Evidence based guidelines for prevention of infection in NICU

Dr. JP Dadhich


Relevance of infection control Out breaks in NICU and lessons learnt from them Evidence based infection control measures in NICU 

Nosocomial Infections
70 60 50 40 30 20 10 0 IM EM 31 EOS LOS 67 56 44

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 ‡ Neurodevelopment impairment

Risk factors for nosocomial infections 

Prematurity Low birth weight Invasive device
‡ Intravascular device ‡ Mechanical ventilation ‡ Urinary Catheter ‡ VP shunt  


Delayed enteral feeding Formula feeding Inadequate nursing staff/overcrowding Poor compliance with hand washing 

‡ H2 Blockers ‡ Steroids


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

health care workers have been the reservoir NEJ 2000. 343 (10):695-700.   Endemic Pseudomonas aeruginosa nfection in a Neonatal ntensive Care Unit Pseudomonas aeruginosa is a wellwellknown cause of nosocomial infections among infants in neonatal intensive care units. aeruginosa Occasionally. . Environmental sources such as sinks and respiratory-therapy equipment respiratoryare the most commonly described reservoirs of P.

6 of whom were identified as being colonized or infected with P. than once a month fo next two months . nasopharyngeal swabs ± twice a month till all babies in the cohort were discharged.Surveillance     An increased incidence of colonization and infection with P. aeruginosa Surveillance cultures were obtained from the other 27 infants ± GA. aeruginosa was noted Surveillance cultures were performed to identify all infants with colonization 33 infants in the neonatal intensive care unit. ET secretions.

Detecting environmental reservoirs  Cultures of environmental specimens ‡ ‡ ‡ ‡ ‡ ‡ ‡ tap water sink drains liquid medications respiratory-therapy equipment respiratoryhand soaps hand creams water baths used to warm formula  Moist and dry environmental surfaces were swabbed with a cotton-tipped swab cotton- .

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 "glove juice" 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 infectionpractitioner through the wall of the bag for 15 to 30 seconds samples were delivered to the microbiology laboratory within 1 hour for processing .

swimming in the preceding year. nail polish. were assessed Risk factors for colonization of the hands of health care workers with P. aeruginosa was assessed     . aeruginosa were determined by logistic-regression analysis logisticwith the use of SAS software The association between exposure to a specific health worker and infection or colonization with the endemic clone of P. such as use of antibiotics and a history of otitis externa. skin lesions or dermatitis. and cracked or inflamed nail beds was noted Possible exposures to P.Risk Factors for Colonization of the Hands with P. aeruginosa and risk factors for infection. latex allergy. and the use of artificial nails or nailnail wraps. nail or nail-bed infections. aeruginosa  The hands of all health care workers were inspected by the infection-control practitioner infectionThe presence of false nails.

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 .Results   None of the cultures of environmental specimens grew P. aeruginosa Among 165 health workers.

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.InfectionInfection-Control  easures Contact isolation procedures were used for infants who were colonized or infected with P. several care practices were changed: ‡ water baths were no longer used to heat formula. 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. ‡ the number of supplies kept by the patients' bedsides was minimized .      At the beginning of each shift.

Lessons    Be vigilant to detect an increased incidence of common organisms Adopt a systematic approach Be prepared to be surprised .

prematurity.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. . and respiratory distress Morbidity & Mortality Weekly Report. CDC.

g. suspected seizure activity) at 11 days Cerebrospinal fluid (CSF) suggestive of Meningitis Culture of CSF grew E. neurologic damage was progressive. tachycardia. and the infant died 9 days later .Cont«     The infant had fever.. sakazakii The infant was treated with intravenous antimicrobials for meningitis. decreased vascular perfusion. and neurologic abnormalities (e. however.

Cont«  Because the organism was a rare cause of neonatal meningitis. in collaboration with the Tennessee Department of Health and CDC. investigated the source of infection . hospital personnel.

Cont«   During the study period. sakazakii Patients were assessed for colonization by stool culture . enhanced case surveillance was performed to find if other infants in the NICU were either infected or colonized with E.

g.Cont«    Confirmed infection was defined as any E. . sakazakiisakazakiipositive culture from a nonsterile site without documented deterioration in clinical status in the 24 hours before collection of the specimen for culture.. sakazakiisakazakii-positive culture from a nonsterile site with documented deterioration in clinical status (e. increased respiratory rate without other evident cause) in the 24 hours before collection of the specimen for culture Colonization was defined as an E. sakazakiisakazakii-positive culture from a normally sterile site Suspected infection was defined as an E.

one from urine) .Cont«   A total of 49 infants were screened Ten E. (culture‡ two suspected infections (both cultureculturepositive from tracheal aspirate) ‡ seven colonization (six culture-positive culturefrom stool. sakazakii infection or colonization events were identified: ‡ one confirmed infection in the index patient (culture-positive from CSF).

  A cohort study was performed on the 49 patients who were screened to determine possible risk factors for acquisition of E. sakazakii infection (confirmed or suspected) or colonization during the study period . sakazakii infection or colonization A case-patient was defined as any caseNICU patient with E.

formula [e. ‡ mechanical ventilator use ‡ humidified incubator use ‡ oral medications ‡ feeding type (TPN.g. continuous or intermittent administration) . powdered or liquid]...Cont«  Medical records were reviewed to assess possible risk factors during the study period. including ‡ gestational age and birth weight. or breast milk) ‡ Feeding method (i.e.

sakazakii infection or colonization all case-patients received Portagen casecompared with 21 of 40 non case-patients case(p<0.01) . Of the 49 patients identified in the cohort. ‡ nine were case-patients case‡ 40 were non case-patients case-   Analysis of risk factors identified only use of a specific powdered infant formula product (Portagen [Mead Johnson Nutritionals. Indiana]) to be significantly associated with E. Evansville.

