This document outlines infection control protocol in the neonatal intensive care unit (NICU). It discusses 8 key steps: 1) Preventing entry of microbes into the NICU, 2) Preventing proliferation of microbes in the NICU, 3) Preventing infection spread between babies, 4) Preventing entry of microbes into infants, 5) Guidelines for breast milk/formula, 6) Kangaroo mother care and early discharge, 7) Decreasing infant susceptibility, and 8) The role of infection control committees and protocols. The document provides detailed guidelines and procedures to implement these 8 steps to effectively control infections in the NICU.

1. INFECTION CONTROL PROTOCOL IN
NICU
DR.PRITESH PATEL
MBBS, MD(PEDIA), FELLOWSHIP IN
NEONATOLOGY (FIAP), PGPN(BOSTON)

2. INTRODUCTION
• NEWBORN CARE – VITAL SECTORS TO BE LOOKED TO
REDUCE NEONATAL MORTALITY AND MORBIDITY
• DIFFICULT TO TREAT BUT EASIER TO PREVENT
• APPROACH TOWARDS THE PREVENTION IS MULTI-
DISCIPLINARY (Neonatologist,Nursing staff, Engineers etc)
• EFFECTIVE INFECTION CONTROL – ONCE JOURNEY OF
MICROBE FROM ENVIRONMENT TO SUSCIPTIBLE INFANT IS
UNDERSTOOD

3. INTRODUCTION
• MICROBES ENTER THE NICU VIA VISITORS AND HEALTH
CARE WORKERS(HCW)
• SPREAD TO NEONATE VIA CONTAMINATED
EQUIPMENTS AND HANDS OF HCWS
• ONCE BABIES ARE COLONIZED , ORGANISMS ENTER
THROUGH
– UMBILICAL CORD,
– SKIN (During IV access, Parentral fluids, Enteral
fluids, Intubation, Suctioning ET)

4. INFECTION CONTROL STEPS
PREVENT ENTRY OF MICROBES INTO THE NICU
PREVENT PROLIFERATION OF MICROBES IN THE
NICU
PREVENTING INFECTON SPREAD FROM
PROLIFERATION SITES TO BABY AND FROM ONE
BABY TO OTHER
PREVENT ENTRY OF MICROBES INTO THE
INFANTS

5. INFECTION CONTROL STEPS
BREAST MILK/BREAST FEEDING AND
CORRECT PREPARATION OF FORMULA MILK
KANGAROO MOTHER CARE/ EARLY
DISCHARGE
DECREASING SUSCEPTIBILITY OF THE BABY
TO INFECTIONS
INFECTION CONTROL PROTOCOLS

6. INFECTION CONTROL STEPS

7. STEP 1. PREVENT ENTRY OF MICROBES INTO THE NICU
A. CLEAN IMMEDIATE ENVIRONMENT
 ORGANISMS FROM LR/ RESUSCITATION ROOM/MATERANAL
VAGINAL FLORA CAN COLONISED NEBORN SKIN
 PREVENTED BY FOLLOWING 6 C’s
1) CLEAN PERINEUM
2) CLEAN DELIVERY SURFACE
3) CLEAN CORD
4) CUTTING INSTRMENTS
5) CLEAN CORD CARE
6) ENSURING NOTHING UNCLEAN
 EQUIPMENTS CLEANED AND REGULARLY AUTOCLAVED

8. B. STANDARDIZE THE NICU DESIGN
1) LOCATION OF NICU
 DISTINCTED AREA WITH CONTROLLED ACCESS
 EACH INFANT SPACE MIN 120 SQ FT FLOOR SPACE
 MINIMUM 4 FT BETWEEN TWO INFANTS
2) AIRBORNE INFECTION ISOLATION ROOM
 SHOULD BE AVAILABLE
 HANDS FREE HAND WASHING STATION
 AREA FOR GOWNING AND STORAGE OF CLEAN MATERIAL
 VENTILATION WITH NEGATIVE PRESSURE WITH EXAUST
 RELATIVE HUMIDITY 30-60% (>60% promote growth of micro-
organisms)

9. 3) HAND WASHING STATION
 INFANT BED SHOULD BE WITHIN 20 FEET FROM HAND WASHING
SINK
 WASHING SINK SOULD BE LARGE ENOUGH TO CONTROL
SPLASHING
 PICTORIAL HAND WASHING INSTRUCTUION
 NON ABSORBENT WALL MATERIAL (To prevent growth mould)
 SPACE FOR SOAP AND TOWEL DISPENSERS
 ELBOW OR FOOT OPERATED TAPS

