Nicu Infection Control


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This is an evidence based presentation describing how to prevent and deal with the NICU infections outbreaks

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Nicu Infection Control

  1. 1. Evidence based guidelines for prevention of infection in NICU Dr. JP Dadhich MD,FNNF,PGD-DN
  2. 2. Outline  Relevance of infection control  Out breaks in NICU and lessons learnt from them  Evidence based infection control measures in NICU
  3. 3. Nosocomial Infections Relevance 70 67 60 56 50 44 40 31 EOS 30 LOS 20 10 0 IM EM NNPD – Time of onset of systemic infection NNPD primary cause of death EM  Significant cause of morbidity and mortality  Infants with nosocomial infections • Longer hospital stays • Higher treatment costs
  4. 4. Risk factors for nosocomial infections  Prematurity  Delayed enteral  Low birth weight feeding  Invasive device  Formula feeding • Intravascular device  Inadequate nursing • Mechanical ventilation staff/overcrowding • Urinary Catheter  Poor compliance • VP shunt with hand washing  Medication • H2 Blockers • Steroids
  5. 5. Epidemics  Cluster of infection with unusual pathogens  Continuous surveillance or monitoring of endemic infection rate to detect a change in baseline pattern  Common source • Contaminated equipments  Thermometers  Ventilators  Stethoscopes • Environmental reservoirs • Lapses in hand washing  Must be identified promptly and control measures instituted immediately
  6. 6. Endemic Pseudomonas aeruginosa Infection in a Neonatal Intensive Care Unit  Pseudomonas aeruginosa is a well- known cause of nosocomial infections among infants in neonatal intensive care units.  Environmental sources such as sinks and respiratory-therapy equipment are the most commonly described reservoirs of P. aeruginosa  Occasionally, health care workers have been 343 (10):695-700. NEJM 2000; the reservoir
  7. 7. Surveillance  An increased incidence of colonization and infection with P. aeruginosa was noted  Surveillance cultures were performed to identify all infants with colonization  33 infants in the neonatal intensive care unit, 6 of whom were identified as being colonized or infected with P. aeruginosa  Surveillance cultures were obtained from the other 27 infants – GA, ET secretions, nasopharyngeal swabs – twice a month till all babies in the cohort were discharged, than once a month fo next two months
  8. 8. Detecting environmental reservoirs  Cultures of environmental specimens • tap water • sink drains • liquid medications • respiratory-therapy equipment • hand soaps • hand creams • water baths used to warm formula  Moist and dry environmental surfaces were swabbed with a cotton-tipped swab
  9. 9. Cultures of the Hands of Health Care Workers  The hands of health care workers who came in contact with infants hospitalized in the neonatal intensive care unit during were cultured for P. aeruginosa with use of a modification of the quot;glove juicequot; method  Both hands of each worker were sequentially put into a sterile polyethylene bag containing 50 ml of sampling solution  One bag was used for each worker  Each hand was massaged by an infection-control practitioner through the wall of the bag for 15 to 30 seconds  samples were delivered to the microbiology laboratory within 1 hour for processing
  10. 10. Risk Factors for Colonization of the Hands with P. aeruginosa  The hands of all health care workers were inspected by the infection-control practitioner  The presence of false nails, nail polish, and cracked or inflamed nail beds was noted  Possible exposures to P. aeruginosa and risk factors for infection, such as use of antibiotics and a history of otitis externa, swimming in the preceding year, skin lesions or dermatitis, latex allergy, nail or nail-bed infections, and the use of artificial nails or nail wraps, were assessed  Risk factors for colonization of the hands of health care workers with P. aeruginosa were determined by logistic-regression analysis with the use of SAS software  The association between exposure to a specific health worker and infection or colonization with the endemic clone of P. aeruginosa was assessed
  11. 11. Results  None of the cultures of environmental specimens grew P. aeruginosa  Among 165 health workers, 3 had positive hand cultures – risk factors were present – furloughed on full pay • The first health care worker wore nail extenders - extenders were removed - hand cultures were subsequently negative • The second health care worker had candida onychomycosis – treated – negative cultures • The third health care worker had otitis externa – treated – negative cultures
