HOW TO PREVENT HOSPITAL

ACQUIRED INFECTION
 

Ema Alasiry
RSUP Dr. Wahidin Sudirohusodo, Makassar/
Departemen Ilmu Kesehatan Anak FK UNHAS
 
Introduction
■  WHO :

–  5.9 million children under the age of 5 years died in 2015.

–  45% (2,7 million babies) in their first month of life and a similar number are
stillborn.

1st mo 5th year

45%

25%
50%
1st
24 hours
week

Global Health Observatory (GHO) data, Child mortality and causes death, 2015,
WHO. Children : Reducing Mortality. www.who.int/mediacentre/factsheets/fs178/en/
■  The Global Network Algorithm (2017):
One-third (33.1%) of the 3068 neonatal deaths were due to suspected infection, 30.8%
to prematurity, 21.2% to asphyxia, 9.5% to congenital anomalies and 5.4% did not have
a cause of death assigned.

Others
Congenital anomaly
5%
11% Suspected infection
33% Suspected infection
Asphyxia
21% Preterm
Asphyxia
Preterm Congenital anomaly
31% Others

Garces AL, et al, Acta Pediatrica 2017;106:904-911

 Definition

■  Hospital-acquired infection (HAI) or Health care–

associated infections (HCAIs) in the NICU are
infections acquired in the hospital while receiving
treatment of other conditions.

Polin RA, Committee on Fetus and Newborn; Strategies for prevention of Health Care-Associated Infections in the
NICU. Pediatrics 2012;129:1085-1093
Consequences

HAI

health economic

microstructural and prolonged length of stay (LOS)

metabolic brain development à increased medical costs.

Polin RA. Committee on Fetus and Newborn; Pediatrics 2012;129:1104-1109

Payne NR, et all Pediatrics 2004;114:348-355
Chau V , Pediatric Research 2012
Risk factor
■  Preterm : intestinal disorders with proliferation of a pathogenic microflora,
lack an effective skin barrier, and immature or ineffective immune systems
■  frequent use of broad-spectrum antimicrobial drugs
■  parenteral nutrition
■  acid inhibitors and steroid
■  long-term use of invasive devices; central venous catheters (CVCs) and ETT

Manzoni P, De Luca D, Stronati M, et al. Am J Perinatol 2013;30:81-88

 Strategies of prevention infection
Prevention of Central Line- Prevention of Ventilator
Hand Hygiene associated bloodstream associated Pneumonia
Infection (CLABSI) (VAP)

Pro,Pre, synbiotic Prevention of Antibiotic

Resistence
Prevention of Fungal
Infection
Breastfeeding

Skin care Kangaroo Mother

Care (KMC)

Ramasethu J, Maternal Health, Neonatology, and Perinatology (2017) 3:5

Hand hygiene

■  The most effective method for reducing HAI

■  Hospitals with á rates of hand hygiene compliance have â rates of central line
bloodstream infection

Aboelela SW, J Hosp In- fect. 2007;66(2):101–108

WHO Recommendations for Hand Hygiene
■  Wash hands with soap and water when visibly dirty or soiled with blood or other body
fluids (IB) or after using the toilet (II).
■  Use of an alcohol-based hand rub for all routine antisepsis if the hands are not
soiled (IA).
■  If an alcohol-based hand rub is not obtainable, wash hands with soap and water (IB).
■  Brushes are no longer recommended (even for surgical scrubs) (IB).
Antimicrobial activity and summary of properties of antiseptics used in hand hygiene
Perform hand hygiene
■  Before and after touching the patient (IB).
■  Before handling an invasive device for patient
care, regardless of whether gloves are worn (IB).
■  After contact with body fluids or excretions,
mucous membranes, nonintact skin, or wound
dressings (IA).
■  If moving from a contaminated body site to another
body site during care of the same patient (IB).

