathogens such as virus, T.
gondii, and M. tuberculosis are still not well understood,
there is evidence of involvement of defects in innate immune
system cell function, such as: delayed recruitment of
monocytes and macrophages to the tissues; reduction of
cytokine production, which increases cell immunity; and
reduction of citotoxicity of NK cells and of production of
gamma-interferon. Moreover, there are other factors that
can contribute to slower differentiation of T cells, such as:
less efficient dendritic cells; greater dependence of dendritic
cells on T cells; greater dependence of dendritic cells on the
levels of cytokines for their induction and proliferation,
and, also, differentiation for T cells. Consequently, this
allows for facilitated replication of intracellular pathogens.8
Hospital infections
Definition
In general, hospital infections include any infection that
are not present or incubated at the moment of hospital
admission and, thus, are acquired during hospitalization or
up to 72 hours after discharge.
Though all infections acquired by babies born in hospitals
can be considered nosocomial infections, infections that
become overt early (during the first week of life) are
frequently caused by microorganisms transmitted by the
Jornal de Pediatria - Vol. 77, Supl.1 , 2001 S83
mother to the newborn. These infections present a
characteristic epidemiology, different from that of hospital
infections acquired later in the neonatal period. Usually,
neonatal infections are divided into early-onset (less than 3
to 7 days of life), originated by the mother, and late-onset
(greater than 3 to 7 days of life), which are those acquired
after birth and thus not originated by the mother.
The Center for Disease Control and Prevention (CDC)
considers that hospital infections includes those acquired
intrapartum, during hospitalization, or up to 48 hours after
hospital discharge. The exception includes transplacental
infections (syphilis, toxoplasmosis, rubella, cytomegalovirus
infection, hepatitis B, herpes simplex, HIV infection, and so
on). Infections that occur up to 48 hours of life are considered
hospital infections originated by the mother and those that
occur after 48 hours of life are considered hospital infections
originated by the environment.15
In Brazil, the Ministry of Health (portaria 2616/98) has
presented guidelines for the control of hospital infections.
These guidelines classify all neonatal infections as hospital
infections with the exception of those acquired through the
placenta or those associated with rupture of amniotic
membranes for more than 24 hours before delivery.16
Epidemiology of hospital infections
The rates of incidence of nosocomial infections vary
considerably. These rates depend on the type of hospital, on
the characteristics of the newborn patients (gestational age,
postnatal age, associated conditions), on the methods for
diagnosis of infections and for epidemiological surveillance.
Term newborn infants submitted to appropriate care,
admitted to rooming-in environments, and breastfed rarely
acquire postnatal infections. Studies have reported that
term newborns acquired infections at rates of 0.6 per 100 to
16.9 per 100 infants.17 In turn, infections in newborns in
neonatal ICUs are increasingly more frequent.
The most comprehensive studies on epidemiology of
hospital infections at neonatal ICUs were carried out by the
CDC, by means of the National Nosocomial Infection
Surveillance System (NNISS), which reported 13,179
nosocomial infections at US neonatal units;18 and by the
National Institute of Child Health and Human Development
(NICHD), which reported data from a cohort of 7,861
babies with birth weights of 401 to 1,500 g.19
The overall rates of nosocomial infections per patient
(total number of infections per 100 patients) at US neonatal
units range from 1.8 to 15.3.20 In the case of newborn
infants with less than 750 g, the incidence of hospital
infections is of at least 42%. There are no comprehensive
studies available in the Latin American or Brazilian literature.
A study carried out by the Brazilian Ministry of Health, in
1994, in 99 tertiary hospitals located in Brazilian capitals
indicated an overall hospital infection rate of 14.4% in
neonatology.21 A study carried out at the Hospital São
S84 Jornal de Pediatria - Vol. 77, Supl.1, 2001
Paulo from 1994 to 1996 reported a cumulative incidence
of hospital infections of 25.6 per 100 discharges for 678
newborns admitted to the ICU, and of 9.3 per 100 patients
for all 1,868 newborns admitted to the nursery.22 When
stratified according to weight at birth, the cumulative
incidence of hospital infections was of 57 per 100 hospital
admissions in newborns with less than 1,000 g; of 59 per
100 in those between 1,000 and 1,500 g; of 20 per 100 in
those between 1,500 and 2,500 g; and of 8.6 per 100 in those
with weight at birth greater than 2,500 g.22
Acquiring microorganisms and the predisposing factors
for infection
The main pathways for acquiring microorganisms that
can cause infections are airborne transmission; direct contact
