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INFECTION CONTROL IN NICUSINFECTION CONTROL IN NICUS

HANY ALY, MD, FAAP

Professor of Pediatrics, Obstetrics &

Gynecology

Director, Newborn Services

The George Washington University

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SEPSIS IN VLBW INFANTS

Vermont-Oxford Network

0

20

40

%

1998 1999 2000 2001

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SEPSIS IN VLBW INFANTS. NICHD

Incidence of 1 episode of late onsetsepsis: 21%

strategies to reduce late infections in

VLBW neonates...are urgently needed. Theuse of collaborative quality improvement

strategies to reduce nosocomial infections

among VLBW NICU patients warrants

additional study.

Stoll et al; Pediatrics, 2000

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FACTORS THAT INCREASE

RISK OF INFECTION IN NICU Immature immune system in the newborn Overcrowding and understaffing

Inadequate numbers or placement ofsinks Neonates may be colonized with

pathogens without overt symptoms

Invasive procedures

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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 frompatient care area

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THE NURSERY: SINKS

A sink should be within 8 steps from each patien

NNNUUURRRSSSEEERRRYYY LLLEEEVVVEEELLL NNNUUUMMMBBBEEERRR OOOFFF SSSIIINNNKKKSSS

Level 1 1 Sink / 6-8 Neonates

Level 2 1 Sink / 3-4 Neonates

Level 3 1 Sink

/ 3-4 Neonatesa

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THE NURSERY: SPACE DESIGN

NNNUUURRRSSSEEERRRYYY LLLEEEVVVEEELLL SSSPPPAAACCCEEE /// NNNEEEOOONNNAAATTTEEE

Level 1 30 ft2/ Neonate

Level 2 50 ft2/ Neonate

Level 3 80- 100 ft2/ Neonate

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THE NURSERY STRUCTURE

Entrance: Foot operated sinkGowns (?)

Disposable trash cans

Isolation rooms: For airborne infectionsFor home admissions

(72 hours)

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PERSONNEL: STAFFING

NNNUUURRRSSSEEERRRYYY LLLEEEVVVEEELLL NNNUUUMMMBBBEEERRR OOOFFF NNNUUURRRSSSEEESSS

Level 1 1 Nurse / 6-8 Infants

Level 2 1 Nurse / 2-3 Infants

Level 3 1 Nurse

/ 1-2 Infantsa

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PERSONNEL: GLOVES

Use gloves for any contact with bodyfluids

Use masks, head covers, sterile gloves

and sterile gowns for procedures:

PCVL

UAC / UVC

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PERSONNEL: OTHERS

Foods and drinks are not allowed

Live plants and flowers are not allowed

Sterile solutions, flushes should not bekept longer than 24 hours

Label all solutions with date and time of

opening

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HANDWASHING

It the MOST important infection controlmeasure

Remove all jewelry

Roll sleeves up to elbows

Use a wet sponge orscrubscrubbrushbrush with anantiseptic: Chlorhexidine Gluconate

Povidone Iodine

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HAND WASHING

P.S. Liquid soap dispensers and theircontents can become contaminated

Alcohol-containing foams and gel killbacteria 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

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HAND WASHING: DURATION

CONDITION DURATION

At the start 2-3 minute scrub

Before procedures 2-3 minute scrubOther consultants 2-3 minute scrub

Hospital technicians 2-3 minute scrub

Between patients 15-30 seconds

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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

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HAND WASHING

Poor hand washing increases the risk oftransmitting infections(Infec Control hospitalEpidemiology 1988)

Transmission of Staphylococci betweennewborns is more likely to occur by personnelwho are less compliant about hand washing(Mortimer et al AMJ. DIS chil.104 1950)

Compliance with hand washing is poor

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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

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HAND WASHING

Six nurses were assigned to monitor handwashing techniques without theircoworkers awareness.

1. Was there a 15 second wash prior to

handling an infant?

2. Was an inanimate object or ones own

body touched while examining the

infant?3. Were bracelets and rings removed ?