■  After contact with inanimate surfaces and objects

(including medical equipment) in the immediate
vicinity of the patient (IB).
■  After removing sterile (II) or nonsterile gloves (IB).
Use of gloves:
■  The use of gloves does not replace the need for hand hygiene (IB).
■  Wear gloves when it can be reasonably anticipated that contact with blood or other
potentially infectious materials, mucous membranes, or nonintact skin will occur
(IC).
■  Remove gloves after caring for a patient. Do not wear the same pair of gloves for
more than 1 patient (IB).
■  Change or remove gloves during patient care if moving from a contaminated body
site to either another body site (including nonintact skin, mucous membrane, or
medical device) within the same patient or the environment (II).
Other aspects of hand hygiene:
■  Do not wear artificial fingernails or extenders when having direct contact with the
patient (IA).
■  Keep natural nails short.
Hand hygiene promotion programs:
■  Focus on factors à significant influence on behavior and not solely on the type of
hand hygiene product.
■  The strategy : multifaceted and multimodal and include education and senior
executive support for implementation (IA).
■  Monitor health care workers : performance feedback (IA).
■  Encourage partnerships between patients, their families, and health care workers to
promote hand hygiene in the health care setting (II)
Prevention of Central Line– Associated
Bloodstream Infections (CLABSI)

■  The most common HAI

■  Poor technique at the time of placement and ongoing care of the catheter site.
■  In the first week : catheters are more mobile, can slide in and out of the insertion site
■  After the first week : intra- luminal colonization after hub manipulation and
contamination

O’Grady NP,Am J Infect Control. 2002;30(8 suppl 1):476–489

MaximumMaximum
barrierbarrier
precaution
precaution
Guidelines for the Prevention of Intravascular Catheter-related
Infections
■  Remove and do not replace UAC if any signs of CLABSI , vascular insufficiency in the lower
extremities, or thrombosis are present (Category II).
■  Cleanse the umbilical insertion site with an antiseptic before catheter insertion.
■  Avoid tincture of iodine because of the potential effect on the neonatal thyroid.
■  Do not use topical antibiotic ointment or creams on catheter insertion sites
■  Add low doses of heparin (0.25–1.0 U/mL).
■  Remove umbilical catheters as soon as possible when no longer needed
■  An umbilical catheter may be replaced if it is malfunctioning
■  Total duration of catheterization has not exceeded 5 d for an UAC or 14 d for an UVC (Category
II).
Ventilator Associated Pneumonia (VAP)
■  VAP = Hospital associated pneumonia (HAP)
■  Due to aspiration of bacteria from the oropharynx or the gastro- intestinal tract.

Hooven TA, Polin RA. Early Hum Dev 2014;90 (suppl.1):S4-S6

Prevention of VAP
■  staff education and training;
■  microbiological surveillance;
■  prevention of cross- transmission (improving hand hygiene); and
■  early removal of mechanical ventilation.
■  elevation of the head-end of the bed by 30-40
■  avoidance of gastric overdistension à use of orogastric tubes;
■  good oral hygiene; and
■  elimination of non-essential tracheal suction.

Boudma L, Deslandes E, Lolom I, et al. Clin Infect Dis 2010;51:1115-1122.

Legeay C, et al. Journal of hospital Infection 2015;89: 319-323
■  Keeping the endotracheal tube and the ventilator circuit in a horizontal position
■  The lateral position is also associated with reduced aspiration of gastric secretions
into the trachea.

Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A. Pediatrics. 2008;122(4):770–774

Torres A, Serra-Batlles J, Ros E, et al. Ann Intern Med. 1992;116(7): 540–543
Prevention of Fungal infections
■  IFIs are the third leading cause of late-onset sepsis in VLBW infants
■  In the first week + 50% à 64% by 4 weeks of age.
■  secondary : maternal transmission or healthcare workers
■  A recent Cochrane meta-analysis suggested that prophylactic systemic antifungal
therapy reduces the incidence of IFIs in VLBW infants.
■  The incidence of ICI/IFIs : 22.3% in the CG, 18.2% in the FG, 2.9% in the IMG (The
integrated measures approach)
■  Prophylaxis for preterm with BW < 1000 g or GA ≤ 27 weeks gestation:
fluconazole IV 3 mg/kg twice a week, start : within 2 days after birth à no necessity
for intravenous access.