(direct physical transmission from an infected or colonized
person to a host by the hands or secretions); 23,24 indirect
contact (physical transmission from inanimate objects such
as transducers, thermometers, stethoscopes, manometers,
suction catheters, and water);25,26 common conveyors
(contaminated fluids, IV solutions, milk, blood, and
derivatives);27 and by vectors (flies and cockroaches).28
The exposure to these sources will contribute to the
establishing of an endogenous flora of the newborn; in other
words, bacterial colonization of the skin, the mucosa, and
the gastrointestinal and respiratory tracts that, in turn, are
also frequently the source of microorganisms that cause
infection. Infections originated by the patient’s own
reservoirs are classified as of endogenous transmission.
Table 1 presents the types of transmission of infections
caused by certain etiological agents.
The main risk factors for infection of newborns can be
divided into intrinsic and extrinsic factors. The intrinsic
factors include characteristics such as gestational age, sex,
birth weight, severity of the disease, and immunologic
development.18 The extrinsic factors include hospital stay;
use of invasive procedures, such as arterial and venous
catheters, tracheal cannulas, gastric or gastric-duodenal
probe, ventriculo-peritoneal shunt, chest drains, and so
on;19 exposure to hospital environment and staff, such as
nurse:patient ratio and physical space (overcrowding and
understaffing), staff training, hygiene and hospital infection
control techniques;30 and use of antimicrobials.31
In general, newborn infants presenting good clinical
status have a short hospital stay and are not submitted to
invasive procedures. In this sense, the exposure to hospital
staff is the most important risk factor for these patients.32
Conversely, newborn infants admitted to neonatal ICUs
have prolonged hospital stay, and frequent exposure to
invasive procedures and to a great number of people
responsible for the care of the baby. The care of these
newborns involves frequent use of the hands. In general,
low weight at birth is the most influential factor for hospital
infections.33 The predisposition to infection in these newborn
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
infants is due to a combination of several risk factors as a
consequence of immature immune defenses and of the use
of life support systems, in the sense that the latter promotes
breakdown of the normal defense barriers. These systems
submit the newborn to use of endotracheal cannulas and
mechanical ventilators, which interfere on local pulmonary
defenses; to use of catheters that allow for spreading of
microorganisms from the cutaneous flora into the
bloodstream; to the use of mechanisms that reduce gastric
acidity, such as H2 blockers, parenteral hyperalimentation
(can convey pathogenic agents to the patient); 34 and to
prolonged and frequent use of antimicrobials such as
cephalosporines and aminoglycosides, whose selective
pressure promotes colonization with resistant pathogens.
Moreover, prolonged neonatal ICU stay facilitates the
colonization with potentially pathogenic, gram-negative
bacterial flora of the environment and hands of hospital
staff. This colonization can be of strains of Staphylococcus
aureus (repeatedly recovered from the hands and nostrils of
30 to 50% of hospital personnel) and, thus, facilitate infection
especially in overcrowded, understaffed units. 35
The combination of these multiple predisposing factors
affects the endemic or epidemic rates of hospital infection.
The relative contribution of different factors is often unclear.
Table 2 presents information on different hospital
infection outbreaks at neonatal units and reported between
1998 and 2000 in the literature. The detection of reservoirs
of infection agents and of the transmission pathways is
possible due to techniques of molecular biology. These
techniques allow for use of DNA markers as surrogate
indicators 36 and for identification of molecular
characteristics of isolates from different sites.37
Infection sites
Infections of term newborns and at normal nurseries are
primarily cutaneous and of soft tissues, including omphalitis,
pocks, abscess, and bullous impetigo. Outbreaks of
conjunctivitis and bacterial or viral gastroenteritis can
spread very rapidly in these nurseries.17
In the case of neonatal ICUs, bacteremia and sepsis are
the most frequent infections and account for 30 to 50% of
hospital infections; these infections are followed by
pneumonia; eye, ear, nose, and throat infections; skin and
soft tissue infections; and gastrointestinal and surgical site
infections.18 There are variations in these sites of infection
according to weight at birth and to the characteristics of the
unit.
Etiology
The microorganisms that cause hospital infections
include bacteria, fungi, and virus; it is also possible to
include all commensal pathogens and organisms of humans.
In normal nurseries, the Staphylococcus aureus, the
Neonatal nosocomial infections - Mussi-Pinhata MM et alii Jornal de Pediatria - Vol. 77, Supl.1 , 2001 S85