11. C. HAND HYGIENE
 CDC RECOMMENDS HAND WASHING BEFORE AND AFTER CONTACT
WITH EVERY PATIENT FOR 20 SECS AND 40-60 SECS BEFORE
ENTERING NICU
 STEP BY STEP HAND WASHING
 REMOVE ALL ACCESSORIES
 TURN ON WATER, WET HANDS, APPLY ANTIMICROBIAL SOAP
 RUBBING PALM TO PALM AND DORSUM OF PALM
 RUBBING FINGER INTERLACED AND BACK OF FINGER
 RUBBING THUMB ROTATIONALLY
 RUBBING WRIST AND THEN FOREARM
 TURN OFF WATER, WIEP HANDS, DISCARD PAPER
 EACH ACTION REQUIRED MINIMUM 5 SECONDS

13. D. USE OF ALCOHOL BASE HAND RUB (ABHR)
 USED AS HAND HYEGIENE AGENTS(2-3 ML) IF HANDS ARE NOT
VISIBLY DIRTY OR CONTAMINATED
 PROVEN MORE EFFECTIVE THAN STANDARD HAND WASHING
 USED IN BETWEEN PATIENT EXMINATION
 NOT USEFUL AFTER TOUCHING INFECTED PATIENT OR HANDS ARE
SOILED
E. VISITOR’S POLICY / MOBILE RESTRICTION
 MICROBES ENTER THROUGH PERSON, SO RETRICT ENTRY IS MUST
 INFECTED PERSON(RESPI / GIT) AND CHILDREN SHOULD NOT ALLOW
 INFECTED AND OUT BORN BABIES MANAGED IN ISOLATION ROOM
 NICU SHOULD BE A CELL PHONE FREE ZONE

15. F. GOWNING TO REDUCED NOSOCOMIAL INFECTION
 NO REDUCTION OF INFECTION
 FOCUS ON ADEQUET HAND WASHING BY ALL
G. JEWELARY AND FINGER NAILS POLICY
 NOT WEAR ARTEFICIAL FINGERNAILS WHEN HAVING DIRECT CONTACT
 NATURAL NAILS SHOULD KEPT SHORT (0.5CM / ¼ INCH LONG)

16. STEP 2. PREVENT PROLIFERATION OF MICROBES IN THE
NICU
 GOOD HOUSEKEEPING ROUTINES HELPFUL IN PREVENTING AND
CURTAILING SPREAD OF INFECTION
 AVOID WET AREA INSIDE NICU
 DRY AND CLEAN UNLIKELY TO HARBOUR MICROBES
DAILY ROUTINE IN NICU
INCUBATORS, WARMERS, SYRINGE PUMP,
INFUSION PUMP, PHOTOTHERAPY UNITS,
MATTRESS,PULSE OXIMETER, MULTIPARA
MONITOR, HOOD, VENILATOR, CPAP, TELEPHONE
DRY DUSTING, CLEAN USING
MOIST WIPE
SUCTION BOTTLES, HUMIDIFIER CHAMBER, WATER
IN BUBBLE CPAP
CHANGED WITH DISTILLED
WATER
VENTILATOR FILTERS CLEAN DAILY AND DUST OFF

17. DAILY ROUTINE IN NICU
BAG AND MASK IMMERSE IN 2% CIDEX FOR 6 TO 8 HOURS
AFTER DISMANTLING AND CLEANING
WITH RUNNING WATER
INCUBATOR, WARMER CLEAN WITH BACILLOCID IF NOT
OCCUPIED BY INFANT
LARYNGOSCOPE, MASK, MEASURE TAPE,
TEMP AND SPO2 PROBE, TORCHS WIPE WITH SPIRIT
WALLS, FLOORS, WASH BASINS
CLEAN WITH PHENOL/ LYSOL/ 2%
BACILOCID IN EACH SHIFT
DUST BINS, BUCKETS, WASTE EMPTY IN EACH SHIFT CLEAN WITH SOAP
AND WATER