Chapman RL. Semin Perinatol 2007; 31: 39-46

Austin NC, Darlow B. Cochrane Database Sys Rev 2004; 1: CD003478
Libovitz E. Pediatr Neonatol 2012; 53: 83-89
Kaufman DA. Early Hum Dev. 2012;88S2:S45–9.
 Breast feeding
■  Early enteral feeding (within 2 to 3 days of life) :
HAI ➡
without increasing rates of necrotizing enterocolitis

§  Human milk contains secretory antibodies, phagocytes, lactoferrin and prebiotics which
improve host defense and gastrointestinal function.
■  The advantages of maternal breast milk : have not been duplicated by the use of donor milk
■  compositional and bioactive differences between mother’s own milk and donor milk.

Flidel-Rimon O, Friedman S, Lev E, et al. Arch Dis Child Fetal Neonatal Ed. 2004; 89:F289–292.
Kangaroo mother care

■  Cochrane meta-analysis (2014) : KMC reduction of nosocomial infections/sepsis

( RR 0.45, 95% CI 0.27 to 0.76)
■  Lawn (2010) :
–  Some preterm infants had fewer infections or none or less severe infections
than infants who did not receive KMC.
–  Baby’s skin in KMC is colonized by the mother’s good commensal organisms

Lawn JE, Int J Epidemiol. 2010; 39(1): i144–i154

Conde-Agudelo A, Díaz-Rossello JL. Cochrane Database Syst Rev. 2014 Apr; 22; 4: CD002771.
■  Key results: Compared with conventional neonatal care, KMC was found to reduce
mortality at discharge or at 40 to 41 weeks' postmenstrual age and at latest follow-up,
severe infection/sepsis, nosocomial infection/sepsis, hypothermia, severe illness, and
lower respiratory tract disease.

Conde-Agudelo A, Díaz-Rossello JL, 2016

Skin care

■  Topical emollients : vegetable oils or aquaphor à improve skin integrity and barrier
function and thereby prevent invasive infection.
■  A recent Cochrane meta-analysis of 18 primary publications involving 3089 infants
did not provide evidence that the use of emollient therapy prevents invasive infec-
tion or death in preterm infants in high, middle or low income settings

Cleminson J, McGuire W. Cochrane Database Syst Rev. 2016;1:CD 001150.

Prevention of Antibiotic resistance
Α ρεχεντ ρεϖιεω οφ οϖερ 50,000 πατιεντσ ιν 127 Χαλιφορνια ΝΙΧΥσ :
–  σηοωεδ α 40 φολδ ϖαριατιον ιν αντιβιοτιχ πρεσχριβινγ πραχτιχεσ,
§  Προλονγεδ ινιτιαλ εµπιριχαλ αντιβιοτιχ τρεατµεντ : ΛΟΣ, ΝΕΧ
ανδ δεατη.
§  εαχη αδδιτιοναλ εµπιριχαλ τρεατµεντ δαψ à ρισκ
§  Περιναταλ ανδ εαρλψ εµπιριχ αντιβιοτιχ υσε à λοωερ βαχτεριαλ
διϖερσιτψ
§  ινχρεασεδ χολονιζατιον : Εντεροβαχτεριαχεαε à CLABSI
§  Ωιδεσπρεαδ αντιβιοτιχ υσε, παρτιχυλαρλψ ωιτη βροαδ σπεχτρυµ
χεπηαλοσπορινσ à τηε δεϖελοπµεντ οφ ρεσισταντ στραινσ, ανδ
ινχρεασεδ χολονιζατιον ανδ ινϖασιϖε δισεασε δυε το χανδιδα
Madan JC, Slari RC, Saxena D, et al.. Arch Dis Child Fetal Neonatal Ed. 2012; 97:F456–62.

Greenwood C, Morrow AL, Lagomarcino AJ, et al. J Pediatr. 2014;165:23–9.

