Article infectious diseases

Infection Control Practices in the NICU:

What is Evidence-based?
Judith A. Guzman-
Cottrill, DO*
Author Disclosure
Dr Guzman-Cottrill
has disclosed that she
is a member of the
speakers’ bureau for
Sanofi Pasteur. This
commentary does not
contain a discussion
of an unapproved/
investigative use of a
commercial
product/device.
Abstract
Nosocomial infections cause significant morbidity and mortality in neonatal intensive
care unit (NICU) patients. Neonates, particularly those who are preterm and low
birthweight, are at higher risk of acquiring infections compared with term and older
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
have been adopted as “standard of care,” but other practices vary substantially from
one unit to another. This review examines several infection prevention strategies used
in the NICU and reviews the literature related to such practices. Evidence-based
recommendations are made when supportive scientific evidence is available for this
specific patient population.
Objectives After completing this article, readers should be able to:
1. Review evidence-based recommendations related to hand hygiene practices in the
NICU.
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”
without supportive evidence. Other infection strategies
have sound scientific support in the adult literature but
have not been well-studied in neonates. Comprehensive
infection prevention staff education can significantly de-
crease rates of nosocomial infection in the NICU. After
implementing best practice education, sharing infection
rates, and implementing a specialty team for venous and
arterial catheter care, one center noted a 29% reduction
in nosocomial infections. (3) A good understanding of
basic infection prevention strategies is the most impor-
tant step toward decreasing nosocomial infections in the
NICU. Techniques for preventing nosocomial infection
by altering the newborn’s immune function have been
discussed previously in this journal. (4) This article con-
centrates on infection control practices in the NICU.
Hand Hygiene Practices
The most common mode of pathogen transmission from
one individual to another is via contact and can occur
directly or indirectly. (1) Direct contact transmission is
defined as the transfer of microorganisms from one in-
fected person to another person without a contaminated
intermediate object or person. An example of direct
contact transmission is the physician who develops a
staphylococcal abscess on a finger after direct, ungloved
contact with a patient’s staphylococcal wound. Indirect
contact transmission occurs when an infectious agent is
transferred through a contaminated intermediate person
or item. Indirect contact transmission in the NICU
setting is well-documented in the literature. Examples
include thermometers colonized with Enterobacter cloa-
cae; (5) Stenotrophomonas maltophilia outbreak associ-
ated with tap water; (6) and Pseudomonas aeruginosa
outbreaks related to contaminated feeding bottles, (7)
hand lotion, (8) and artificial fingernails (9)(10) Con-
taminated hands of health-care workers (HCWs) trans-
mitting organisms if adequate hand hygiene is not per-
formed has been documented in bacterial, candidal, and
respiratory syncytial virus outbreaks. (10)(11)(12)
Meticulous, routine hand hygiene effectively inter-
rupts both direct and indirect contact transmission.
Thus, hand hygiene is the single most important inter-
vention to prevent nosocomial infection. Despite this
well-known fact, HCWs consistently demonstrate sub-
optimal hand hygiene compliance, with an overall aver-
age 40% compliance rate. (13) For many years, hand
hygiene in the NICU has been identified as an important
infection prevention strategy, with a surgical scrub on
unit entry considered standard of care. The American
Academy of Pediatrics and American College of Obste-
e420 NeoReviews Vol.11 No.8 August 2010
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tricians and Gynecologists Guidelines for Perinatal Care
recommend that “personnel should scrub their hands
and arms to a point above the elbow with an antiseptic
soap. Disposable sponges are as effective as brushes. . . .”
(14) However, no scientific evidence indicates that a
routine surgical scrub on unit entry decreases nosocomial
infections in the NICU. Moreover, infection preven-
tion guidelines for other highly immunocompromised
groups, such as bone marrow transplant recipients, (15)
do not recommend surgical scrubbing prior to unit en-
try. Instead, efforts should focus on routine, meticulous
hand hygiene before and after every patient contact.
Sinks and alcohol-based hand hygiene product dispens-
ers should be numerous and conveniently located
throughout the unit for easy HCW access. Fingernails
should be natural, trimmed short, and free of artificial
nails or wraps; previous P aeruginosa outbreak investiga-
tions have demonstrated significantly increased transmis-
sion risk from HCWs who have either long or artificial
fingernails. (9)(10)
Many NICUs recommend that all jewelry (eg, rings,
bracelets, wrist watches) be removed distal to the elbows
because multiple studies have proven that ring-wearing
increases the bacterial colonization of hands. (16)(17)(18)
One study found a high risk of colonization regardless
of ring type (including plain, flat wedding bands). (17)
Fagerenes and associates (18) attempted to determine
the impact of finger rings on transmission of bacteria.
They found the prevalence of gram-negative organism
contamination was higher on the hands of those wearing
rings, but they were unable to demonstrate an increased
risk of direct contact transmission in their study model,
which was not specific to the NICU setting.
Personal Protective Equipment and Universal
Gloving
Personal protective equipment (PPE) refers to the vari-
ous barriers used alone or in combination to protect the
HCW from contact with infectious microorganisms.
PPE includes gloves, isolation gowns, masks, goggles,
and face shields. Precautions to prevent transmission of
infectious pathogens include standard, contact, droplet,
or airborne precautions (Table). In some situations, a
combination of precaution categories is required (eg,
contact plus droplet precautions for adenovirus bronchi-
olitis). (19)
Standard precautions should be followed with every
single patient encounter; HCWs should assume that all
patients are potentially infected or colonized with patho-
gens that may be transmitted in the health-care setting.
Thus, the HCW should wear the appropriate PPE to
 infectious diseases infection control

