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Infection Outbreaks in a Neonatal Nursery

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Presentation on theme: "Infection Outbreaks in a Neonatal Nursery"— Presentation transcript:

1 Infection Outbreaks in a Neonatal Nursery
Dr Sandi Holgate Division of Neonatology Department of Paediatrics and Child Health Tygerberg Children’s Hospital & University of Stellenbosch

2 Overview Outbreaks What we learnt How we managed Hand washing
Rotavirus MRSA What we learnt How we managed Hand washing For future

3 TBH Neonatology WARD WHO NUMBER A9 ICU ≥1000g ≥28weeks 8 G2 Inborn 44
A9 E Stable overflow G2 14 G1 “out born” Ex - ICU 36

4 2 Outbreaks of Infection
Rotavirus MRSA

5 Rotavirus – Clinical “Self limiting” diarrhoea & vomiting
Infants & young children (<2yr) Adults – mild Immunity incomplete

6 Rotavirus - Epidemiology
Seasonal: winter Incubation period 2-4 days Spread Faecal – oral Air borne Stable in environment

7 Rotavirus - Virology Double stranded RNA Group A – infection in humans
Two outer protein layers: VP7 = G genotypes VP4 = P genotypes TBH rotavirus = G12 P6 VP 7 and VP 4 - are the 2 major antigens of this virus Group A Rotavirus are classified accordingly, for eg. the strain we encountered was identified as G12P [6] 7

8 Rotavirus - diagnosis Diagnosis Antigen test
Strains: not commonly done Enzyme immunoassay RT PCR

9 Rotavirus – TBH Cases Premature baby Loose stools
No other features of NEC Sent sample for virology screen ROTAVIRUS + 2nd then 3rd baby with loose stools Both Rotavirus positive

10 Rotavirus – at TBH Duration Total Cases – 58 29 May – 30 June 2008
Symptomatic Positive lab result

11 Rotavirus at TBH

12 Rotavirus – Risk Assessment
Number % Admitted 307 Loose stools 94 30.6 Rotavirus + 58 18.9

13 Rotavirus

14 Legend Rotavirus positive Rotavirus contact Clean

15 29 May 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

16 Rotavirus – UIPC findings
Overcrowding 30cm between incubators Movement of babies Progress through the wards Transfer to other wards

17 Rotavirus – UIPC findings
Staff shortage Couldn’t dedicate Agencies Understanding of precautions Waste bins not emptied regularly

18 Rotavirus – UIPC findings
Shared utensils (feed preparation) Shared equipment Supplies overstocked in patient rooms

19 Rotavirus – UIPC Actions
Main suggestion was: WARD CLOSURE “Couldn’t” - full labour ward & tertiary referral centre

20 Rotavirus – UIPC Actions
Document “SOP” Outbreak warning notices Surveillance Daily progress reports Monitoring isolation precautions Training staff & parents Availability of PPE Assessment of ward ventilation Checklist for ward cleaning

21 Standard Operating Procedure
Patients Waste Sharps Equipment Environment Parents Health care workers

22 Standard Operating Procedure
Patients Closed incubators Minimal movement Waste Infectious Non infectious

23 Standard Operating Procedure
Sharps Equipment No sharing Labelling of incubators Environment Clean (+) rooms last Separate equipment New cloths daily Soap & water – damp dusting surfaces & floors Wipe surfaces 95% ethyl alcohol

24 Standard Operating Procedure
Parents Hand washing & spray Masks Reporting loose stools Their baby only Pamphlets Limit visitors Health Care Workers Limit staff exposure Limit students Hand washing & spray PPE per procedure

25 Personal Protective Equipment
Procedure Mask Gloves Apron Nappy change NG feeds Medication Insert IV Draw blood Hold baby Examine baby Do dressing Wash baby

26 Assessment of Ward Ventilation – smoke test
No proper mechanical ventilation in rooms. Some air outlets closed. Circulation of air b/w the incubators - ↑ likelihood of aerosol transmission of the rotavirus. Smoke particles remained suspended in far corners of the rooms, ↑ the risk of aerosol transmission in these areas. There was no real movement of air from the rooms into the passages.