Table 1 - Major modes of transmission of some nosocomial infections

Mode of Nosocomial infection Infectious reservoir Source of infection

transmission

Air Measles, Infected individuals Air-borne particles

pulmonary tuberculosis

Direct contact Staphylococcal neonatal Colonized / infected Hands containing

infection individuals secretions from
infected wounds

Indirect contact Respiratory Syncytial Virus Infected individuals Hands and fomites
Antibiotic-resistant bacteria Colonized/ infected Hands and fomites
individuals

Droplets Whooping cough, invasive Colonized / infected Large respiratory

meningococcal disease, individuals droplets
Streptococcal infection -
group A

Endogenous Bacteremia caused by Skin at the insertion Intravascular catheter

coagulase-negative site of the vascular
Staphylococcus catheter
Urinary tract infection Periurethral skin and Urinary catheter
caused by Escherichia coli mucous membranes

Common source Bacteremia caused by Liquid substances Contaminated IV fluids

gram-negative bacteria in the environment Donor’s contaminated
Posttransfusion infection Infected individuals blood products
with HIV, HBV, HCV, CMV

Vectors Salmonellosis Infected / colonized Contaminated food

individuals
Enteric infection Infected individuals Flies, ants
or infectious material

HIV: human immunodeficiency virus; HBV: hepatitis B virus; HCV: hepatitis C virus; CMV: cytomegalovirus.
Adapted from Huskins WC, Goldman DA. Nosocomial Infections. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric. Infectious
Diseases, 4th ed. Philadelphia: WB Saunders; 1998. p.2545-85

enteropathogens, and the respiratory virus are the main
infection agents. At high-risk nurseries, there is a broad
spectrum of infection agents that includes microorganisms
normally nonpathogenic for term newborns, such as
negative-coagulase staphylococci and Candida.18 In the
assessment of the etiology of neonatal hospital infections it
is important to consider that it also depends on birth weight;
on characteristics of the unit; on use of invasive procedures;
on maternal or nonmaternal origin of the infection; and on
temporal evolution of etiological agents in the unit. It is
fundamental that each institution register the microbiological
ecology of its units through epidemiological surveillance.
Table 3 presents the etiology of hospital neonatal
infections of two selected studies.
Next, we will comment some of the aspects of the main
etiological agents and the most frequent clinical
manifestations according to different agents.
Gram-positive bacteria
The Staphylococcus is the main gram-positive infection
agent of hospital infections of the newborn; the most
important being negative-coagulase Staphylococci such as
Staphylococcus epidermidis, which frequently affects low
S86 Jornal de Pediatria - Vol. 77, Supl.1, 2001 Neonatal nosocomial infections - Mussi-Pinhata MM et alii

Table 2 - Reports of nosocomial infection at neonatal units, possible modes of transmission, and associated
factors

Reference # Country/region Agent Probable mode of transmission /

associated factors

36 New York, USA P. aeruginosa Nurses’ false nails

25 Netherlands Multiresistant Enterobacter Digital electronic thermometer

cloacae

37 Washington DC, USA Enterobacter cloacae Endogenous flora

Horizontal transmission

38 Boston, USA Several– causing sepsis Broviac catheter

Parenteral nutrition

28 South Africa Multiresistant Klebsiella Cockroaches

pneumoniae

31 Madrid, Spain Enterobacter cloacae Inadequate hygiene, overcrowding

39 Southeast of India Klebsiella pneumoniae Intravenous dextrose solution

40 Ottawa, Canada coagulase-negative Enteral nutrition through

Staphylococcus aureus nasogastric tube

41 New York, USA Vancomycin-resistant Prolonged antibiotic therapy

Enterococcus and low birthweight

42 St-Ettiene, France Serratia marcencens Transducers with built-in tachograph

26 Brussels, Belgium Pseudomonas aeruginosa Water bath used to thaw frozen plasma

43 Bahamas Acinetobacter spp. Aerosols and air-conditioners

27 Roraima, Brazil endotoxins Intravenous solutions

clinical sepsis and 35 deaths

44 Netherlands Stenotrophomonas Tap water

maltophilia

birth weight newborns with prolonged hospital stay, venous
catheter, and administration of parenteral lipids.
Bloodstream is the most frequent pathway of infection,
presenting nonspecific and difficult to diagnose signs. This
type of infection can, also, cause focal infections.46
Considering that the referred agents are a part of the normal
cutaneous flora, they can also contaminate hemocultures.
Thus, the diagnosis after isolation of the agents becomes
more difficult. Confirmed diagnosis of bloodstream infection
follows criteria of resistance to at least six antimicrobial
agents, since most strains are resistant to oxacillin.47
The Staphylococcus aureus is also a concern for most
nurseries around the world. Cutaneous lesions and invasive
procedures are predisposing factors for occurrence of focal
lesions, bacteremia, meningitis, or pneumonia. The main
reservoir of this bacterium is the hospital staff and
contamination usually occurs through the hands.
The Enterococcus spp can be acquired by the mother,
but it is turning into a prevalent agent in nosocomial
infections. The most common source of infection is the
gastrointestinal tract of the newborn. There is also possibility
of colonization of the mouth, respiratory tract, cutaneous
lesions, and of contamination by objects and surfaces of the
environment.48 Preterm newborns who remain hospitalized
for more than 30 to 60 days, with prolonged use of venous
catheters and exposed to multiple antimicrobials, are
especially predisposed to infections by Enterococcus. These
infections can be severe and include: necrotizing
enterocolitis, sepsis, pneumonia, meningitis, and
endocarditis.32
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Table 3 - Frequency (%) of pathogens causing early-onset (maternal origin) and late-onset (environmental
origin) nosocomial infection at neonatal intensive care units in selected studies

USA, NNISS 1986-199418 USA, NICHD

1991-199319
Pathogen maternal origin environmental origin
Sepsis Pneumonia Sepsis Pneumonia Sepsis
n=1,114 n=380 n=6,303 n=2,243 n=2,355

Gram-positive Bacteria
Staphylococcus aureus 2.6% 2.4% 8.4% 18.7% 9%
Coagulase-negative Staphylococcus 12.3% 14.7% 57.9% 16.6% 55%
Streptococcus - group B 46.4% 31.8% 0.9% 1.3% 2%
Enterococcus (Streptococcus - group D) 2.1% 6.1% 6.9% 4.2% 5%
Other streptococci 10.0% 6.8% 1.4% 2.7% 2%

Gram-negative Bacteria
Escherichia coli 10.2% 7.4% 2.8% 5.5% 4%
Klebsiela species 3.2% 6.0% 4%
Pseudomonas species 2.9% 12.9% 4%
Enterobacter 0.5% 0.8% 3.1% 9.5%

Fungi
Candida species 1.2% 8.9% 7%
Other 14.7% 23.9% 9.7% 22.6% 8%

n= number of infants diagnosed with infection.