Table. Transmission-based Precautions

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

prevent potential occupational exposures. PPE recom-
mendations may differ based on the anticipated extent of
exposure (eg, wearing gloves while changing a wound
dressing, regardless of culture results) and the potential
(or known) pathogens with which the patient is colo-
nized or infected (eg, wearing a mask when entering the
room of a coughing infant who has possible pertussis).
When the etiologic agent of an infant’s infection is un-
known, HCWs should choose PPE based on the differ-
ential diagnosis of possible pathogens, until diagnostic
test results are available.
Some NICUs have adopted a “universal gloving pol-
icy” for all patient contact, with the presumed rationale
that the gloves prevent transmission of pathogens from
HCW hands to the infant. No strong scientific evidence
routinely supports this practice; in fact, one study found
that universal gloving may lead to diminished hand hy-
giene compliance in between glove use. (20) HCWs may
be misled to think that hand hygiene is not required if a
universal gloving policy is followed. Because hands may
become contaminated during glove manipulation, hand
hygiene always is required after glove removal. (13)
One NICU reported a significant decrease in late-
onset infection in very low-birthweight infants after im-
plementing a universal alcohol hand rub and glove com-
bination regimen. (21) This protocol included: 1) hand
washing up to the elbows on unit entry; 2) hand hygiene
with alcohol-based rub; 3) donning disposable, clean
latex gloves after handrubbing; 4) application of alcohol-
based rub onto the gloves before touching an infant;
5) reapplication of alcohol-based rub onto gloves after
touching surrounding environment; 6) removal of gloves
after patient contact; and 7) hand hygiene with alcohol-
based rub after glove removal. In addition, the hospital’s
infection control program provided educational work-
shops and feedback on a monthly basis. This interven-
tion led to an impressive 2.8-fold reduction in the inci-
dence of late-onset infection. Unfortunately, this was not
a randomized, controlled trial; instead, the authors used
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
achieved by implementing the infection prevention edu-
cation campaign with the meticulous hand hygiene pro-
tocol (without glove use). In addition, the authors did
not comment about the effect of repeated application
of an alcohol-based agent on the permeability of latex
gloves. Certain petroleum-based creams or hand lotions
may affect the integrity of latex gloves. (13) Before
recommending routine, repeated application of alcohol-
based products directly onto disposable gloves, it should
be established that the gloves can continue to protect the
HCW from exposure to infectious pathogens.
With the exception of sterile procedures, disposable
gloves should be used as a means to protect the HCW.
Gloves should be used to prevent contamination of
HCW hands when: 1) anticipating direct contact with
mucous membranes, blood or body fluids, or nonintact
skin; 2) having direct contact with infants who are in-
fected or colonized with pathogens transmitted by con-
tact route; or 3) touching visibly soiled or potentially
contaminated surfaces or equipment. (1) Rather than a
universal gloving policy, HCWs should follow these
guidelines in conjunction with routine hand hygiene
before and after each patient contact.
Antisepsis for Central Catheter Insertion
Extensive evidence-based guidelines exist for the preven-
tion of intravascular catheter-associated infections in the
non-neonatal population. Hand hygiene, aseptic tech-
nique, maximal sterile barrier precautions, standardiza-
tion of catheter insertion kits, and chlorhexidine glu-