18. WEEKLY ROUTINE IN NICU
VENTILATOR AND CPAP MACHINE CHANGE NEW CIRCUIT
PROCEDURE SETS AUTOCLAVE AFTER EVERY USE
WINDOW AIR CONDITIONERS SURFACE AND FILTERS WITH SOAP AND
WATER
REFRIGERATORS SOARTED AND CLEANED
SEPARATE FRIDGE DOOR FOR MILK AND
LAB SAMPLES
WEIGHING SCALE, STETHOSCOPE, BP
CUFF, LARYNGOSCOPE
CLEANED AND WIPE WITH SPIRIT AFTER
EVERY USE
FEEDING UTENSIL BOILED FOR 15 MIN AFTER CLEANING

21. WASTE DISPOSAL
BLACK DRUMS
(DISPOSAL BY DUMPING) {disposed off by
routine municipal council committee
machinery}
LEFT OVER FOOD, VEG, WASTE PAPER,
PACKINGS , EMPTY BAGS
YELLOW DRUMS
(DISPOSAL BY INCINERATON)
INFECTED NON PLASTIC, HUMAN
SECRETA, BLOOD AND BODY FLUIDS
BLUE DRUMS
(NON INFECTIOUS BY AUTOCLAVE AND
DISPOSED BY SHEDDING)
INFECTED PLASTIC WASTE (IV SETS, ET
TUBE, CATHETER, UTOBAGS)

22. STEP 3. PREVENTING INFECTON SPREAD FROM
PROLIFERATION SITES TO BABY AND FROM
ONE BABY TO OTHER
• MOST IMORTANT STEP
A. NURSE TO PATIENT RATIO
 1:1 IF BABY HAS MULTI DRUG RESISTENT MICROBES
 1:2 SUSCEPTIBLE OR BABIES HAVE SIMILAR ORGANISM
 1:3 ADEQUATE ANTIBIOTICS COVER
B. LAMINAR FLOW SYSTEM FOR DRUGS, FLUIDS AND TPN
PREPARATION
 DECREASE LOCAL COMPLICATIONS AND SEPSIS

23. C. USE DISPOSABLES
 BABY KIT – STETHOSCOPE, MEASURE TAPE, THERMOMETER, TORCH
IN STERILE CONTAINER AT EACH BED
 SEPARATE SYRINGE FOR EACH MEDICINE, FOR EACH BABY
 FRESH SUCTION CATHETER FOR ET/ORAL SUCTION
 SEPARATE GLOVES, ANTIBIOTICS VIALS, DISPOSABLE RESPIRATORY
CIRCUIT
 DON’T KEEP FOMITES (FILE, PEN, X RAY) ON BABY COT
 FLUSHING OF CATHETER -STOCK SOLUTION (HEPARINISED) SHOULD
NOT USED
 EPIDEMIC OF ENTEROBACTER CLOACE WITH USE OF MULTI DOSE
ANTIBIOTICS VIAL

24. STEP 4. PREVENT ENTRY OF MICROBES INTO THE
INFANTS
A. CORD CARE
 CORD INFECTION PREVENTED BY CLEAN CORD CARE AND REDUCING
HARMFUL CORD APPLICATIONS
 WHO RECOMMENDS DRY CORD CARE AND USE OF SOAP AND
WATER SOLUTION TO CLEAN IF SOILED
B. SKIN CARE
 SKIN INJURY PREVENTED BY APPLYING LESS ADHESIVE TAPE, USING
TEGADERM BETWEEN SKIN AND ADHESIVE
 PRECAUTION DURING ADHESIVE REMOVAL
 USE SKIN FRIENDLY DUROPORE INSTEED OF DYNAPLAST/MICROPORE

25. C. PRECAUTIONS DURING PROCEDURES
 ASEPTIC PRECAUTION TAKEN DURING ALL PROCEDURES
 HAND SCRUB PRIOR TO EACH PROCEDURE
 SKIN CLEANED WITH SPIRIT-BETADINE-SPIRIT
 DISPOSABLE GLOVES WORN
 AFTER IV CANNULA INSERTION FIXED WITH TRANSPARENT TAPE
 CANNULATION SITE MONITORED DAILY FOR THOMBOPHLEBITIS
 CATHETER (IF INSERTED IN EMERGENCY) REMOVED ONCE PATIENT
CONDITION STABILISED