Gram-negative bacteria infections are associated with prolonged exposure to

Gram-negative bacteria are the cause of approximately
19% of cases of nosocomial sepsis, and of over 30% of
pneumonias.18,19 These infections are severe and present
high lethality rates (40 to 90%). Nonmaternal strains of
Escherichia Coli (other patients or environment) can cause
invasive diseases.49 The main reservoir of Klebsiela and
Enterobacter are the gastrointestinal tract of the patient,
invasive procedures, and catheters.25,28,31,37-40 Several
gram-negative bacillus have been associated with outbreaks
of hospital infections at neonatal units, especially those
associated with environmental contamination, such as:
Pseudomonas aeruginosa, 26 Serratia marcencens, 43
Acinetobacter spp,44 Stenotrophomonas maltophilia,45
among others.
Fungi
Similarly to infections by gram-negative bacteria, those
by fungi are increasingly prevalent in neonatal units. These
antibiotics, with parenteral hyperalimentation, with tracheal
intubation, and with IV infusion of lipids.50 Different
Candida strains (albicans, tropicalis, parapsilosis) account
for most hospital infections. The most common presentation
is fungemia. However, the fungi can spread and cause
meningitis, spleen or kidney abscess, endophtalmitis,
osteomyelitis, or invasive dermatitis with mortality rates as
high as 25 to 50%.51
Virus
Despite the fact that they are usually not identified, viral
nosocomial infections are very common. Hospital staff,
family members, and other infected patients represent the
main conveyors of viral infections in neonatal units. The
most frequent viral nosocomial infections are caused by
respiratory syncytial virus and by rotavirus.
Nosocomial transmission of respiratory syncytial virus
can result in increased morbidity and mortality for all
S88 Jornal de Pediatria - Vol. 77, Supl.1, 2001
infected newborns, but especially for premature newborns,
with congenital cardiac disease or associated pulmonary
conditions, and for post-surgical patients. 52
Neonatal outbreaks of rotavirus can be a result of
transmission by contaminated hands.53 Both symptomatic
and asymptomatic children can excrete the virus in feces.
There are reports of viral excretion in feces of premature
newborn infants for periods as long as 6 or more weeks.
Epidemiological surveillance
Epidemiological surveillance is a set of activities aimed
at active, systematic and continuous observation of
collection, analysis and assessment of data regarding
infection.54 The main objectives of surveillance of neonatal
hospital infections, which is fundamental for prevention,
are:
1. to determine the epidemiological profile of hospital
infections evaluating etiological agents, microbial
sensitivity, and affected sites;
2. to observe the endemic levels of infection and early
detection of outbreaks;
3. to define risk factors according to type of patient and
procedures used;
4. to prioritize control and prevention measures, as well as
the evaluation of necessary strategies of intervention.
Hence, the development of a surveillance program
involves choosing a surveillance method, establishing
uniform criteria for hospital infections, for identification of
types of infection, and rationalizing control and use of
antimicrobials.
There are several methods of epidemiological
surveillance of hospital infections. The method of choice
will depend on the characteristics of the hospital, on the
available resources, on the type of patient, and on the most
frequently identified infections. This allows for choosing
between global hospital surveillance and site or type of
infection surveillance, or a combination of both; both types
involve evaluation of risk factors through microbiological
data. In epidemiological surveillance, it is possible to
collect data passively, actively, or by review of medical
records. In any of these methods, following the isolation of
the etiological agent, it is necessary to characterize the
susceptibility to antimicrobials.
A traditional method of epidemiological surveillance is
based on the calculation of cumulative incidence of
infections. The numerator of the formula of this calculation
is the number of identified cases, which can be either the
number of infected newborns or of hospital infections; the
denominator is the number of admissions, births, or
discharges of the unit (discharge and deaths). In this method
of surveillance, the concept of cumulative incidence of
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
infections assumes that there is an equivalent risk for
infection for each patient, thus not taking into consideration
the duration of exposure to important risk factors.
Cumulative incidence of infections
number of infected newborns or of hospital infections in all sites X 100
number of admissions/births/discharges
The data should be analyzed and assessed monthly. The
calculated rate can be used for assessment of endemic
patterns and for early detection of possible outbreaks. The
results should be distributed to the staff involved in healthcare
of newborns with the objective of involving all professionals
in the problem of hospital infections and in the carrying out
of control measures.
The National Nosocomial Infection Surveillance System
(NNISS) is an epidemiological surveillance system for
hospital infections with the use of protocols called
surveillance components. This method is widely used in
ICUs. It was developed in the United States during the
1970s55 and is based on nosocomial infection rates being
associated with risk factors such as average hospital stay in
units and number and duration of invasive procedures
(central catheters, artificial ventilators, and so on). Based
on these observations, the notion of incidence density rates
was introduced for the calculation of nosocomial infection
rates. The numerator of the formula of this calculation is the
number of hospital infections, and the denominator is the
factor of duration of exposure. Thus, the denominator for
incidence density is based on patient-day and device-day
(catheters-day and ventilators-day). The rates for
epidemiological surveillance provided by this methodology
are divided into rates of use of devices, of infections, and of
average length of stay (ALOS) of patients, stratified
according to weight at birth: less than 1,000 g; 1,000 to
1,500 g; 1,501 to 2,500 g; and greater than 2,500 g. These
rates should be calculated monthly for high-risk neonates
who fulfill the following criteria: birth weight less than
1,500 g; use of central catheter; use of ventilatory support;
use of antiinfectious therapy; and postoperative period (up
to 30 days after surgery). Next, we will present the formulas
for calculating some of the NNISS rates.
Device utilization rates
number of devices (central catheter; ventilator)-day X 100
number of patients-day
Global nosocomial infection rates
number of hospital infections in all sites X 1000
number of patients-day
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
Bloodstream infection rates
associated with central catheter
# of bloodstream infection rates associated with central catheter X 1000
number of catheters-day
Pneumonia rates associated with ventilator
number of pneumonias associated with ventilator X 1000
number of ventilators-day
Average length of stay (ALOS)
a+b+c
d+e
a = sum of the number of days of hospitalization for all