conate (CHG)-based products for skin antisepsis have
become standard of care when inserting a central venous
catheter in adults and children. (22) Studies in adults
have proven that skin antisepsis with CHG is superior to
povodine-iodine (PI) in decreasing intravascular catheter-
associated infection. (23) To date, no randomized trial
has demonstrated that CHG is more effective that PI in
preventing CLABSIs in neonates. In addition, no CHG-
containing skin preparation has been approved by the
United States Food and Drug Administration for use in
neonates, and no standard recommendation exists about
its use in this age group. The National Association of
Neonatal Nurses Peripherally Inserted Central Catheters
Guideline for Practice, 2nd edition, recommends to
“prep the insertion site and surrounding skin with chlo-
rhexidine gluconate (CHG) or povidone iodine (PI) per
facility protocol.” (24)
CHG use in neonates may be associated with contact
dermatitis, including severe skin blisters and burns. This
risk was demonstrated in a 2001 randomized trial com-
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paring a 10% PI skin scrub to a 70% alcohol scrub
followed by placement of a CHG-impregnated dressing
for preventing catheter-associated infections. (25) Dur-
ing the first 15 months of the study, several extremely
low-birthweight neonates developed severe contact der-
matitis under the CHG dressing. The mean birthweight
was 720 g (range, 560 to 880 g) and mean gestational
age of affected neonates was 24.5 weeks (range, 22.5 to
26.5 weeks). During the entire study period, 15 of 98
neonates (15%) who weighed less than 1,000 g and 4 of
237 neonates (1.5%) who weighed 1,000 g or more and
received the CHG dressing developed related contact
dermatitis. It must be emphasized that this significant
finding was associated with CHG-impregnated foam,
which allows for continuous release of CHG onto the
underlying skin. Such a severe degree of dermatitis may
not be associated with the transient use of CGH for skin
antisepsis before central catheter insertion.
A recent pilot study reviewed the effectiveness and
tolerability of 2% CHG versus 10% PI skin preparation
for 48 neonates during insertion of peripherally inserted
central catheters. (26) Neonates who were younger than
7 days of age or who weighed less than 1,500 g were
excluded. The authors found no significant difference in
dermatitis in the CHG group compared with the PI
group. They also found no statistically significant differ-
ence in catheter tip colonization or bloodstream infec-
tions, although the study likely was not large enough to
detect such benefit. Larger randomized trials are needed
in this special population to determine the best skin
antisepsis for the various birthweight categories.
Health-care Worker Vaccination
Routine immunization of HCWs is a critical component
of patient safety in the NICU. Nosocomial outbreaks of
vaccine-preventable disease have been documented ex-
tensively in the literature. Influenza virus is an easily
transmissible pathogen known to be associated with
higher morbidity and mortality in the very young popu-
lation. In addition, HCWs may shed (and transmit) virus
for 1 to 2 days before the onset of symptoms. A level III
NICU experienced a severe influenza A virus outbreak in
1998 (27) in which 19 of 54 infants (35%) in the unit
during the 18-day long outbreak became infected, in-
cluding one fatal case of a 27-week gestation twin who
became ill at 7 days of age.
An epidemiologic outbreak investigation revealed
that of 86 NICU staff who responded to the question-
naire, only 13 (15%) had been immunized against influ-
enza that season. The medical staff had a higher vaccina-
tion rate (67%) compared with nursing staff (9%). In