  12. 12. Infection-Control Measures  Contact isolation procedures were used for infants who were colonized or infected with P. aeruginosa: • gown and gloves were used during any contact with these patients, and • the patients were placed in a separate room and cared for by designated nurses.  At the beginning of each shift, health care workers washed their hands with a preparation containing 4 percent chlorhexidine gluconate for two minutes  during their shifts, the workers washed their hands with a preparation containing 2 percent chlorhexidine gluconate  Staff members were asked to wear no jewelry other than wedding bands and wristwatches  Cosmetic nail treatments were not permitted  In addition, several care practices were changed: • water baths were no longer used to heat formula, • the number of supplies kept by the patients' bedsides was minimized
  13. 13. Lessons  Be vigilant to detect an increased incidence of common organisms  Adopt a systematic approach  Be prepared to be surprised
  14. 14. E Sakazakii outbreak  A male infant (1,270 grams) was delivered by cesarean section at 33.5 weeks' gestation and was admitted in NICU because of low birthweight, prematurity, and respiratory distress Morbidity & Mortality Weekly Report, CDC. Report
  15. 15. Cont…  The infant had fever, tachycardia, decreased vascular perfusion, and neurologic abnormalities (e.g., suspected seizure activity) at 11 days  Cerebrospinal fluid (CSF) suggestive of Meningitis  Culture of CSF grew E. sakazakii  The infant was treated with intravenous antimicrobials for meningitis; however, neurologic damage was progressive, and the infant died 9 days later
  16. 16. Cont…  Because the organism was a rare cause of neonatal meningitis, hospital personnel, in collaboration with the Tennessee Department of Health and CDC, investigated the source of infection
  17. 17. Cont…  During the study period, enhanced case surveillance was performed to find if other infants in the NICU were either infected or colonized with E. sakazakii  Patients were assessed for colonization by stool culture
  18. 18. Cont…  Confirmed infection was defined as any E. sakazakii-positive culture from a normally sterile site  Suspected infection was defined as an E. sakazakii-positive culture from a nonsterile site with documented deterioration in clinical status (e.g., increased respiratory rate without other evident cause) in the 24 hours before collection of the specimen for culture  Colonization was defined as an E. sakazakii- positive culture from a nonsterile site without documented deterioration in clinical status in the 24 hours before collection of the specimen for culture.
  19. 19. Cont…  A total of 49 infants were screened  Ten E. sakazakii infection or colonization events were identified: • one confirmed infection in the index patient (culture-positive from CSF), • two suspected infections (both culture- positive from tracheal aspirate) • seven colonization (six culture-positive from stool, one from urine)
  20. 20.  A cohort study was performed on the 49 patients who were screened to determine possible risk factors for acquisition of E. sakazakii infection or colonization  A case-patient was defined as any NICU patient with E. sakazakii infection (confirmed or suspected) or colonization during the study period
  21. 21. Cont…  Medical records were reviewed to assess possible risk factors during the study period, including • gestational age and birth weight, • mechanical ventilator use • humidified incubator use • oral medications • feeding type (TPN, formula [e.g., powdered or liquid], or breast milk) • Feeding method (i.e., continuous or intermittent administration)
  22. 22.  Of the 49 patients identified in the cohort, • nine were case-patients • 40 were non case-patients  Analysis of risk factors identified only use of a specific powdered infant formula product (Portagen [Mead Johnson Nutritionals, Evansville, Indiana]) to be significantly associated with E. sakazakii infection or colonization  all case-patients received Portagen compared with 21 of 40 non case-patients (p<0.01)