patients in the unit on the first day of the month
b = sum of the number of days of hospitalization for all
patients in the unit for the month (patients-day)
c = sum of the number of days of hospitalization in the unit
on the last day of the month
d = sum of the number of patients in the unit on the first day
of the month
e = sum of the number of patients admitted in the unit
during the month
Investigation and control of hospital infection outbreaks
in nurseries
Hospital infection outbreaks occur in cases of significant
increase of infections (above the upper endemic limit of the
neonatal unit). The increase in infection rates in specific
sites or by a specific microorganism calls for measures
aimed at identifying the agent, the reservoir, and the risk
factors for transmission of the infection. Moreover, the
occurrence of infections caused by unusual pathogens that
are associated with high morbidity and/or lethality rates in
newborns call for special concern with, and investigation of
the matter.
In cases of suspected outbreaks, all infection control
measures should be reviewed. Special attention should be
given to the washing of the hands of the staff between
handling of newborn infants, to the sterilization and
disinfecting routine procedures, to the preparation of
formulas, and to the asepsis techniques for invasive
procedures.
Jornal de Pediatria - Vol. 77, Supl.1 , 2001 S89
The origin of cases of outbreak due to unusual
microorganisms is probably on the nonobservance of
infection control measures, such as overcrowding,
understaffing, hygiene, and so on.
If only one microorganism is responsible for the outbreak,
infected or colonized patients, as well as the staff should be
located in a cohort. The cohort can be located in a separate
or marked area inside the neonatal unit with newborn
infants isolated inside incubators.56
The collection of cultures for identification of reservoirs
in staff or equipment is indicated only in cases in which
preliminary epidemiological investigation is suggestive of
association with the outbreak. One of the typical examples
is that of outbreaks caused by S. aureus resistant to oxacillin
and in which culture from the nasal mucosa indicates
colonization of the staff. The topic use of mupirocin to the
anterior nares is indicated. 57
Use of antimicrobials and hospital infection: the need
for rationalization and control
Antimicrobials can save lives in the treatment of infected
children; whereas in the case of newborns, there are
substantial risks, such as: superinfection and infection by
microorganisms resistant to toxicity and drugs. That is
because antimicrobials interfere in both the endogenous
and pathogenic microbiota.
The use of antibacterials is frequent in newborns,
especially in those admitted to ICUs. The reported data
indicates that the use of these drugs varies from 4.4% to
10.5% for all newborns, and from 42% to 60.4% for all
preterm newborns.20 At ICUs, at least 75% of all newborns
are administered antibacterials for at least 40 hours, with
rates of use as high as 92% for preterm newborns with less
than 1,500 g.58 In general, the frequent use of antibacterials
is justifiable by the risks and high lethality rates of bacterial
infections in newborns. However, it has not been
demonstrated that the prophylactic use of antibiotics prevents
nosocomial infections. Moreover, newborns whose normal
flora is still not established and who are treated with
antibiotics can develop colonization of microorganisms not
detected in normal children. It has been reported that these
microorganisms include those that are resistant to antibiotics.
These microorganisms were selected from numerous patients
on antibacterials and are part of the flora of the unit.20 In this
sense, bacterial invasions are generally resistant to
antibacterials used in the specific unit.
Multiresistance to antibacterial drugs has been identified
with frequency. In this sense, over 80% of Staphylococcus
epidermidis strains and at least 60% of Staphylococcus
aureus strains that cause nosocomial infections in neonatal
units are methicillin/oxacillin resistant; in other words,
resistant to beta-lactamic antibiotics (including penicillin,
cephalosporin, and carbapenem) and to a combination of
S90 Jornal de Pediatria - Vol. 77, Supl.1, 2001
drugs with beta-lactamases inhibitors. The appearance of
strains of enterococcus resistant to vancomycin has been
reported in ICUs.42 This could be a problem since these
bacteria are resistant to all available antibiotics and have the
potential of being reservoirs for glycopeptide-resistant genes
that can be transferred to other more virulent pathogens.
As to the gram-negative bacteria, studies have reported
that the appearance of resistance to antibacterials of Klebsiela
and Enterobacter strains has caused problems and
nosocomial outbreaks.28,30,31,37,38 The resistance, which
is mediated by plasmid, induces extended-spectrum beta-
lactamases (ESBLs) protection providing resistance to
penicillin, cephalosporin, and monobactam to both
microorganisms. This resistance can also be transferred to
other microorganisms and can develop during antimicrobial
therapy.59
Consequently, it is fundamental to rationalize the use of
antimicrobials during the neonatal period. In the choice of
antimicrobials, priority should be given to drugs that are
safer and present more successful in therapeutics or
prophylaxis; well-tolerated and that cause less adverse
effects; less toxic and cause less selective induction on the
endogenous microbiota of the patient; and more cost-
effective.
In addition, the understanding of the prevalence of
bacteria sensitivity to antimicrobials with epidemiological
surveillance at each hospital unit, as well as that of the
modifications in this sensitivity that occur with time are
fundamental for the designing of empirical recommendations
of antibacterial therapy and for a more rational use of
antimicrobials.
Prevention and control of nosocomial infections
Nosocomial infection prevention and control measures
are aimed at minimizing the exogenous and endogenous
transmission of pathogenic microorganisms. These measures
are directed to the pregnant woman, to the hospital
environment, to the hospital staff, and to the newborn him
or herself.
Pregnant and parturient woman
In order to understand the factors that determine the
prevention of maternally acquired neonatal bacterial
infection in the view of current knowledge, we should
review and discuss several aspects involved in this process:
premature labor, bacterial colonization and invasion in
pregnant women by potential neonatal infection agents,
premature and/or prolonged amniorrhexis in different
gestational ages, obstetric and perinatal risk factors for
early-onset neonatal bacterial infection, maternal antibiotic
therapy, intrapartum antibiotic prophylaxis, handling of
newborns presenting risks for infection, among others. In
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
this paper, we will limit ourselves to aspects of bacterial
infection prevention that do not have a maternal origin. For
more information, readers can consult the literature on the
matter.60-62
Hospital environment
In relation to hospital environment, some factors
associated with the acquisition of infections are physical
area, nurse:patients ratio, and equipment.35 In our setting,
