How are viral respiratory infections detected and prevented in the neonatal intensive care unit?

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Viral respiratory infections (VRIs) are an important cause of morbidity and mortality in critically ill infants in the neonatal intensive care unit (NICU). The spread of respiratory pathogens within the NICU is influenced by a variety of factors, including the structural design of the ward and human behavior. Because infants are not candidates for respiratory virus vaccination, prevention of transmission of VRIs within the NICU is critical. The United States Society of Healthcare Epidemiology (SHEA) has published a white paper on a practical approach to prophylaxis of VRIs in the NICU, which provides guidance on common problems in the detection and prevention of VRIs in the NICU.

When should I be tested for VRIs?

➤ According to the clinical signs and suspicion index of the individual patient

• VRI testing is performed in infants who exhibit signs that may be consistent with infection, including apnea, bradycardia, fever, and poor feeding, as well as respiratory symptoms including congestion, cough, tachypnea, and respiratory failure.

➤ After contact with a caregiver or visitor

• Isolation or testing of asymptomatic infants exposed to respiratory viruses from the source caregiver or visitor is generally not recommended, but oseltamivir prophylaxis may be considered in infants after known influenza exposure.

➤ Outbreak setting or possible nosocomial transmission (patient or health care worker [HCP])

• Active screening of asymptomatic infants may be considered to understand the extent of the outbreak and monitor the impact of infection control interventions.

➤ Record resolution of infection

• In general, HCP should continue to take precautions for patients at least as long as they are ill. In patients without respiratory problems and ongoing exposure issues, HCP may consider a strategy of repeat molecular testing and ongoing isolation until the test result is negative.

如何预防 NICU 内医疗保健相关的VRI(HA-VRI)?

A bundled approach to the prevention of HA-VRI in the NICU is recommended, including hand hygiene, visitor screening, staff sick leave and vaccination policies, appropriate isolation precautions and personal protective equipment (PPE), and environmental cleaning.

➤ Hand hygiene

• The NICU should be actively integrated into an existing hand hygiene program. In addition to observations and immediate feedback to staff, indicators of hand hygiene adherence should be provided to units and hospitals. Caregiver and family involvement and education are important components of the prevention of healthcare-associated infections (HAIs).

➤ Caregiver and visitor screening

• Hospitals should implement caregiver and visitor screening measures that are sustainable within the resources available to their particular institution. When a caregiver is sick, NICU leaders should clearly communicate the hospital's infection prevention and control guidelines for when the caregiver can return to the ward.

➤ Medical staff are sick

• Robust and non-punitive sick leave policies can help discourage health care workers from coming to work sick. When an increase in transmission within the unit and/or within the community is noted, an annual review of the disease course should be considered.

➤ Chemoprophylaxis after vaccination and exposure

• Influenza vaccination is strongly recommended for HCPs and caregivers and adherence to the agency's seasonal vaccine policy to prevent transmission of viral respiratory pathogens to infants younger than 6 months of age who are not eligible for influenza and other vaccines to prevent VRI infection.

• In the context of outbreak control, oseltamivir is recommended for influenza antiviral chemoprophylaxis in all asymptomatic patients and post-risk assessment immunosusceptible HCPs within the unit.

• Palivizumab should not be used as part of the management of respiratory syncytial virus (RSV) outbreaks to prevent further transmission within the unit.

➤ Quarantine measures and personal protective equipment (PPE)

• When a patient first develops symptoms, appropriate isolation precautions should be applied, with or without testing.
• All patients on isolation precautions should wear appropriate PPE and put it on and take off in the appropriate order.
• Clear documentation of appropriate transmission-based precautions should be placed immediately in the patient's medical record, and clear signage should be placed at the entrance to the patient's room or bed.
• If resources permit, units may consider conducting audits of donning and taking off PPE and appropriate isolation procedures, and provide immediate feedback and unit metrics on appropriate isolation precautions for comparison.

➤ Clean environment

• All shared equipment should be properly cleaned and disinfected after use and stored in designated clean utility areas.
• Clean and disinfect high-touch surfaces at least once a day using appropriate surface disinfectants that are registered with national regulatory agencies and comply with hospital regulations.
• Inpatient wards should be kept tidy and families should be provided with support and education on their important role in preventing HAIs.
• Ideally, families should keep bedside tables and windowsills clean. The goal should be to keep personal belongings to a minimum, no more than a week's supply of items, and to keep personal belongings in available drawers.
• Some NICUs have a fixed routine of daily cleaning (e.g., every 14 days) to ensure continuous cleaning and thorough disinfection.

What is the optimal isolation distance between patients if they are not isolated in a single room?

Given the physical layout of the NICU, patient census, and staffing levels, infants in the NICU who require respiratory isolation should be allocated as much space as possible.

• The absolute minimum distance between babies should be one meter (3 feet).

• The distance is not affected by the type of bed (crib, infant radiant warmer or isolation bed).

What do you think of the NICU VRIs 患者应该隔离多久?

If respiratory symptoms develop at the time of VRI diagnosis, precautions should be continued at least for the duration of the illness.

• In the setting of ongoing exposure and no respiratory symptoms, repeat molecular testing and other precautions may be considered for HCP until repeat testing is negative.

• If clinical symptoms are attributable to a noninfectious cause and the respiratory virus test is negative, prophylaxis can be discontinued.

• The length of isolation after testing for asymptomatic respiratory viral pathogens is unknown. Testing of asymptomatic infants outside of the outbreak is discouraged.

参考来源：Thampi N, Guzman-Cottrill J, et al. SHEA NICU white paper series: Practical approaches for the prevention of viral respiratory infections. Infect Control Hosp Epidemiol. 2024 Mar; 45(3):267-276. doi: 10.1017/ice.2023.120. Epub 2023 Oct 25. PMID: 37877172.