Mansoura 2009

INFECTION CONTROL IN NICUS HANY ALY, MD, FAAP Professor of Pediatrics, Obstetrics & Gynecology Director, Newborn Services The George Washington University

SEPSIS IN VLBW INFANTS Vermont-Oxford Network

%

40

20

0

1998

1999

2000

2001

SEPSIS IN VLBW INFANTS…. NICHD

Incidence of ≥ 1 episode of late onset sepsis: 21% ……”strategies to reduce late infections in VLBW neonates...are urgently needed. The use of collaborative quality improvement strategies to reduce nosocomial infections among VLBW NICU patients warrants additional study.” Stoll et al; Pediatrics, 2000

Infection/1000 line days

INFECTIONS AT GWU 20

Aly et al., 2005 - Aly & Herson 2006

15 10 5 0 98 99 0

1

2

3

4

5

6

7

8

FACTORS THAT INCREASE RISK OF INFECTION IN NICU

• Immature immune system in the newborn • Overcrowding and understaffing • Inadequate numbers or placement of • •

sinks Neonates may be colonized with pathogens without overt symptoms Invasive procedures

THE NURSERY: LOCATION

• It should be in a low traffic area • Access to the unit should be restricted • No open windows to the outside • Nursing station should be away from patient care area

THE NURSERY: SINKS A sink should be within 8 steps from each patient

a

NURSERY LEVEL

NUMBER OF SINKS

Level 1

1 Sink / 6-8 Neonates

Level 2

1 Sink / 3-4 Neonates

Level 3

1 Sink / 3-4 Neonates

THE NURSERY: SPACE DESIGN NURSERY LEVEL

SPACE / NEONATE

Level 1

30 ft2 / Neonate

Level 2

50 ft2 / Neonate

Level 3

2

80- 100 ft / Neonate

THE NURSERY STRUCTURE

• Entrance:

Foot operated sink Gowns (?) Disposable trash cans

• Isolation rooms: For airborne infections For home admissions (72 hours)

PERSONNEL: STAFFING

a

NURSERY LEVEL

NUMBER OF NURSES

Level 1

1 Nurse / 6-8 Infants

Level 2

1 Nurse / 2-3 Infants

Level 3

1 Nurse / 1-2 Infants

PERSONNEL: GLOVES

• Use gloves for any contact with body •

fluids Use masks, head covers, sterile gloves and sterile gowns for procedures: – PCVL – UAC / UVC

PERSONNEL: OVERSHOES

?

PERSONNEL: OTHERS

• Foods and drinks are not allowed • Live plants and flowers are not allowed • Sterile solutions, flushes should not be kept longer than 24 hours

– Label all solutions with date and time of opening

HANDWASHING

• It the MOST important infection control measure

• Remove all jewelry • Roll sleeves up to elbows • Use a wet sponge or scrub brush with an antiseptic:

Chlorhexidine Gluconate Povidone Iodine

HAND WASHING

• P.S. Liquid soap dispensers and their contents can become contaminated

• Alcohol-containing foams and gel kill

bacteria when applied to clean hands. It does not work when hands are physically soiled

• Alcohol-containing products require 15 seconds to 2 minutes of contact

HAND WASHING: DURATION CONDITION

DURATION

At the start

2-3 minute scrub

Before procedures

2-3 minute scrub

Other consultants

2-3 minute scrub

Hospital technicians 2-3 minute scrub Between patients

15-30 seconds

HAND HYGIENE

• Fingernails should be trimmed short • Artificial fingernails or extenders should not be permitted

• Clear nail polish on natural nails appear to have no effect , but dark colors may obscure the subungual space and reduce the likelihood of careful cleaning

HAND WASHING

• Poor hand washing increases the risk of transmitting infections (Infec Control hospital Epidemiology 1988)

• Transmission of Staphylococci between

newborns is more likely to occur by personnel who are less compliant about hand washing (Mortimer et al AMJ. DIS chil.104 1950)

• Compliance with hand washing is poor

HAND WASHING SAVES LIVES

WHY IS COMPLIANCE SO POOR?

• Hand washing takes too much time (44%) • Hand washing is not important if an infant • • •

is receiving antibiotics (10%) One thorough wash/ day is sufficient (26%) Gloves can substitute for hand washing (25%including 50% of physician ) Lack of soap (54%) and towels (65%) Wharton et al Ped Res 1998

HAND WASHING

• Six nurses were assigned to monitor hand washing techniques without their coworkers awareness. 1. Was there a 15 second wash prior to handling an infant? 2. Was an inanimate object or one’s own body touched while examining the infant? 3. Were bracelets and rings removed ? Raju & Kobler Am J Med SCI 1991

HAND WASHING Compliance Rate

Item #1 Doctors 37.5% Nurses 53.9% Ancillary staff 48.5%

Item #2

Item #3

29.2% 29.2% 25.0%

72.7% 75.3% 85.7%

Initial overall compliance 28.2% Vs 62.6% (after an educational process) Raju & Kobler Am J Med SCI 1991

ROUTINE GOWNS !!!