26. D. PRECAUTIONS DURING CVC/PICC UMBILICAL CATHETER/
HANDLING OF CATHETER
 TRAINING AND EDUCATION OF HCW
 HAND HYGIENE / WEAR GLOVES
 POVIDONE IODINE ON SKIN FOR ATLEAST 2 MIN
 STERILE GAUGE/ STERILE TRANSPARENT , SEMI PERMEABLE DRESSING
TO COVER CATHETER SITE
 MONITOR CATHETER SITE VISIBLY OR PALPATION
 REPLACE CATHETER SITE DRESSING IF DRESSING DAMP, LOOSENES,
SOILED
 REMOVE CATHETER IF NO LONGER ESSENTIAL / COMPLICATIONS
(CLABSI, THROMBOSIS)
 CAHNGE TUBE AND BOTTLE EVERY 24 HOURS
 UAC NOT BE LEFT IN PLACE >5 DAYS
 UVC REMOVED AS SOON AS POSSIBLE BUT USED UPTO 14 DAYS

27. E. PRECAUTIONS DURING ENDOTRACHEAL INTUBATION
AND SUCTION
 WEAR FACE MASK, SCRUB HANDS, WEAR GOWN AND GLOVES
 ET TUBE STAY IN PACK UNTILL POINT OF USE
 DON’T TOUCH TRACHEAL TIP
 WEAR STERILE GLOVES FOR SUCTION
 FIRST TRACHEAL SUCTION THEN MOUTH
 DISCARD SUCTION CATHETER AFTER SINGLE USE
 TAKE HELP OF NURSE FOR INSTILLING SALINE OR DISCONNECTING
VENTILATOR

28. STEP 5. BREAST MILK/BREAST FEEDING AND CORRECT
PREPARATION OF FORMULA MILK
 SUPPORT BREASTFEEDING AND PROMOTE ITS BENEFITS TO INFANTS
 ENCOURAGE USE OF COLOSTRUMS, TOPHIC FEEDS WITH EBM AND NNS
 MOTHER’S ENTRY INTO NICU AND PUMPING OF MILK TO ENSURE
ADEQUATE MILK FOR INFANT
 FOR FORMULA FEED WATER TEMPEARURE -70 C AT TIME OF
RECONSTITUTION AND DECREASE HOLDING AND FEEDING TIME TO
REDUCE RISK OF CONTAMINATION
 IF PREPARE IN ADVANCE , REFRIGERATED TO BELOW 50 C BUT NOT MORE
THEN 24 HOURS.
 REWARMING DONE IMMEDIATELY BEFORE FEEDING
 FEED SHOULD NOT BE LEFT WARMING FOR MORE THAN 15 MIN.

29. STEP 6. KANGAROO MOTHER CARE/ EARLY
DISCHARGE
 KMC WAS ASSOCIATED WITH SIGNIFICANT REDUCTION IN
 SEVERE INFECTION/ SEPSIS AT FOLLOW UP,
 NOSOCOMIAL INFECTION / SEPSIS AT DISCHARGE OR AT 40 WEEKS OF
CORRECTED GESTATIONAL AGE
(Cochrane meta-analysis)

30. STEP 7. DECREASING SUSCEPTIBILITY OF THE BABY TO
INFECTIONS
A. EARLY BREAST FEEDING / USE OF COLOSTRUMS / MINIMAL
ENTERAL NUTRITION
 OWN MOTHER MILK/ COLOSTRUM- LOWER INCIDENCE AND
SEVERITY OF NOSOCOMIAL INFECTION /LOS
 TROPHIC FEEDING IMPROVED MILK TOLERANCE, GREATER POST
NATAL GROWTH, REDUCED SYSTEMIC SEPSIS AND SHORTEN
HOSPITAL STAY
B. IMMUNOMODULATORS
 NO ROLE OF IVIG AND GM-CSF FOR PREVENTION OF SEPSIS
 ROLE OF PROBIOTICS IS PROMISING
(But Right choice, Right dose and Right patient is still under review)
C. ANTIFUNGAL PROPHYLAXIS
 RECOMMENDED FOR ELBW