Raju & Kobler Am J Med SCI 1991

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HAND WASHINGCompliance Rate

Item #1 Item #2 Item #3

Doctors 37.5% 29.2% 72.7%

Nurses 53.9% 29.2% 75.3%

Ancillary staff 48.5% 25.0% 85.7%

Initial overall compliance 28.2% Vs 62.6% (after an

educational process)

Raju & Kobler Am J Med SCI 1991

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ROUTINE GOWNS !!!

Practice transferred from policiesdeveloped for surgical asepsis during

operations

Very limited data to support its efficacyand much data to say it is ineffective*

*Forfar & McCabe BJM 1958,Williams&Oliver Pediatrics1969,Donowitz Pediatrics 1986, Pelke Arch Ped &Adol

Med 1994

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ROUTINE GOWNS !!!

Does the gown serve as a reminder towash hands? No! (Donowitz et al

Pediatrics 1986) The risk of transmission infection through

clothing is less than 2/10,000

(Larson JOGNN 1987)

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EMPLOYEE HEALTH

ILLNESS: Respiratory: Use masks

Conjunctivitis: Do not enter the unit

Skin lesions: Do not touch patients or

equipment

VACCINES:

Hepatitis B Td (every 10 years)

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INFECTION CONTROL

EDUCATION

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

A written test may be conducted Conferences

Flyers

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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 orany other infant

Visitors to well babies should be inmothers rooms

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ENVIRONMENT: ISOLETTES

Should be cleaned in a designated roomwith a quaternary ammonia product

Should be replaced every 7 days

Should be wiped form outside every 8hours

Should be wiped from inside once a day

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ENVIRONMENT: ISOLETTES

Humidifier reservoirs should be cleanedand filled with sterile water

Linens should be replaced every day

Soiled linens will be kept in coveredcontainers until removed by laundry

personnel

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ENVIRONMENT: OTHERS

Waste should be collected in plastic bagsand placed in soiled utility room

Needle containers should be placed ineach room and replaced when they are 3/4full

Room temperature at 24-27 0C

Relative humidity at 30-60 %

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EQUIPMENT: RESPIRATORY

Ventilator circuit should be replaced everyweek (?)

Water condensate in the tubing should bedrained periodically

Use only sterile water for the humidifier Ventilators should be replaced and

disinfected every week

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ENVIRONMENT: RESPIRATORY

Each infant should have his ownresuscitation bag and mask

They should be kept clean away form the

floor

They should be replaced and disinfectedevery week (?)

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CPAP AND SEPSIS (GNS)

Graham et al, 2006

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0

5

10

15

20

98 99 0 1 2 3 4 5 6 7 8

Infection/100

0

line

days

Aly et al., 2005 - Aly & Herson 2006

CPAP AND SEPSIS

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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 affectcolonization

GN colonization was associated with CPAP (P=0.04)

Vaginal delivery (p=0.02)

TRACHEAL COLONIZATION AND ETT

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ABSTINENCE IS THE KEY

During intubation think about

Ventilator Associated

Pneumonia

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ENVIRONMENT: FEEDING

Nasogastric tubes should be changedevery 3 days

Feeding syringes should be replacedevery 4 hours

Once out, gavage feeding tubes should bere-inserted again

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ENVIRONMENT: IV LINES

Document the date of insertion of any line

UAC/UVC should not remain >15 days (?)

