Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. The Pediatric Infectious Disease Journal •  Volume 35, Number 4, April 2016 www.pidj.com | 401 ORIGINAL STUDIES Aim: Late onset sepsis (LOS) and central-line associated blood stream infection (CLA-BSI) contribute toward the mortality and morbidity in pre- maturely born infants. The aim of this study is to investigate the effects of hospital-wide and unit-based interventions on LOS and CLA-BSI in infants born at <32 weeks gestation. Methods: Intensive care, high dependency days and catheter days were obtained from the unit database and blood culture results from a microbiol- ogy laboratory database. Poisson regression was used to evaluate the effects of interventions on LOS and CLA-BSI. Results: Quarterly rates of LOS reduced from 26.1 to 2.9 per 1000 intensive care, high dependency days and CLA-BSI from 31.6 to 4.3 per 1000 catheter days between 2007 and 2012. Appointment of a hospital specialist vascular device nurse, a change in the mode of administration of vancomycin, stand- ardization of the hospital skin and hub disinfection policy and the introduc- tion of a venous infusion phlebitis scoring system were associated with a reduction of LOS to 55% (95% confidence interval: 40–74%) and CLA- BSI 45% (95% confidence interval: 33–61%) of pre-intervention levels. The standardization of the neonatal unit policy for skin disinfection and a move to a new building were associated with reductions of LOS to 64% (47–87%) and 54% (34–88%), respectively, and aseptic no touch technique for infusion access with CLA-BSI to 53% (37–75%) of pre-intervention levels. Conclusion: A multifaceted approach involving changes in antimicrobial and skin disinfection policy, training for aseptic no touch technique and surveillance resulted in sustained reduction in LOS and CLA-BSI rates. Key Words: premature infant, infection, nosocomial infection, sepsis, Catheter-associated infection, prevention, patient care bundles (Pediatr Infect Dis J 2016;35:401–406) L ate onset sepsis (LOS) is a major cause of mortality in extremely preterm infants 1,2 and has become a more important cause of death and disability with increasing survival of prematurely born infants. 3 Sepsis is associated with long-term adverse neurodevel- opmental outcomes in survivors 4,5 with nearly two thirds of LOS being associated with a central-line associated blood stream infec- tions (CLA-BSI). 6 A large proportion of these infections may be preventable. 7 Approaches to reduce LOS and catheter-related infections have included individual interventions and more recently “Neona- tal Intensive Care Unit” care bundles. Interventions such as use of probiotics and prebiotics have not been shown to reduce the rates of LOS. 8,9 Administration of prophylactic immunoglobulins to pre- term infants led to a modest reduction in sepsis rates; however, no significant improvement in clinical outcomes was reported. Spe- cific anti-staphylococcal immunoglobulins, colony stimulating fac- tors and glutamine supplementation have also been used but did not improve sepsis rates in preterm infants. 10–12 Although small studies have demonstrated a reduction in infection rates after use of pro- phylactic intravenous vancomycin, concerns regarding emergence of resistant organisms and lack of evidence of clinical efficacy have discouraged the use of this intervention. 13 More recently, the imple- mentation of a care bundles, that is, “small set of evidence-based interventions for a defined population and care setting implemented together in NICUs has been associated with a reduction in CLA- BSI rates but only a modest reduction in LOS rates.” 14–17 The evi- dence base for individual elements that are included in care bundles for prevention of sepsis and CLA-BSI in preterm infants is limited. The burden of LOS and CLA infection in preterm infants is a global challenge. Preventing health-care acquired infection is a priority for all hospitals across the world and is a key indicator of the quality of care among health-care policy makers, 18,19 hence, the change in practices needs to be health organization-based to achieve significant reduction in the infection rate. An updated evidence- based national guideline to prevent health-care acquired infection in acute care settings for adults and adolescents has been published 20 ; however, this is yet to be established for neonatal units where central line days were significantly higher compared with adult intensive care (IC) units. In the United Kingdom, rates of CLA-BSI have been introduced by specialty commissioning group(s) as an important quality of care indicator for hospitals providing NICU care. 19 In our hospital, a number of interventions were introduced across the hospital in 2007, to decrease the rate of BSIs. These pan-hospital interventions resulted in a reduction of BSI rates. 21 In addition to pan-hospital interventions, the neonatal unit introduced local changes to the clinical practice. Establishing a care bundle may have to be individualized according to local clinical care set- ting; hence, a need for analysis of the effect of local and organiza- tion-based interventions on infection rates in a clinical setting may be necessary for creating evidence-based care bundles. The aim of this study was to investigate the effects of Hospital-wide and local interventions on CLA-BSI and LOS rates in preterm infants born at less than 32 weeks of gestation. METHODS Babies who were born at <32 weeks gestation and received care in the neonatal unit between January 2007 and December 2012 were included in the study. This study was approved by the Royal London Hospital’s Clinical effectiveness group as a retrospective study for evaluation of service improvement. The neonatal unit at the Royal London Hospital provides tertiary care for newborn infants with medical and surgical problems for North East London and South Essex. Demographic details, care days and number of central line days for each patient were extracted from the Neonatal Database (Clevermed) using MS Access (Microsoft). Unit activity Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/16/3504-0401 DOI: 10.1097/INF.0000000000001019 Prevention of Late Onset Sepsis and Central-line Associated  Blood Stream Infection in Preterm Infants Ajay K. Sinha, MB BS, FRCPCH, MD,*† Vadivelam Murthy, MB BS, DCH, MRCPCH,* Puneet Nath, MB BS, DCH, MRCPCH,* Joan K. Morris, PhD,‡ and Mike Millar, MB ChB, MA, MD, PhD, FRCPath§ Accepted for publication October 6, 2015. From the *Neonatal Medicine, Barts Health NHS Trust, London, United King- dom; †Centre for Paediatrics, Blizard Institute, Barts and the London School of Medicine and Dentistry, ‡Centre for Environmental and Preventive Medi- cine, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, London, United Kingdom; and §Department of Microbiology, Barts Health NHS Trust, London, United Kingdom. The authors have no funding or conflicts of interest to disclose. Address for correspondence: Ajay K. Sinha, MB BS, FRCPCH, MD, Neonatal Unit, Ward 8D, Royal London Trust, Whitechapel, London E1 1BB, United Kingdom. E-mail: ajay.sinha@bartshealth.nhs.uk.