31. STEP 8. INFECTION CONTROL PROTOCOLS
A. ROLE OF HOSPITAL MANAGEMENT
 ESTABLISHED MULTI DISCIPLINARY INFECTION CONTROL COMMITTEE
WHO CAN USE APPROPIATE RESOURCES AND METHODS TO
MONITOR AND PREVENT INFECTION, ENSURE EDUCATION AND
TRAINING
 THE PHYSICIAN, MICROBILOGIST, NURSING MANAGER, RESIDENT
AND HOUSE KEEPING STAFF PLAY THEIR ROLE IN INFECTION
SURVIELLANCE AND PREVENTION OF INFECTION OUTBREAKS
B. INFECTION CONTROL COMMITTEE
 HOSPITAL SHOULD HAVE COMMITTEE WITH GOAL TO REVIEW
 YEARLY PROGRAMME OF ACTIVITY FOR SURVILLANCE AND
PREVENTION
 EPIDEMIOLOGICAL SURVEILLANCE
 APPROPIATE STAFF TRAINING IN INFECTION CONTROL AND SAFETY
 PROVIDE INPUT INTO INVESTIGATION OF EPIDEMICS

32. C. ANTIBIOTIC USAGE AND MICROBIAL RESISTANCE
 HOSPITAL MUST HAVE ANTIBIOTICS POLICY DEPEND UPON LOCAL
CONDITIONS
 PROPHYLACTIC ANTIBIOICS NOT BE STARTED IN BIRTH ASPHYXIA,
NNHB, CS DELIVERY, EXCHANGE TRANSFUSION
 BLOOD CULTURE OBTAINED BEFORE STARTING ANTIBIOTICS
 IF BLOOD CULTURE STERILE AFTER 48-72 HOURS OF INCUBATION,
SAFE TO STOP ANTIBIOTICS
 RESTRICT USE OF EMPIRICAL BROAD SPECTRUM ANTIBIOTICS
 CRP SHOULD NOT BE A GUIDE FOR ANTIBIOITC THERAPY
 SHORTEN DURATION OF ANTIBIOTICS WHENEVER POSSIBLE
 ANTIBIOTICS STEWARDSHIP IS MULTISYSTEM TEAM APPROACH
LIMITING INAPPROPIATE USE OF ANTIBIOTICS AND WHILE
CHOOSING SELECTION, DOSE DURATION AND ROUTE WITH MOST
APPROPIATE DRUG
 TREAT INFECTION , NOT COLONIZATION OR CONTAMINATION

33. • WHAT DO UNIVERSAL PRECAUTIONS MEAN?
 ALWAYS WEAR STERILE GLOVES FOR HEEL STABS, PHLEBOTOMY
AND INSERTION OF VASCULAR CATHETERS
 WEAR GLOVES WHILE HANDLING ANY KIND OF BODY FLUIDS
 DO NOT RECAP USED NEEDLES BY HAND
 DO NOT REMOVE USED NEEDLES FROM DISPOSABLE SYRINGES BY
HAND
 DO NOT BEND, BREAK, OR OTHERWISE MANIPULATE USED
NEEDLES BY HAND
 DESTROY NEEDLES USING THE NEEDLE DESTROYER PROVIDED IN
EVERY WARD
 DISPOSE SCALPEL BLADES AND OTHER SHARP ITEMS IN PUNCTURE-
RESISTANT CONTAINERS FOR DISPOSAL.

34. TAKE HOME MESSAGES
1) MORBIDITY AND MORTALITY REDUCED BY INSTITUTING STRICT INFECTION CONTROL
PROTOCOL
2) PREVENTION OF ENTRY OF MICROBE IN NICU BY CLEAN ENVIRONMENT, HAND HYGIENE,
CONDUCTIVE INFRASTRUCTURE
3) CURTAILING PROLIFERATION OF MICROBE BY DAILY AND WEEKLY MAINTAINANCE OF
EQUIPMENTS LIKE (Incubatores, Warmer, Syringe pump, Ventilator filter, Circuits, Bag and
Mask)
4) EFFICIENT BIO-MEDICAL WASTE DISPOSAL IS VERY IMPORTANT
5) CORD CARE, SKIN CARE, PRECAUTIONS DURING PROCEDURES (Vene puncture, Intubation,
UAC/UVC insertion) ARE IMPORTANT
6) EARLY BREAST FEEDING, USE OF COLOSTRUM ,EARLY DISCHARGE PLAY AN IMPORTANT
ROLE
7) HOSPITAL MANAGEMENT AND ROBUST INFECTION CONTROL COMMITTEE PLAY MAJOR
ROLE IN PREVENTION OF INFECTION