Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Nosocomial viral infections in the neonatal intensive care unit

Leonard E Weisman, MD
Section Editors
Steven A Abrams, MD
Morven S Edwards, MD
Deputy Editor
Carrie Armsby, MD, MPH


Although the published incidence of viral neonatal nosocomial infection is considerably lower than bacterial nosocomial infection [1], significant mortality and morbidity occur in the estimated 1 percent of infants who acquire a viral infection after admission to the neonatal intensive care unit (NICU) [2].

The epidemiology, and the viruses and their clinical manifestations of nosocomial viral infection in the NICU will be reviewed here.


The incidence of neonatal nosocomial viral infections has probably been underestimated because viral studies are not routinely obtained in neonates. The lack of testing for viral infection is due to the overlap of clinical signs and symptoms of viral infections from other conditions seen in the critically ill neonate, the difficulty in obtaining laboratory confirmation of a viral infection, and the lack of effective therapeutic interventions.

Prospective data demonstrate that the frequency of detected respiratory viral infections in infants evaluated for sepsis ranges from 6 to 10 percent.

In a prospective study conducted in two neonatal intensive care units (NICUs) in the United States from 2012 to 2013, a respiratory viral infection was identified in 8 cases of the 135 sepsis evaluations (6 percent) [3]. During the 13-month study period, viruses detected by polymerase chain reaction (PCR) included enterovirus/rhinovirus (n = 2), rhinovirus (n = 2), coronaviruses (n = 2), and parainfluenza virus (n = 3).