Prevention of Antibiotic Resistence
Ten point plan to reduce antibiotic resistance in neonatal units
1 Always take cultures of blood (and perhaps cerebrospinal fluid and/or urine) before starting the
infant on antibiotics
2 Use the narrowest spectrum antibiotics possible, almost always a penicilin (e.g. Benzylpenicilin,
flucloxacilin, piperacilin,ticarcilin) and an aminoglycoside (e.g. Gentamicin,netilmicin, amikacin)
3 Do not start treatment, as a general rule, with a third generation cephalosporin (e.g. Cefotaxime,
Ceftazidime) or a carbapeneme (e.g. Imipenem, meropenem)
4 Develop local and national antibiotic policies to restrict the use of expensive, broad spectrum
antibiotics
5 Trust the microbiology laboratory: rely on the blood culture results
6 Do not believe that abnormal results for a non-spesific test , such as raised serum C-reactive protein,
mean that the baby is definetly septic
7 If blood cultures are negative at 2-3 days, it is almost always safe and appropriate to stop antibiotics

8 Try not to use antibiotics for long periods

9 Treat sepsis, but not colonisation
10 Do your best to prevent nosocomial infection, by reinforcing infection control, particularly hand
washing
 Probiotic, prebiotic and sinbiotic
§  2014 : Α Χοχηρανε µεταναλψσισ οφ 16 ελιγιβλε τριαλσ (ν =5338) :
προβιοτιχ συππλεµεντατιον διδ νοτ ρεσυλτ ιν στατιστιχαλλψ σιγνιφιχαντ
ρεδυχε οφ ΛΟΣ ιν πρετερµ.
■  2015 : Τηε Προβιοτιχσ ιν Πρετερµ Ινφαντσ Στυδψ Χολλαβορατιϖε (ΠιΠσ
τριαλ) ιν τηε ΥΚ (ν= 1315, Βιφιδοβαχτεριυµ βρεϖε ΒΒΓ-001) à νο
σιγνιφιχαντ διφφερενχε ιν τηε ινχιδενχε οφ ΛΟΣ & ΝΕΧ. Νο αδϖερσε
εφφεχτσ, βυτ τηερε ηαϖε βεεν χασε ρεπορτσ οφ βαχτερεµια ιν πρετερµ
ινφαντ οριγινατινγ φροµ προβιοτιχ τηεραπψ
■  2016 : Α µεταναλψσισ οφ 37 ΡΧΤ (ν= 9416) : προβιοτιχσ σιγνιφιχαντλψ
ρεδυχεδ τηε ρισκ οφ ΛΟΣ.(13.9% ϖερσυσ 16.3%, ΝΝΤ =44), βυτ οφ αλλ τηε
στυδιεσ αναλψζεδ, τηε τωο λαργεστ τριαλσ διδ νοτ σηοω α σιγνιφιχαντ
ρεδυχτιον ιν τηε ρατεσ οφ ΛΟΣ ωιτη προβιοτιχσ
Al Faleh K, Anabrees J. Cochrane Database Syst Rev. 2014;4:CD005496.
Bertelli C, Pillonel T, Torregrossa A, et al. Clin Infect Dis. 2015;15:924–7.
Rao SC, et al. Pediatrics. 2016;137:e20153684
■  A metanalysis of 7 trials (n=417) : prebiotics significantly higher growth of
beneficial microbes but did not decrease the incidence of sepsis, NEC or reduce the
time to full feeding
■  Synbiotic can improve survival of the probiotic bacteria, but there is no clinical
evidence that synbiotics are useful in preventing neonatal infection

Srinivasjois R, Rao S, Patole S. Clin Nutr. 2013;32:958–65.

Underwood MA, Salzman NH, Bennett SH, et al. J Pediatr Gastroenterol Nutr. 2009;48:216–25.
Conclusion
Hospital acquired infections (HAI) :
■  infections acquired in the hospital while receiving treatment of other conditions.
■  considerable health and economic consequences.
■  Hand hygiene is the most important intervention for reducing HAI.
■  Other interventions to prevent HAI including improving neonatal management,
avoiding unnecessary use of central venous catheter, restricting use of antibiotic,
and introducing antifungal prophylaxis.
■  The use of maternal breast milk and kangaroo mother care are other inexpensive
and simple measures to reduce infection rates.
Thank you