with the aim of reducing the indices of nosocomial infection,
the Society of Pediatrics from São Paulo64 delivered to all
neonatal units of the state specific recommendations related
to the physical space required between incubators, to the
adequate number of sinks and to the ideal nurse:patients
ratio in high, medium, and low-risk units. The same
publication recommends that the nursery be located close to
the obstetric unit and count on internal divisions, with beds
for intermediary and intensive care. According to these
recommendations, the intermediary care unit should have
an area of 3.5 m2 for each bed and a 60 cm distance between
the cradles; for the Intensive Care Unit, these measures
should be of 5 m2 and 80 cm, respectively. The rooming-in
environments should have an area of 6 m2 for the mother
and the newborn, with, at the maximum, six rooms in each
unit. Concerning sinks, one sink is necessary to every five
patients in medium and high-risk nurseries.
Besides these routine procedures, the publication also
establishes measures related to the asepsis of equipment. It
is recommended that every material in direct contact with
the newborn’s skin or mucosa be decontaminated or sterilized
between its use with different patients.65 Materials such as
thermometers and stethoscopes should be of individual use
or cleaned with alcohol or iodophor every time it is used
with a different patient. Water may also be a source of
bacterial proliferation (examples are Pseudomonas spp and
Serratia spp); thus it is recommended that sterile liquids be
used in nebulizers and humidifiers, and that the liquid that
condenses in the ventilator circuit be thrown away, in order
to prevent it from returning to the nebulizer. Ventilators
should be cleaned externally with liquid soap and water,
and the circuits should be changed every 48 hours and
disinfected with glutaraldehyde at 2% (the nasal cannula
should also be disinfected using this solution). Similarly,
equipment used in neonatal resuscitation, such as balloons,
masks, and laryngoscopes should be cleaned every time
they are used, according to the hospital protocol. Cradles
and incubators should be washed with water and liquid soap
every day, and terminal cleaning should be performed every
7 days or after the bed is disoccupied.66 The floor, walls,
windows, and other surfaces should be cleaned every day
using methods that minimize the spread of dust, using
chlorinated and quaternary ammonium compounds. The
use of phenolic compounds is not indicated in neonatal units
due to their absorption by the skin and to the risk for
hyperbilirubinemia in newborns.65
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
Another concern in terms of measures for the prevention
of nosocomial infections is related to the presence of
visitors in the neonatal unit. The risks for transmission of
pathogens through family visits are probably small, although
some studies suggest that neonatal colonization and infection
do not increase with the presence of visitors. However,
visits to the Neonatal Intensive Care Unit should follow
some rules67: the visitor cannot have been recently exposed
to infectious or contagious diseases, such as chickenpox,
rubella, and measles; the visitor should not present fever or
acute respiratory, gastrointestinal, or cutaneous infections;
the visitor should not have contact with the other newborns
present in the unit and should not touch any equipment.
Another prevention measure is the limitation of number of
visitors and of duration of visits.
Hospital staff
The recommendations related to the hospital staff64
advocate an adequate number of personnel for the continuous
observation of the newborns, as well as a enough time to
wash the hands between the handling of patients. In the
medium-risk nursery, the presence of one nurse for every
ten patients and one nursing assistant for every four beds is
recommended. In the high-risk unit, one nurse and one
nursing assistant for every two beds is recommended.
Some routine procedures are recommended for the
prevention of nosocomial infection. Among them, washing
of the hands is the most effective measure, avoiding bacterial
transmission and propagation. The hands have a resident
flora, composed by low-virulence microorganisms, and a
transitory flora, with potentially pathogenic microorganisms;
the latter is especially important in the hospital environment.
Washing of the hands removes transitory flora
microorganisms and controls the growing of resident flora.
When entering the unit, the staff member should fasten long
hair, remove watch, rings, and bracelets, as well as wash
hands, forearms and nails for approximately 3 minutes.
After this, between the manipulation of one patient and
another, hands can be washed with water and soap for a
period of 15 seconds; this time is then enough to remove the
transitory flora. Washing hands with water and soap acts
effectively in the removal of microorganisms.68 The use of
a specific antiseptic agent will be based on the bacterial
prevalence at each unit. However, the use of antiseptic
agents with residual antibacterial activity is recommended
in neonatal units. The antiseptic agents most commonly
used are iodophors, iodine compounds combined with a
solubilizing agent (bactericidal activity), and chlorhexidine
(a colorless, odorless, and basic salt, which has a
bacteriostatic action when in low concentrations and a
bactericide action when in high concentrations). Iodophors
are more irritative to the skin of the hospital staff; this makes
the appearance of desquamation and dermatitis more
common and may provoke an increase in bacterial
colonization. This disadvantage makes the chlorhexidine
become the most used antiseptic agent in nurseries.
Jornal de Pediatria - Vol. 77, Supl.1 , 2001 S91
The wearing of aprons in neonatal units has given raise
to controversy. The routine use of aprons by the hospital
staff has not shown to be an important measure in the control
of nosocomial infections, since the transmission of
microorganisms usually occurs through the hands. Several
studies showed that the use of aprons does not alter the
bacterial colonization of the newborn or the rate of infection
in neonatal units.69,70 The use of aprons is indicated in the
performance of invasive procedures and in some situations
of contact isolation.71 Wearing gloves is indicated as part of
universal prevention measures whenever there is the
possibility of the professional getting in contact with the
patient’s blood and secretions.71
Still concerning the hospital staff, immunity for rubella
and hepatitis B should be investigated, and vaccination is
recommended whenever necessary. Annual immunization
against prevalent strains of the influenza virus is highly
recommended, because the neonates, especially preterms
or those with chronic pulmonary disease, are particularly
vulnerable to complications when they acquire infections;
vaccination of the staff presents a very good cost-benefit
ratio.72
Individuals presenting a clinical viral status or contagious
respiratory diseases, such as tuberculosis, should be
temporally kept away from the unit; any other potentially
contagious condition should be carefully evaluated.
Newborn
The basic measures for the prevention of nosocomial
infection in newborns include the colonization of the newborn
with nonpathogenic bacterial flora; the main procedures are
