الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
HAIs are deemed to be the most frequent adverse event threatening patients’ safety worldwide. They are a leading cause of morbidity and mortality in NICU. Critically ill neonates at NICU are at an increased risk of nosocomial infection due to immunological immaturity and impaired defense mechanisms as well as the abundance of invasive diagnostic and therapeutic procedures. Pneumonia is the second most common HAI in the NICUs following BSI and is usually associated with mechanical ventilation.
Ventilator associated pneumonia (VAP) is a subtype of hospital acquired pneumonia and it is defined as nosocomial pneumonia in mechanically ventilated patients that develops after 48 hours from initiation of mechanical ventilation, it includes also pneumonia diagnosed within 48 hours of cessation of mechanical ventilation. Ventilator associated pneumonia represents a significant problem in both developed and developing countries. There is a wide range of VAP incidence density rates in neonates depending mainly on the country income level. It ranges from 1/ 1000 to 83/ 1000 ventilator-days.
Prevention of VAP is one of the major priorities in NICUs and it relies on the infection prevention precautions as well as specific measures recommended for VAP prevention (VAP prevention bundle). VAP prevention bundle includes hand hygiene of health care workers, preferably with alcohol-based hand rub; gloves and gown use for endotracheal tube manipulation; backrest elevation of 15° to 30°; oral care with chlorhexidine; stress ulcer prophylaxis; cuff pressure maintenance; use of orogastric tubes; avoidance of gastric over distension; and elimination of non-essential tracheal suction.
The current study aimed to study the occurrence of VAP among preterm neonates admitted to NICUs in El Shatby University Hospital for Children and El Anfoshy Pediatric hospital in Alexandria. This work specifically aimed to calculate the incidence density rate of VAP at the studied NICUs during the duration of field work, determine the different risk factors among neonates that may predispose to VAP, and to assess some of infection control standard precautions and specific infection control measures for prevention of VAP adopted in the studied NICUs compared to CDC and the Egyptian national guidelines of infection prevention and control.
All neonates that were preterm mechanically ventilated for at least 48 hours and were not diagnosed with congenital pneumonia on admission at the NICUs of El Shatby University Hospital for Children and El Anfoshy Pediatric hospital and their medical records were included in the study. The neonates were followed up during the duration of mechanical ventilation till 48 hrs. after weaning for determining the occurrence and onset of VAP. Medical records of all studied neonates were reviewed to collect data about the type of delivery, place of delivery, cause of admission as well as cause of starting mechanical ventilation and clinical, laboratory and radiological investigations’ results. Then they were followed up to diagnose the occurrence of clinically diagnosed VAP based on CDC criteria for diagnosis.
The study included a total number of 55 neonates, 32 at El Shatby NICU, 16 of them (50%) developed VAP and 23 neonates at El Anfoshy NICU, 7 of them (30.4%) developed VAP. The results of this study were presented in two main parts. They are as follows:
Part A: Study of Ventilator Associated Pneumonia (VAP) in the NICUs of El Shatby University hospital for Children and El Anfoshy Pediatric hospital. It includes the following sections:
I. Description of the studied neonates:
Slightly less than three quarters (72.7%) of the studied neonates were moderate to late preterm. The mean gestational age of neonates at El Shatby NICU was 32.86 ± 2.5 weeks while at El Anfoshy NICU it was 33.55 ± 3.34 weeks, (P= 0.39). In El Shatby NICU 59.5% of neonates were males compared to 72.2% of neonates in El Anfoshy NICU (P = 0.698). Cesarean section was the type of delivery for 70.3% of studied neonates in El Shatby NICU compared to 88.9% of neonates in El Anfoshy NICU, (P = 0.182).
The mean birth weight of studied neonates at El Shatby NICU was 1.5 ± 0.59 kg compared to 1.94 ± 0.69 kg for neonates in El Anfoshy NICU (P= 0.017). All studied neonates (100%) at El Shatby NICU were admitted at birth compared to 33.3% of those at El Anfoshy NICU, (P = < 0.001).
II. Admission of studied neonates:
The majority of the studied neonates at El Shatby NICU (86.4%) were admitted due to respiratory distress syndrome grades II and III-IV while in El Anfoshy NICU more than half of cases (66.7%) were admitted due to respiratory distress syndrome grade II (P = 0.001).
All studied neonates in El Anfoshy NICU were ventilated because of significant apnea on non-invasive ways of ventilation compared to 51.4% of neonates in El Shatby NICU, (P = < 0.001). The mean duration of stay at NICU for VAP group was 16.69 ± 6.37 days compared to 12.37 ± 10.45 days for those who did not develop (P= 0.005). Also, the mean duration of stay on mechanical ventilation for VAP group was significantly longer than that for non VAP group (10.87 ± 4.54 days, 4.59 ± 2 days respectively, P = < 0.001).
III. Occurrence of VAP:
The calculated incidence density rate (IDR) of VAP at both units was 75.9 VAP cases / 1000 ventilator days. IDR of VAP at El Shatby University Hospital for Children was 78.8 VAP cases / 1000 ventilator days while it was 70 VAP cases / 1000 ventilator days at El Anfoshy Pediatric hospital.
IV. Risk factors for development of VAP:
Slightly more than two fifths (43.2%) of the studied neonates who were admitted to El Shatby NICU developed VAP compared to 38.9% of the neonates who were admitted to El Anfoshy NICU, (P = 0.759).
All cases that were extremely preterm developed VAP, while 50% of very preterm and 35% of moderate to late preterm neonates developed VAP, (P = 0.065).
There is a significant association between positioning of the neonates in the incubators during mechanical ventilation and development of VAP as 75% of VAP cases were placed in supine position compared to 36.2% who were positioned with elevation of