  23. 23. Cont…  To determine the source of infection, microbiologic studies were performed on samples of commercially sterile water used for formula preparation and from samples of formula taken from opened cans of Portagen from the same two batches used in the NICU during the study period
  24. 24. Cont…  Environmental swab cultures were taken from surfaces on which the product had been prepared  Cultures also were performed on unopened containers of Portagen supplied by the manufacturer with batch codes matching those of opened cans
  25. 25. Cont…  Cultures of formula taken from both opened and unopened cans of Portagen from a single batch grew E. sakazakii  Water and all environmental cultures were negative  Pulsed-field gel electrophoresis revealed that isolates of E. sakazakii from the CSF culture of the neonate with meningitis and from the culture of formula from both opened and unopened containers were indistinguishable
  26. 26. Cont…  To prevent additional infections, the hospital made several policy changes  Principal formula type for NICU patients was changed from powdered formula to a commercially sterile, ready-to-feed liquid formula  Portagen use was stopped  Other powdered formula products are reserved for specific needs and, when necessary, are prepared in a designated formula preparation room in the pharmacy  No additional episodes of infection or colonization have been detected at the reporting hospital
  27. 27. Lessons  Be vigilant for presence of unusual pathogens  Powdered formula is not a sterile product  Always include PIF in surveillance in case of E sakazakii
  28. 28. Neonatal Serratia marcescens outbreak  Observational study of microbiological and epidemiological investigations  Nine cases were observed in a 5 months period. A Serratia outbreak was therefore identified, and all the strains were compared by pulsed-field gel electrophoresis (PFGE)  Data from medical notes were gathered retrospectively  Environmental samples were gathered prospectively Acta Pædiatrica 97(10):2008
  29. 29. Cont…  Four infants were colonized and five infants were infected by S. marcescens.  PFGE revealed that three different strains were present.  Seven of the nine babies were infected by only one of these strains.  This same strain was found in a non-antimicrobial soap bottle (NAS) that could be the source of contamination  The outbreak was controlled with cohorting, contact isolation, surveillance cultures, and careful review of cleaning procedures
  30. 30. Flow Chart for outbreak investigation Incident Cases and Infection Rate Surveillance Cultures Processing of Specimens Pulse-field gel electrophoresis Identifying risk factors for colonization Infection control measures
  31. 31. Infection Control in the NICU – Recommended Standards NICU C2CE414Dd01.pdf  Adapted mainly from “Guidelines for Perinatal Care, 4th Edition by AAP and ACOG  Focuses on the following areas:- • Physical Setup • Administrative arrangement
  32. 32. Prevention of Nosocomial Infections  Each unit has a baseline rate of infection due to inherent modifiable risk factors  Effective strategy focus on modifiable risk factors • Strategic nursery design – space, sinks, soaps, paper towel • Adequate staffing • Hand hygiene compliance • Minimization of catheter days • Sterile preparation of all fluids to be administered • Promoting enteral feeding esp. with EBM/breastfeeding • Monitoring/ surviellance of nosocomial infection • Education and frequent feedback from staff
  33. 33. General Housekeeping  Cleaning should be performed in the following order – patient areas, accessory areas and then adjacent halls  In the cleaning procedure, dust should not be dispersed into the air  Once dust has been removed, scrubbing with a mop and a disinfectant/detergent solution should be performed  Cabinet counters, work surfaces etc should be cleaned once a day and between patient use with a disinfectant/detergent and clean cloths  Walls, windows, storage shelves and similar non- critical surfaces should be scrubbed periodically with a disinfectant/detergent solution  Sinks should be scrubbed clean at least daily with a detergent
  34. 34. Recommendations for Hand Hygiene  Wash hands with soap and water when hands are visibly soiled contaminated  If hands are not visibly soiled, alcohol based waterless antiseptic (ABWLAS) agents for routine decontamination of hands in all clinical situations  Before regular hand decontamination begins all wrists and hand jewelry should be removed  Cuts and abrasions must be covered with waterproof dressings  Fingernails should be kept short and clean