Apply betadine or alcohol if the umbilicalsite is moist

Central lines dressing should beevaluated daily and changed weekly

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If blood culture remains positive after 48

hours of antibiotics treatment, PICC

should be removed

Continuous infusion of heparinized fluidsshould run all times in central lines

Sterile fluids should be replaced daily

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IV tubing should be replaced every 24hours

IV medications should be administeredmaintaining aseptic technique (closed

medication system)

IV pumps should be cleaned every 8hours and when soiled

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BLOOD INFECTIONSBLOOD INFECTIONS--NICUsNICUs

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Infections/1000 line days

Medical Management Planning, Inc. 1999

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0

5

10

15

20

25

30

35

'95 '96 '97 '98 '99 '00 '01

B

S

I

/

1

0

0

0

l

i

ne

d

a

y

s

CCMC GWUH

INFECTIONS AT GWUH

INFECTIONS AT GWU

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0

5

10

15

20

1999 2000 2001

U Con GWU NNN

INFECTIONS AT GWU

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SEPSIS IN VLBW INFANTS

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Vermont-Oxford Network

0

20

40

%

1998 1999 2000 2001

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ENVIRONMENT:

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SCALES, MONITORS & SUPPLIES

Dinamaps, stethoscopes and diaperweighing scales should be wiped with

disinfectant between infants

Cardiac monitors and POX should bedisinfected daily Supplies should not be shared between

infants

Soiled and clean items should not bemixed

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INFANTS

Remove infants from radiant warmers assoon as possible

Infants admitted from community shouldbe admitted to isolation area with contactprecautions for 72 hours

Umbilical stumps should be cleaned withalcohol with each diaper change

INFANTS

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INFANTS

If omphalitis is endemic use triple dyeroutinely to to reduce Staph. aureuscolonization

Triple dye: 2.29g brilliant green + 1.14gprofavine hemisulfate + 2.29g crystalviolet in a letter of sterile water

Infants should be bathed 3 times a week.

Do not apply soap to the face

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INFANTS

Erythromycin eye ointment to all infantson admission

Use only CMV-antibody negative blood(via Leukopoor filtration) for all infants

transfusions

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NUTRITION: FORMULA

Formula should be discarded after 24hours from preparation

Sterile water should be used forpreparation

Fortification with non-cow proteinformulas only

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NUTRITION: FORMULA

Formula should be discarded after 24hours from preparation

Sterile water should be used forpreparation

Fortification with non-cow proteinformulas only

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NUTRITION: BM EXPRESSION

Give proper instructions to mothers Careful washing of nipple and hand

Pumps should be sterilized by boiling for 10-

15 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

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NUTRITION: BM STORAGE

BM should be stored in sterile bagslabeled 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 0C)

for months

Do not use microwave for thawing frozenmilk

CPAP and NEC (n=342)

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CPAP and NEC (n=342)

Aly et al Pediatrics 2009

0.762.210.340.86Hospital site

0.624.840.391.37Delivery room intubation0.9312.4940.101.12Early sepsis

0.0020.520.060.18Patent ductus arteriosus

0.116.990.822.4Umbilical artery Catheter

0.921.020.980.99FiO2

during CPAP

0.081.00.970.99PaO2

0.922.330.471.04Duration of CPAP

0.384.350.571.58Prenatal steroids

0.076.270.932.42Gender (Male)

0.051.00.990.99Birth weightP95% CIORVariables

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ZANTAC IS ASSOCIATED WITH

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ZANTAC IS ASSOCIATED WITH

INCREASED SEPSIS

0

30

60

Zantac No Zantac

Sepsis %

J Perinatal Med 2007:35:147

OR=6.99

ANTIBIOTIC CHOICE

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ANTIBIOTIC CHOICE

The use of cephlosporins as the primarychoice of antibiotics are associated with

significantly increased mortality

Mortality is explained by increasedCandida sepsis

IMMUNIZATION

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IMMUNIZATION

In accordance to the postnatal age

OPV only at discharge, otherwise use IPV

BCG can be given at discharge

ISOLATION NON NEONATAL

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ISOLATION: NON-NEONATAL

Respiratory Meningitis due to H. influenzae orN.

meningitidis

Measles

Pertussis

Tuberculosis

ISOLATION

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ISOLATION

TYPES OF ISOLATION EXAMPLES

Strict Varicella

Contact URI, C. Rubella, HSV,

Staph woundsEnteric NEC, Gastroenteritis,

viral meningitis

Drainage/Secretions Non-Staph wounds

None CMV, GBS

Mansoura 2009

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