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Jul 11, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Gaynes RP, Edwards JR, Jarvis WR, et al. Nosocomial infections among neonates in high-risk nurseries in the United States. National Nosocomial Infections Surveillance System. Pediatrics 1996; 98:357.
  2. Verboon-Maciolek MA, Krediet TG, Gerards LJ, et al. Clinical and epidemiologic characteristics of viral infections in a neonatal intensive care unit during a 12-year period. Pediatr Infect Dis J 2005; 24:901.
  3. Ronchi A, Michelow IC, Chapin KC, et al. Viral respiratory tract infections in the neonatal intensive care unit: the VIRIoN-I study. J Pediatr 2014; 165:690.
  4. Kidszun A, Hansmann A, Winter J, et al. Detection of respiratory viral infections in neonates treated for suspicion of nosocomial bacterial sepsis: a feasibility study. Pediatr Infect Dis J 2014; 33:102.
  5. Bennett NJ, Tabarani CM, Bartholoma NM, et al. Unrecognized viral respiratory tract infections in premature infants during their birth hospitalization: a prospective surveillance study in two neonatal intensive care units. J Pediatr 2012; 161:814.
  6. Civardi E, Tzialla C, Baldanti F, et al. Viral outbreaks in neonatal intensive care units: what we do not know. Am J Infect Control 2013; 41:854.
  7. Heerens AT, Marshall DD, Bose CL. Nosocomial respiratory syncytial virus: a threat in the modern neonatal intensive care unit. J Perinatol 2002; 22:306.
  8. Vieira RA, Diniz EM, Vaz FA. Clinical and laboratory study of newborns with lower respiratory tract infection due to respiratory viruses. J Matern Fetal Neonatal Med 2003; 13:341.
  9. White MP, Mackie PL. Respiratory syncytial virus infection in special care nursery. Lancet 1990; 335:979.
  10. Kilani RA. Respiratory syncytial virus (RSV) outbreak in the NICU: description of eight cases. J Trop Pediatr 2002; 48:118.
  11. Halasa NB, Williams JV, Wilson GJ, et al. Medical and economic impact of a respiratory syncytial virus outbreak in a neonatal intensive care unit. Pediatr Infect Dis J 2005; 24:1040.
  12. Kang JO, Kim CR. Nosocomial respiratory syncytial virus infection in a newborn nursery. J Korean Med Sci 1997; 12:489.
  13. Wilson CW, Stevenson DK, Arvin AM. A concurrent epidemic of respiratory syncytial virus and echovirus 7 infections in an intensive care nursery. Pediatr Infect Dis J 1989; 8:24.
  14. Ng W, Rajadurai VS, Pradeepkumar VK, et al. Parainfluenza type 3 viral outbreak in a neonatal nursery. Ann Acad Med Singapore 1999; 28:471.
  15. Moisiuk SE, Robson D, Klass L, et al. Outbreak of parainfluenza virus type 3 in an intermediate care neonatal nursery. Pediatr Infect Dis J 1998; 17:49.
  16. Simmonds A, Munoz J, Montecalvo M, et al. Outbreak of parainfluenza virus type 3 in a neonatal intensive care unit. Am J Perinatol 2009; 26:361.
  17. Meissner HC, Murray SA, Kiernan MA, et al. A simultaneous outbreak of respiratory syncytial virus and parainfluenza virus type 3 in a newborn nursery. J Pediatr 1984; 104:680.
  18. McCarthy VP, Carlile JR, Reichelderfer PS, Clark JS. Parainfluenza type 3 in newborns. Pediatr Infect Dis J 1987; 6:217.
  19. Singh-Naz N, Willy M, Riggs N. Outbreak of parainfluenza virus type 3 in a neonatal nursery. Pediatr Infect Dis J 1990; 9:31.
  20. Abzug MJ, Beam AC, Gyorkos EA, Levin MJ. Viral pneumonia in the first month of life. Pediatr Infect Dis J 1990; 9:881.
  21. Heidemann SM. Clinical characteristics of parainfluenza virus infection in hospitalized children. Pediatr Pulmonol 1992; 13:86.
  22. Munoz FM, Campbell JR, Atmar RL, et al. Influenza A virus outbreak in a neonatal intensive care unit. Pediatr Infect Dis J 1999; 18:811.
  23. Cunney RJ, Bialachowski A, Thornley D, et al. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2000; 21:449.
  24. Sagrera X, Ginovart G, Raspall F, et al. Outbreaks of influenza A virus infection in neonatal intensive care units. Pediatr Infect Dis J 2002; 21:196.
  25. Bauer CR, Elie K, Spence L, Stern L. Hong Kong influenza in a neonatal unit. JAMA 1973; 223:1233.
  26. Meibalane R, Sedmak GV, Sasidharan P, et al. Outbreak of influenza in a neonatal intensive care unit. J Pediatr 1977; 91:974.
  27. Vij NK, Stryker CC, Esper FP, et al. Influenza A/H1N1/09-10 infections in a NICU during the 2009-2010 H1N1 pandemic. Pediatrics 2011; 128:e1297.
  28. Piedra PA, Kasel JA, Norton HJ, et al. Description of an adenovirus type 8 outbreak in hospitalized neonates born prematurely. Pediatr Infect Dis J 1992; 11:460.
  29. Faden H, Wynn RJ, Campagna L, Ryan RM. Outbreak of adenovirus type 30 in a neonatal intensive care unit. J Pediatr 2005; 146:523.
  30. Birenbaum E, Linder N, Varsano N, et al. Adenovirus type 8 conjunctivitis outbreak in a neonatal intensive care unit. Arch Dis Child 1993; 68:610.
  31. Percivalle E, Sarasini A, Torsellini M, et al. A comparison of methods for detecting adenovirus type 8 keratoconjunctivitis during a nosocomial outbreak in a Neonatal Intensive Care Unit. J Clin Virol 2003; 28:257.