the prophylaxis for neonatal ophthalmia and care with the
newborn’s skin and umbilical stump.
The prevention of gonococcal ophthalmia is
recommended, and the agents used for this are silver nitrate
at 1%, erythromycin ointment at 0.5%, and tetracycline
ointment at 1%.65 The use of erythromycin and tetracycline-
based preparations prevents chemical conjunctivitis, which
commonly occurs as a result of the instillation of silver
nitrate. However, these preparations are not superior to
others in terms of prophylaxis for ophthalmia caused by C.
trachomatis.73
Simple techniques with the skin and the umbilical stump
are able to prevent infection.65 After the stabilization of the
newborn’s temperature, the first bath should be carried out
with warm water and individual neutral soap. This procedure
is recommended during the whole stay of the newborn at the
unit. Several substances, such as bacitracin, the triple stain,
and sulfadiazine are used in American nurseries for the care
of the umbilical stump. However, none of these substances
showed great advantages in terms of limitation of pathogenic
bacterial colonization. In our setting, Fogliano et al.74
carried out a study comparing four different antiseptic
solutions used in the umbilical stump care of term newborns:
S92 Jornal de Pediatria - Vol. 77, Supl.1, 2001
ethyl alcohol at 70%; iodinated alcohol at 2%; povidone
iodine; and alcoholic chlorhexidine. These authors observed
a decrease in bacterial colonization (mainly by S. aureus)
with the use of chlorhexidine. However, the use of antiseptic
agents both in the umbilical stump care and in the newborn’s
daily bath has been restricted to situations in which high
rates of colonization are associated with a high frequency of
staphylococcal infection at the unit. In this case, the
application of chlorhexidine is preferred, since iodophors
may impair the thyroidal function when absorbed by the
newborn’s skin and hexachlorophene may lead to
neurotoxicity in the neonatal period.
Besides the care with the newborn’s skin and umbilical
stump, attention should be given to the breast milk and the
milk-based formula. When a sick newborn is not able to be
breastfed, the breast milk should be carefully stored in order
to prevent bacterial contamination. The mother’s hands
should be washed with antiseptic agents, and the milk
should be collected and stored in sterilized feeding-bottles.
When a breast pump is used to collect the milk, all
components that get in contact with the breast milk should
be washed with water and soap after each collection; they
should also be sterilized every day.75 Breast milk should be
stored in the refrigerator for 24 to 48 hours or frozen at -20
ºC for a maximum period of 6 months.65 When milk-based
formulas are used, the utensils involved in its preparation
should be sterilized, and the water should be boiled during
5 minutes. The formula should be stored in individual
feeding-bottles and refrigerated for a maximum period of
24 hours; after being taken out of the refrigerator, the
formula should be consumed within 4 hours. In cases of
milk administration through probes, these should be changed
every 24 hours, and the syringe, every 4 hours. Routine
microbiological monitoring is not recommended neither for
breast milk nor for milk-based formulas, except for cases in
which the newborns present gastrointestinal intolerance
and sepsis, among other pathologies.76 It is important to
emphasize that one of the main prevention measures for
nosocomial infection at neonatal units is the incentive to
rooming-in environments and to breastfeeding.
On the other hand, the use of central venous catheters in
critically ill newborns is a potential source of nosocomial
infection. One of the factors associated with the increase in
catheter-related infections in the blood flow is its insertion
method. The risk for sepsis with central venous catheters
inserted surgically is three times higher in the neonatal
period when compared to peripherally inserted catheters. 77
Based on these data, percutaneous catheters have been
more often used than surgical catheters. The main prevention
measures for infections related central venous catheters are
the use of maximum barrier precautions, such as the use of
surgical caps, masks, aprons, gloves, sterilized areas and
materials, skin disinfection with alcoholic chlorhexidine,
and a team specialized in the insertion and maintenance of
the catheter.78,79
Neonatal nosocomial infections - Mussi-Pinhata MM et alii
Recent proposals for the prevention of nosocomial
infection in preterm newborns in Intensive Care Units
Besides basic care, some measures have been proposed
to reduce the risk for nosocomial infection in preterm
newborns, mainly those presenting low weight and
gestational age. In general, the usefulness of these measures
has not been proved yet, and they are usually expensive.
Some examples are mentioned below.
Emollient lotions
Some studies 80,81 suggest that the prophylactic
application of emollient lotions, such as Aquaphor TM and
EucerinTM, in preterm newborns may protect the stratum
corneum, increasing the epidermal barrier function and,
consequently, contributing to the improvement of skin
integrity and decreasing the risk for nosocomial infection.
However, these results were observed in studies with a
small number of patients, and the groups were heterogeneous.
Campbell et al.82 showed that the use of emollients in
preterm newborns increased the incidence of systemic
candidiasis. Therefore, the routine prophylactic indication
of emollient lotions for the prevention of nosocomial
infections still seems to be controversial, and further
controlled studies with a higher number of patients are
necessary in order to determine the impact of this strategy
in the prevention of the neonatal nosocomial infections.
Use of intravenous immunoglobulin
Considering that preterm newborns, mainly those with
a gestational age below 32 weeks, receive low concentrations
of maternal immunoglobulin G, and that the administration
of IgG may improve the opsonic activity, activate
complement, and promote citotoxicity, the administration
of intravenous immunoglobulin has been assessed for the
prevention of nosocomial infections. In a recent systematic
review of 15 clinical controlled studies with placebo in
preterm newborns (<37 weeks), Ohlsson & Lacy83 verified
a significant reduction of one or more episodes of severe
infection during a 8-day or longer hospitalization. This
administration resulted in a reduction of 3-4% in the number
of episodes of severe infection and was not associated with
short-term side effects. There was no reduction in incidence
of other diseases, hospitalization time, or mortality. The
decision about the prophylactic use of immunoglobulins
will depend on the cost, and it is important to observe that
24 to 32 children have to be treated so that nosocomial
infection is prevented in one child.
Low-dose vancomycin infusion
Considering that late-onset sepsis occurs in at least 50%
of the <1000 g newborns, and that coagulase-negative
staphylococci are the most frequent agents, several studies
have assessed the efficacy of low doses of vancomycin
administrated through continuous infusion, in parenteral
Neonatal nosocomial infections - Mussi-Pinhata MM et alii Jornal de Pediatria - Vol. 77, Supl.1 , 2001 S93