• Practice transferred from policies •

developed for surgical asepsis during operations Very limited data to support its efficacy and much data to say it is ineffective*

*Forfar & McCabe BJM 1958,Williams&Oliver Pediatrics 1969,Donowitz Pediatrics 1986, Pelke Arch Ped &Adol Med 1994

ROUTINE GOWNS !!!

• Does the gown serve as a reminder to •

wash hands? No! (Donowitz et al Pediatrics 1986) The risk of transmission infection through clothing is less than 2/10,000 (Larson JOGNN 1987)

EMPLOYEE HEALTH

• ILLNESS: – Respiratory: – Conjunctivitis: – Skin lesions:

• VACCINES:

Use masks Do not enter the unit Do not touch patients or equipment

– Hepatitis B – Td (every 10 years)

INFECTION CONTROL EDUCATION

• Infection control course review every 2 years for all staff and nurses

• A written test may be conducted • Conferences • Flyers

VISITORS

• They must do 2-3 minute scrub • Visitation should be restricted during URI • • •

outbreaks Only 2 visitors at a time They should not contact any equipment or any other infant Visitors to well babies should be in mothers’ rooms

ENVIRONMENT: FLOORS

• Dust sweep every 8 hours • Wet cleaning at least once a day • Use any of the following: – Quaternary ammonium compounds – Chlorine – Alcohol

• Walls, curtains

and windows should be cleaned every week

ENVIRONMENT: ISOLETTES

• Should be cleaned in a designated room with a quaternary ammonia product

• Should be replaced every 7 days • Should be wiped form outside every 8 hours

• Should be wiped from inside once a day

ENVIRONMENT: ISOLETTES

• Humidifier reservoirs should be cleaned and filled with sterile water

• Linens should be replaced every day • Soiled linens will be kept in covered containers until removed by laundry personnel

ENVIRONMENT: OTHERS

• Waste should be collected in plastic bags • • •

and placed in soiled utility room Needle containers should be placed in each room and replaced when they are 3/4 full Room temperature at 24-27 0C Relative humidity at 30-60 %

EQUIPMENT: RESPIRATORY

• Ventilator circuit should be replaced every • • •

week (?) Water condensate in the tubing should be drained periodically Use only sterile water for the humidifier Ventilators should be replaced and disinfected every week

ENVIRONMENT: RESPIRATORY

• Each infant should have his own resuscitation bag and mask

• They should be kept clean away form the floor

• They should be replaced and disinfected every week (?)

ENVIRONMENT: RESPIRATORY

• Suction catheters should be discarded • • •

after single use (? Re-sterilization ?) Suction tubing should be changed every day or when soiled Suction reservoir liner should be changed when it is full Sterile gloves and sterile saline bullets (5 ml) should be used with suction

CPAP AND SEPSIS (GNS)

Graham et al, 2006

Infection/1000 line days

20

CPAP AND SEPSIS

15 10 5 0 98 99

0

1

2

3

4

5

6

7

8

Aly et al., 2005 - Aly & Herson 2006

NASAL COLONIZATION AND CPAP

• 829 cultures from 170 premature infant • Only one infant had GN bacteremia • BW, Gender, race, Prenatal steroids, •

PROM, Maternal infection did not affect colonization GN colonization was associated with – CPAP (P=0.04) – Vaginal delivery (p=0.02)

TRACHEAL COLONIZATION AND ETT

TRACHEAL COLONIZATION AND ETT

Cultures on day 5 • Gram negative rods: Klebsiella Pseudomonus Enterobacter

• Gram positive cocci: Staphylococcus Streptococcus

• Candida • Mixed

Supine (n=30)

Lateral (n=30)

P

26 (87) 18 (60)

9 (30) 6 (20)

<0.01

10 (33) 6 (20) 2 (7)

4 (13) 2 (7) 0 (0)

0 (0)

2 (7)

0 (0) 0 (0)

1 (3) 1 (3)

2 (7) 6 (20)

0 (0) 1 (3)

ABSTINENCE IS THE KEY During intubation think about Ventilator Associated Pneumonia

ENVIRONMENT: FEEDING

• Nasogastric tubes should be changed every 3 days

• Feeding syringes should be replaced every 4 hours

• Once out, gavage feeding tubes should be re-inserted again

ENVIRONMENT: IV LINES

• Document the date of insertion of any line • UAC/UVC should not remain >15 days (?) • Apply betadine or alcohol if the umbilical site is moist

• Central lines dressing should be

evaluated daily and changed weekly

ENVIRONMENT: IV LINES

• If blood culture remains positive after 48 • •

hours of antibiotics treatment, PICC should be removed Continuous infusion of heparinized fluids should run all times in central lines Sterile fluids should be replaced daily

ENVIRONMENT: IV LINES

• IV tubing should be replaced every 24 hours

• IV medications should be administered maintaining aseptic technique (closed medication system)