  35. 35. Recommended technique for Hand Hygiene ABWLAS agents  Apply enough of the product to cover all the surfaces of the hands and fingers  Rub hands together until they are dry  Enough volume should be applied – such that it takes 15-25 seconds to dry
  36. 36. Recommended technique for Hand Hygiene Hand Washing
  37. 37. Hand Hygiene Practices in a Neonatal Intensive Care Unit  A problem-based and task-orientated education program can improve hand hygiene compliance  Overall hand hygiene compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact  There was improvement in most aspects of hand-washing technique in the postintervention stage.  The health care–associated infection rate decreased from 11.3 to 6.2 per 1000 patient-days PEDIATRICS 2004;114 (5) :e565-e571
  38. 38. Use of Human-milk Feedings  Neonates fed breast milk were less likely to become septic compared to formula-fed neonates (Narayanan I et al. J Pediatr 1981)  human-milk feedings reduced the odds of sepsis/ meningitis compared to preterm milk feedings (Hylander MA et al. Pediatrics 1998 )  The efficacy of breast milk also appears to be dose dependent (Schanler RJ. Pediatr Clin North Am 2001)
  39. 39. Ventilation  A minimum of 6 air changes per hour is required for the NICU, with a minimum of 2 changes being outside air  Ventilation air delivered to the NICU shall be filtered with at least 90 % efficiency
  40. 40. Catheter related blood stream infections (CDC)  Isolation of a recognized pathogen from one blood culture or isolation of a skin commensal from two blood culture specimens  One/more clinical signs of infection  Presence of an intravascular device CDC’s National Nosocomial Infection Surveillance System (NNIS) reported CABSIs - pooled means – 28.2/1000 catheter days in VLBW babies
  41. 41. RECOMMENDATIONS FOR PLACEMENT OF INTRAVASCULAR CATHETERS Health-care worker education and training Category IA Category IB  Educate health-  Ensure appropriate care workers nursing staff levels  Assess knowledge in ICUs of and adherence to guidelines periodically
  42. 42. Surveillance  Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis - IB  Record the operator, date, and time of catheter insertion and removal, and dressing changes on a standardized form - II
  43. 43. Aseptic technique during catheter insertion and care  Maintain aseptic technique for the insertion and care of intravascular catheters - Category IA  Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site - Category IA  Promptly remove any intravascular catheter that is no longer essential - Category IA  Clean injection ports with 70% alcohol or an iodophor before accessing the system - Category IA
  44. 44. Strategies that do not Appear to Work  Ventilator circuit changes more often than one time per week were not associated with a decrease in pneumonia or sepsis (Long M et al. Infection Control & Hospital Epidemiology,1996)  Gowning before entering the NICU has no effect on reducing HAI (Tan S et al. International J of Nursing Practice 1995)  Changing the frequency of tracheal suctioning from every 4 hours to 8 hours did not change pneumonia or blood stream infection rate (Cordero I et al. Journal ofPerinatolgy 2000)
  45. 45. Prophylactic IVIG  Meta analysis of IVIG in preterms  Only 3% reduction in nosocomial infection  No reduction in mortality (Modi and Carr, 2000)
  46. 46. Haemopoietic Colony Stimulating Factor (G-CSF, GM-CSF)  Effective in raising neutrophil count  Not consistent in decreasing nosocomial infections or mortality (Modi and Carr 2000)
  47. 47. Gowns  Routine use does not help in reducing endemic nosocomial infection rate  Should be used • In specific circumstances in which the risk of contamination is high • The infant is being held
  48. 48. Conclusions  HAIs/NCIs could be prevented with a systematic, evidence based approach  Outbreaks need prompt identification and remedial actions  Do not hesitate to report and document the outbreaks
  49. 49. Their Future is in Our Hands  Thanks !!!!
  50. 50. Antibiotics for preterm rupture of membranes (Cochrane Review - 2005) Parameter RR 95% CI chorioamnionitis 0.57 0.37 to 0.86 born within 48 0.71 0.58 to 0.87 hours of randomisation born within seven 0.80 0.71 to 0.90 days of randomisation neonatal infection 0.68 0.53 to 0.87 use of surfactant 0.83 0.72 to 0.96 Co-amoxiclav - 4.60 1.98 to 10.72 NNEC