  32. Sizun J, Soupre D, Legrand MC, et al. Neonatal nosocomial respiratory infection with coronavirus: a prospective study in a neonatal intensive care unit. Acta Paediatr 1995; 84:617.
  33. Steiner M, Strassl R, Straub J, et al. Nosocomial rhinovirus infection in preterm infants. Pediatr Infect Dis J 2012; 31:1302.
  34. Rodriguez-Baez N, O'Brien R, Qiu SQ, Bass DM. Astrovirus, adenovirus, and rotavirus in hospitalized children: prevalence and association with gastroenteritis. J Pediatr Gastroenterol Nutr 2002; 35:64.
  35. Berner R, Schumacher RF, Hameister S, Forster J. Occurrence and impact of community-acquired and nosocomial rotavirus infections--a hospital-based study over 10 y. Acta Paediatr Suppl 1999; 88:48.
  36. Tzialla C, Civardi E, Borghesi A, et al. Emerging viral infections in neonatal intensive care unit. J Matern Fetal Neonatal Med 2011; 24 Suppl 1:156.
  37. Red Book Atlas of Pediatric Infectious Diseases, 1st ed, American Academy of Pediatrics, Elk Grove Village, IL 2007.
  38. Chandran A, Heinzen RR, Santosham M, Siberry GK. Nosocomial rotavirus infections: a systematic review. J Pediatr 2006; 149:441.
  39. Cicirello HG, Das BK, Gupta A, et al. High prevalence of rotavirus infection among neonates born at hospitals in Delhi, India: predisposition of newborns for infection with unusual rotavirus. Pediatr Infect Dis J 1994; 13:720.
  40. Ramani S, Sowmyanarayanan TV, Gladstone BP, et al. Rotavirus infection in the neonatal nurseries of a tertiary care hospital in India. Pediatr Infect Dis J 2008; 27:719.
  41. Linhares AC, Mascarenhas JD, Gusmão RH, et al. Neonatal rotavirus infection in Belém, northern Brazil: nosocomial transmission of a P[6] G2 strain. J Med Virol 2002; 67:418.
  42. Haffejee IE. Neonatal rotavirus infections. Rev Infect Dis 1991; 13:957.
  43. Sharma R, Hudak ML, Premachandra BR, et al. Clinical manifestations of rotavirus infection in the neonatal intensive care unit. Pediatr Infect Dis J 2002; 21:1099.
  44. Dearlove J, Latham P, Dearlove B, et al. Clinical range of neonatal rotavirus gastroenteritis. Br Med J (Clin Res Ed) 1983; 286:1473.
  45. Akinci A, Teziç T, Gür I, et al. Rotavirus diarrhea in newborn infants. Turk J Pediatr 1991; 33:153.
  46. Rotbart HA, Levin MJ, Yolken RH, et al. An outbreak of rotavirus-associated neonatal necrotizing enterocolitis. J Pediatr 1983; 103:454.
  47. Sharma R, Garrison RD, Tepas JJ 3rd, et al. Rotavirus-associated necrotizing enterocolitis: an insight into a potentially preventable disease? J Pediatr Surg 2004; 39:453.
  48. Rotbart HA, Nelson WL, Glode MP, et al. Neonatal rotavirus-associated necrotizing enterocolitis: case control study and prospective surveillance during an outbreak. J Pediatr 1988; 112:87.
  49. Parashar UD, Hummelman EG, Bresee JS, et al. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003; 9:565.
  50. Raad II, Sherertz RJ, Russell BA, Reuman PD. Uncontrolled nosocomial rotavirus transmission during a community outbreak. Am J Infect Control 1990; 18:24.
  51. Kilgore PE, Unicomb LE, Gentsch JR, et al. Neonatal rotavirus infection in Bangladesh: strain characterization and risk factors for nosocomial infection. Pediatr Infect Dis J 1996; 15:672.
  52. Bhan MK, Lew JF, Sazawal S, et al. Protection conferred by neonatal rotavirus infection against subsequent rotavirus diarrhea. J Infect Dis 1993; 168:282.
  53. Ramachandran M, Vij A, Kumar R, et al. Lack of maternal antibodies to P serotypes may predispose neonates to infections with unusual rotavirus strains. Clin Diagn Lab Immunol 1998; 5:527.
  54. Gianino P, Mastretta E, Longo P, et al. Incidence of nosocomial rotavirus infections, symptomatic and asymptomatic, in breast-fed and non-breast-fed infants. J Hosp Infect 2002; 50:13.
  55. Mastretta E, Longo P, Laccisaglia A, et al. Effect of Lactobacillus GG and breast-feeding in the prevention of rotavirus nosocomial infection. J Pediatr Gastroenterol Nutr 2002; 35:527.
  56. Berger R, Hadziselimovic F, Just M, Reigel F. Influence of breast milk on nosocomial rotavirus infections in infants. Infection 1984; 12:171.
  57. Yen MH, Huang YC, Chen MC, et al. Effect of intravenous immunoglobulin for neonates with severe enteroviral infections with emphasis on the timing of administration. J Clin Virol 2015; 64:92.
  58. Davis J, Fairley D, Christie S, et al. Human parechovirus infection in neonatal intensive care. Pediatr Infect Dis J 2015; 34:121.
  59. Piralla A, Mariani B, Stronati M, et al. Human enterovirus and parechovirus infections in newborns with sepsis-like illness and neurological disorders. Early Hum Dev 2014; 90 Suppl 1:S75.
  60. Khatami A, McMullan BJ, Webber M, et al. Sepsis-like disease in infants due to human parechovirus type 3 during an outbreak in Australia. Clin Infect Dis 2015; 60:228.
  61. Shoji K, Komuro H, Kobayashi Y, et al. An infant with human parechovirus type 3 infection with a distinctive rash on the extremities. Pediatr Dermatol 2014; 31:258.