• IV pumps should be cleaned every 8 hours and when soiled

BLOOD INFECTIONS-NICUs Infections/1000 line days 25 20 15 10 5 0 1

2

3

4

5

6

7

8

9 10 11 12 13 14 15 16 Medical Management Planning, Inc. 1999

INFECTIONS AT GWUH CCMC

35

GWUH

30 25 B S I /

20 1 15 0 0 0

10 l i n e d a y s

5 0 '95

'96

'97

'98

'99

'00

'01

INFECTIONS AT GWU U Con

GWU

NNN

20 15 10 5 0 1999

2000

2001

Infection/1000 line days

INFECTIONS AT GWU 20

Aly et al., 2005 - Aly & Herson 2006

15 10 5 0 98 99 0

1

2

3

4

5

6

7

8

SEPSIS IN VLBW INFANTS Vermont-Oxford Network

%

40

20

0

1998

1999

2000

2001

SEPSIS IN VLBW INFANTS…. NICHD

Incidence of ≥ 1 episode of late onset sepsis: 21% ……”strategies to reduce late infections in VLBW neonates...are urgently needed. The use of collaborative quality improvement strategies to reduce nosocomial infections among VLBW NICU patients warrants additional study.” Stoll et al; Pediatrics, 2000

ENVIRONMENT: SCALES, MONITORS & SUPPLIES

• Dinamaps, stethoscopes and diaper • • •

weighing scales should be wiped with disinfectant between infants Cardiac monitors and POX should be disinfected daily Supplies should not be shared between infants Soiled and clean items should not be mixed

INFANTS

• Remove infants from radiant warmers as soon as possible

• Infants admitted from community should

be admitted to isolation area with contact precautions for 72 hours

• Umbilical stumps should be cleaned with alcohol with each diaper change

INFANTS

• If omphalitis is endemic use triple dye • •

routinely to to reduce Staph. aureus colonization Triple dye: 2.29g brilliant green + 1.14g profavine hemisulfate + 2.29g crystal violet in a letter of sterile water Infants should be bathed 3 times a week. Do not apply soap to the face

INFANTS

• Erythromycin eye ointment to all infants on admission

• Use only CMV-antibody negative blood

(via Leukopoor filtration) for all infants’ transfusions

NUTRITION: FORMULA

• Formula should be discarded after 24 hours from preparation

• Sterile water should be used for preparation

• Fortification with non-cow protein formulas only

NUTRITION: FORMULA

• Formula should be discarded after 24 hours from preparation

• Sterile water should be used for preparation

• Fortification with non-cow protein formulas only

NUTRITION: BM EXPRESSION

• Give proper instructions to mothers – Careful washing of nipple and hand – Pumps should be sterilized by boiling for 1015 minutes every day – Pumps should be cleaned with hot soapy water after each use – HBsAG positive mother can breast feed if the infant received the HBIG and vaccine

NUTRITION: BM STORAGE

• BM should be stored in sterile bags labeled with date and name on it It can be refrigerated for 24 hours It can be frozen for 2-3 weeks

• • • It can be stored in deep freezers (-18 •

0

C)

for months Do not use microwave for thawing frozen milk

CPAP and NEC (n=342) Variables

OR

95% CI

P

Birth weight

0.99

0.99

1.0

0.05

Gender (Male)

2.42

0.93

6.27

0.07

Prenatal steroids

1.58

0.57

4.35

0.38

Duration of CPAP

1.04

0.47

2.33

0.92

PaO2

0.99

0.97

1.0

0.08

FiO2 during CPAP

0.99

0.98

1.02

0.92

Umbilical artery Catheter

2.4

0.82

6.99

0.11

Patent ductus arteriosus

0.18

0.06

0.52

0.002

Early sepsis

1.12

0.10

12.494

0.93

Delivery room intubation

1.37

0.39

4.84

0.62

Hospital site

0.86

0.34

2.21

0.76

Aly et al Pediatrics 2009

NUTRITION: CANDIDA PROPHYLAXIS

• Nystatin is given to all ELBW infants • • •

<1000 g after the first week of life Oral swab Q 8 hours Prophylaxis continues until infants are on full enteral feed and weighs >1 kg Infants on steroid nebulization also receives nystatin

ZANTAC IS ASSOCIATED WITH INCREASED SEPSIS

60

30

Sepsis %

OR=6.99 0 Zantac

No Zantac

J Perinatal Med 2007:35:147-150

ANTIBIOTIC CHOICE

• The use of cephlosporins as the primary choice of antibiotics are associated with significantly increased mortality

• Mortality is explained by increased Candida sepsis

IMMUNIZATION

• In accordance to the postnatal age • OPV only at discharge, otherwise use IPV • BCG can be given at discharge

ISOLATION: NON-NEONATAL

• Respiratory – Meningitis due to H. influenzae or N. meningitidis – Measles – Pertussis

• Tuberculosis

ISOLATION TYPES OF ISOLATION EXAMPLES

Strict

Varicella

Contact

Drainage/Secretions

URI, C. Rubella, HSV, Staph wounds NEC, Gastroenteritis, viral meningitis Non-Staph wounds

None

CMV, GBS

Enteric