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 .

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  .

Cont«    Cultures of formula taken from both opened and unopened cans of Portagen from a single batch grew 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 . sakazakii Water and all environmental cultures were negative PulsedPulsed-field gel electrophoresis revealed that isolates of E.

when necessary. ready-to-feed liquid ready-toformula Portagen use was stopped Other powdered formula products are reserved for specific needs and. 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 . the hospital made several policy changes Principal formula type for NICU patients was changed from powdered formula to a commercially sterile.Cont«      To prevent additional infections.

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 .

A Serratia outbreak was therefore identified.Neonatal Serratia marcescens outbreak     Observational study of microbiological and epidemiological investigations Nine cases were observed in a 5 months period. and all the strains were compared by pulsed-field gel pulsedelectrophoresis (PFGE) Data from medical notes were gathered retrospectively Environmental samples were gathered prospectively Acta Pædiatrica 97(10):2008 .

Cont«      Four infants were colonized and five infants were infected by S. marcescens. and careful review of cleaning procedures . contact isolation. Seven of the nine babies were infected by only one of these strains. PFGE revealed that three different strains were present. This same strain was found in a non-antimicrobial nonsoap bottle (NAS) that could be the source of contamination The outbreak was controlled with cohorting. surveillance cultures.

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 .

4th Edition by AAP and ACOG Focuses on the following areas:areas:‡ Physical Setup ‡ Administrative arrangement .Infection Control in the NICU ± Recommended Standards NICU C2CE414Dd01.pdf   Adapted mainly from ³Guidelines for Perinatal Care.

soaps. paper towel ‡ Adequate staffing ‡ Hand hygiene compliance ‡ Minimization of catheter days ‡ Sterile preparation of all fluids to be administered ‡ Promoting enteral feeding esp.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. with EBM/breastfeeding ‡ Monitoring/ surviellance of nosocomial infection ‡ Education and frequent feedback from staff . sinks.

work surfaces etc should be cleaned once a day and between patient use with a disinfectant/detergent and clean cloths Walls. storage shelves and similar nonnoncritical surfaces should be scrubbed periodically with a disinfectant/detergent solution Sinks should be scrubbed clean at least daily with a detergent . accessory areas and then adjacent halls In the cleaning procedure. windows. scrubbing with a mop and a disinfectant/detergent solution should be performed Cabinet counters. dust should not be dispersed into the air Once dust has been removed.General Housekeeping       Cleaning should be performed in the following order ± patient areas.

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 .Recommendations for Hand Hygiene      Wash hands with soap and water when hands are visibly soiled contaminated If hands are not visibly soiled.

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 15dry .

Recommended technique for Hand Hygiene Hand Washing .

The health care±associated infection rate care± decreased from 11.2 per 1000 patientpatient-days PEDIATRICS 2004.114 (5) :e565-e571 .3 to 6.Hand Hygiene Practices in a Neonatal Intensive Care Unit     A problem-based and task-orientated problemtaskeducation program can improve hand hygiene compliance Overall hand hygiene compliance increased 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 handpostintervention stage.

Pediatrics 1998 ) The efficacy of breast milk also appears to be dose dependent (Schanler RJ.Use of Human-milk Feedings Human-  Neonates fed breast milk were less likely to become septic compared to formula-fed neonates formula(Narayanan I et al. J Pediatr 1981)   human-milk feedings reduced the odds of humansepsis/meningitis compared to preterm milk feedings (Hylander MA et al. Pediatr Clin North Am 2001) .

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 .

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 .

RECOMMENDATIONS FOR PLACEMENT OF INTRAVASCULAR CATHETERS Health-care worker education and training   Category IA Educate healthhealthcare workers Assess knowledge of and adherence to guidelines periodically  Category IB Ensure appropriate nursing staff levels in ICUs .

date.IB Record the operator. and time of catheter insertion and removal. and dressing changes on a standardized form .Surveillance   Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis .II .

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 .Aseptic technique during catheter insertion and care     Maintain aseptic technique for the insertion and care of intravascular catheters .

Journal ofPerinatolgy 2000) . Infection Control & Hospital Epidemiology. 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.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.1996)  Gowning before entering the NICU has no effect on reducing HAI (Tan S et al.

2000) .Prophylactic IVIG    Meta analysis of IVIG in preterms Only 3% reduction in nosocomial infection No reduction in mortality (Modi and Carr.

Haemopoietic Colony Stimulating Factor (G-CSF. GM-CSF) (GGM  Effective in raising neutrophil count Not consistent in decreasing nosocomial infections or mortality (Modi and Carr 2000) .

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 .

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 .

Their Future is in Our Hands Thanks !!!! jpdadhich@gmail.com .

2005) Parameter chorioamnionitis born within 48 hours of randomisation born within seven days of randomisation neonatal infection use of surfactant CoCo-amoxiclav NNEC RR 0.80 0.72 to 0.60 0.37 to 0.72 .Antibiotics for preterm rupture of membranes (Cochrane Review .90 0.71 to 0.87 0.53 to 0.96 1.68 0.57 0.83 4.86 0.87 0.98 to 10.71 95% CI 0.58 to 0.

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