Nosocomial sepsis in very preterm neonates (gestational age < 32 weeks) has considerable
implications in terms of acute mortality or life-threatening morbidity and the risk
of long-term sequelae [5]
[11]
[19]
[20]. During the past decade, nosocomial gram-negative translocation sepsis and necrotizing
enterocolitis have been researched extensively with the aim to identify molecular,
immunologic and clinical risk factors [17]. Molecular factors, such as polymorphisms in genes controlling local immunity and
cell-to-cell-communication [17], immunologic risk factors including quantitative and qualitative specifics in complement
components and innate immunity [10] as well as phagocytic activity and immunoglobulines [5] among others, have been identified as contributing factors in the development of
the nosocomial sepsis. New and highly specific and sensitive diagnostic tools have
been developed in order to identify neonates with sepsis early on [12]. Furthermore, in large clinical trials additional risk factors have been identified,
those include, among others, vascular access for providing parenteral nutrition as
well as babies who were born with a low birth weight following impaired intrauterine
growth (IUGR – Intrauterine Growth Restriction) [7]
[15]. Even the colonization with causative agents of nosocomial sepsis has been proven
to be associated with the degree of neonatal immaturity and birth weight [14].
One major step in understanding the pathophysiology of nosocomial sepsis and necrotizing
enterocolitis was the finding that microbial translocation from the neonatal intestine
could explain a major part of the pathogenesis of necrotizing enterocolitis as well
as nosocomial gram-negative translocation sepsis [17]. It has been shown that the immaturity of the local immune system within the intestine,
cell-to-cell-communication and cell-mediated immunity are key players in the high
susceptibility of very preterm neonates for developing gram negative sepsis [10]
[17].
On the basis of our improved knowledge, a number of immunologic interventions were
investigated in carefully controlled clinical trials, such as the administration of
hematologic growth factors (GM-CSF and G-CSF) and intravenous and oral immunoglobulines,
among others. So far, none of these concepts proved to be effective in reducing neither
necrotizing enterocolitis nor nosocomial sepsis [5]
[6]
[9].
However, it had been clear for more than 2 decades that breast milk may reduce the
frequency of nosocomial sepsis and necrotizing enterocolitis. This also has recently
been proven for the administration of lactoferrin [13] and probiotics [8]. The adoption of a standardized nutritional regimen in very preterm neonates has
further been shown to reduce above-mentioned complications [16].
Additionally, a decline of nosocomial infections was achieved through the implementation
of programs for quality improvement through improved catheter care [11]. Moreover, national programs for quality control in neonatal care with respect to
nosocomial infections (NEO-KISS program, Germany) [12] were also able to impact on the reduction of the severity of infections.
It is also known from registers in other settings that outcomes can be improved [18]. Registers, when using similar criteria, enable the scientific community to compare
mortality and morbidity rates of e. g. nosocomial sepsis in very low birth weight
neonates, who were cared for in different geographical regions: For example, the reported
rates of nosocomial infections from a large German national network (German Neonatal
Network, GNN) were recently reported to be between 9 and 10% and compared with the
data from the Vermont-Oxford Network mainly enrolling neonates from North America,
which was reported to be between 17 and 18%. Definitions of nosocomial infections
and enrollment criteria, i. e., birth weight categories, were identical in both registers.
However, how do those improvements in the better understanding of the pathophysiology
of nosocomial infections and the related progress in the field of neonatology translate
into the German public perception in print and electronic media? During the past decade,
a number of series of nosocomial infections attracted a considerable public interest
in Germany. Public awareness has increased considerably during the last 3 years in
particularly through the clusters of infections in various neonatal intensive care
units in Berlin, Charité [2], Bremen [3] and in Mainz [1].
The leitmotif of all discussions in the public on nosocomial infections appears to
be poor hygiene and public opinion seems to indicate that high numbers of infections
could be prevented by improving hygienic measures, thereby ignoring the high risk
state of very preterm neonates and the above outlined complex pathophysiology [4]. Through the press, it further has been suggested that several thousands of deaths
could be readily prevented by improving basic hygienic measures in neonatal intensive
care units [4].
Thus, there seems to be an increasing gap in the progress we were able to achieve
with respect to understanding and preventing nosocomial infections in very preterm
neonates and the public perception. This appears to be compounded by willful ignorance
and sensational press. The longing for oversimplification along with aforementioned
factors threatens the care for severely sick and susceptible neonates in German neonatal
intensive care units by affecting the atmosphere of trust. Thus, German neonatology
went from being the darling of the press to be the whipping boy. No parallels to this
development have been reported from other developed countries.
It is the strong hope of the editor that the substantial progress that had been made
by reducing nosocomial translocation sepsis in very preterm neonates will continue,
e. g. by a targeted use of lactoferrin, probiotics and immune modulation. This in
turn will enable us to further improve neonatal outcome with respect to mortality
and long-term morbidity secondary to nosocomial infections. An objective dialogue
between the German scientific neonatal community and investigative journalists is
mandatory in order to regain a climate of confidence in German neonatal intensive
care units, which got lost during the past decade secondary to above-mentioned events.
The responsibility of media does not end in the quote of the viewers or the company’s
profit.