addition, although 14 HCWs admitted to having an
influenzalike illness during the outbreak period, only
four reported taking time off of work. Similarly low
influenza immunization rates among HCWs were re-
ported (45% of physicians and 5% of nurses) from an-
other outbreak investigation in a 20-bed NICU where
four infants became ill. (28) After this outbreak, 100% of
NICU staff was immunized against influenza within 2
months.
Policies mandating seasonal influenza immunization
of HCWs have been implemented by several large med-
ical centers in the United States as a condition for em-
ployment, (29) resulting in vaccination rates as high as
98.4%. (30) In 2009, the New York State Health Depart-
ment mandated influenza vaccination for HCWs as a
component of their 2009 H1N1 pandemic prepared-
ness. (31) In institutions where immunization is not
mandatory, NICU leadership (both physicians and nurs-
ing representatives) should implement an annual sea-
sonal influenza employee immunization campaign. Rou-
tine HCW influenza immunization should be regarded
as standard practice for the protection of vulnerable
patients, fellow HCWs, and HCW families and to de-
crease the risk of occupational exposure to influenza
virus.
In the 1980s, Bordetella pertussis re-emerged as a
significant infectious disease, in part due to waning im-
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
this highly contagious pathogen from HCW to neonate
has been described, including a 2003 outbreak in a
neonatal intermediate care nursery. (32) A 26-week ges-
tation infant who had been hospitalized since birth
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-
break period. Infection control measures included active
screening, testing, and treatment of suspect cases; HCW
furlough; and antibiotic prophylaxis to 72 infants and
72 HCWs. A 29-year-old pregnant resident physician
who had cared for the index patient but declined post-
exposure prophylaxis developed pertussis 7 days after her
first patient encounter. This example illustrates the sub-
stantial financial, clinical, and administrative impact of a
pertussis outbreak.
In 2005, a tetanus, diphtheria, and acellular pertussis
vaccine was licensed in the United States. This vaccine is
recommended routinely for adults who have contact
with infants younger than 12 months of age, including
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infectious diseases infection control
HCWs who may transmit pertussis to infants in the
hospital. Persons who have pertussis are contagious be-
fore developing the classic paroxysmal cough. In fact, the
period of highest infectivity begins during the catarrhal
stage of illness, when symptoms are similar to the com-
mon cold (19) (and HCWs often continue to work
despite mild upper respiratory tract illness). Routine
vaccination of NICU staff may be effective in decreasing
the risk of nosocomial pertussis. In addition, education
about pertussis vaccination should be provided to NICU
parents and other close contacts of these vulnerable
patients (eg, older siblings, extended family, childcare
providers).
Summary
Neonates in the NICU are at high risk of nosocomial
infections. The risk of infection and the associated com-
plications increase with the degree of prematurity and
low birthweight. NICU staff should regard nosocomial
infections as preventable and unacceptable, maintaining
a “zero tolerance unit culture.” Basic infection control
practices, such as excellent hand hygiene compliance,
appropriate use of PPE, and routine HCW vaccination,
can decrease the risk of nosocomial infection in this
patient population. Staff education and continued rein-
forcement of these strategies must be a part of every
NICU’s infection prevention and control plan.
American Board of Pediatrics Neonatal-Perinatal
Medicine Content Specification
• Know the effective techniques for control
of nosocomial infection in the nursery,
neonatal intensive care unit, and
obstetrical unit.
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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.

NeoReviews Vol.11 No.8 August 2010 e425

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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

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/11/8/e419

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