Table 4 - Isolation techniques and precaution measures used at the neonatal unit

Type of isolation / Technique

Precaution measure

Total isolation Private room, use of apron, mask, and gloves

Respiratory isolation Private room, use of mask for contact with newborns
Contact isolation (fluids, dejecta, Use of mask, apron, and gloves
and infectious material) for contact with newborns
Enteric precautions, Use of apron and gloves
and precautions with for contact with body fluids
drainage/secretions and blood
Standard precautions Use of apron, gloves, and eye protection for
contact with blood and secretions

Adapted from Feferbaum R, Rugolo LMSS. Rev Paul Pediatria 1996;14:194.

solutions, or through intermittent intravenous infusion.
These studies were recently revised by the Cochrane
Neonatal Review Group, which concluded that the use of
vancomycin reduces the incidence of nosocomial sepsis
caused by Staphylococcus. However, in view of the risk for
developing resistant organisms and the few clinical benefits
shown, these authors suggest that the routine use of
vancomycin should not be practiced.84
Isolation measures in the neonatal unit
The routine isolation strategies used in neonatal units
are based on the CDC and the American Academy of
Pediatrics recommendations.65 This isolation system is
extremely complex, which makes its implementation in our
setting more difficult, due to the lack of medical and nursing
personnel. The recommendations of Feferbaum & Rugolo,85
presented in Tables 4 and 5, seem to adapt better to our
practical needs.
In conclusion, we would like to say that even considering
a great number of measures aimed at controlling and
preventing nosocomial infections, at the hospital
environment, at the hospital staff and the newborn, and
associated with the frequent overcrowding of neonatal units
and with the clinical severity of the hospitalized patients,
often any act of carelessness in the practice of these measures
may cause increased rates of nosocomial infection.
Therefore, only with an active, systematic, and continuous
process of collection, analysis, and assessment of data, as in
epidemiological surveillance, we will be able to detect
failures and implement adequate intervention strategies.

Table 5 - Types of isolation and precautions against neonatal infections

Type of isolation Neonatal infection

Total Chickenpox
Contact Herpes simplex, rubella, and multiresistant bacteria
Respiratory Pertussis, respiratory syncytial virus, and influenza
Enteric precaution Hepatitis A, cytomegalovirus, diarrheal disease,
and necrotizing enterocolitis
Standard precaution Hepatitis B, HIV, syphilis, sepsis, meningitis,
pneumonia, skin infection

Feferbaum R, Rugolo LMSS. Rev Paul Pediatria 1996;14:194.

S94 Jornal de Pediatria - Vol. 77, Supl.1, 2001
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