27 Please report to nurse in charge
Rota Notices Rotavirus Outbreak in Progress Please report to nurse in charge upon entering the ward. UIPC, June 2008

28 11 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

29 20 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9


31 Rotavirus – Morbidity & Mortality
Only symptomatic babies screened Loose stools Dehydration Abdominal distension 3 deaths 2 NEC – possibly related 1 epidermolysis bullosa - unrelated

32 23 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

33 10 July 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

34 Rotavirus Literature Tested Positive Symptomatic 1037 164 (16%)
Chen et al. J of Formosan Med Assoc Taiwan, 1997, Nov 96(11):884-9 91 same strain Different strain to 64 infants/toddlers in Paeds wards Eradicated 8 months after onset Tested Positive Symptomatic 1037 164 (16%) 94 (57%)

35 Rotavirus Literature Infection Control & Hospital Epidemiology; Nov 2002, Vol 23, No 11, p665. Widdowson et al Attack rate 40% Un-gloved NG feeds a significant risk factor Persistence on surfaces despite cleaning Mothers with high antibodies not necessarily protective

36 Rotavirus Literature Widdowson et al:
Outbreak ended with in 7 days of WARD CLOSURE, proper disinfection and gloved NG feeds

37 Rotavirus Literature Ramani et al: Journal of Medical Virology 80: 1099 – 1105 (2008) Difference in clinical & epidemiology in neonates vs older children Neonates: Unusual strains Single strains persist long time High transmission, less virulence

38 Rotavirus Literature cont
Ramani et al: Journal of Medical Virology 80: 1099 – 1105 (2008) Virus detected in environment of ⅓ of neonates Need STANDARD PROTOCOLS for cleaning, procedures etc

39 Rotavirus - G genotypes
This slide illustrates the distribution of circulating Group A rotavirus amongst children in European countries. It demonstrates very nicely the high prevalence of G1,G2,G3 and G4 strains. ( Therefore one can also understand why these strains are covered by the new rotavirus vaccine rotateq. I would like to use this opportunity to show you the novel G12 strain. Although rare, it is occuring more frequenty and also especially in newborn nurseries. We have encountered the G12P[6] in our unit. Grey et al. JPGN 2008 39

Staph infections common in hospitals MRSA previously “hospital pathogen” Recently “community acquired” MRSA Equally – if not more - pathogenic

41 MRSA - Microbiology Resistant to: Cephalosporins Cloxacillin
Erythromycin Tetracyclines Fusidic acid Gentamicin

42 MRSA Treatment of choice = Gylcopeptide If resistance (GRSA or GISA)
Vancomycin Teichoplanin If resistance (GRSA or GISA) Very difficult to treat Linezolid Rifampicin

43 MRSA - Reservoirs Nose and groin Skin lesions Dust and enviroment
Linen and bed clothing Clinical equipment

44 MRSA – route of spread Hands of staff or mothers or other patients
Skin scales or excoriating skin lesions Air and environment (unusual) Equipment - clinical and non-clinical (rare)

45 Methacillin Resistant Staph Aureus
TBH index case: Term IDM with hypoglycaemia UVC for 15% Dextrose infusion Omphalitis Cultured MRSA

46 MRSA Removed UVC Vancomycin IV Bactroban (Mupiricin) topical

47 MRSA Septic arthritis “GISA” cultured…
Glycopeptide Intermediate Sensitivity Staph Aureus

48 MRSA – UIPC investigation
Incorrectly given antibiotic doses Low vancomycin trough levels Overuse bactroban – resistance “Incorrect” hand spray

49 MRSA – Screening Sterile swab – dipped in sterile saline Patients
Esp if on antibiotics or steroids Wounds, skin lesions Urine catheters, venous access lines Staff Nose & 1 of: Groin Axilla Hair line

50 MRSA – Contact precautions
Hand disinfection Wash Alcohol spray Gloves Masks not needed Isolate Procedure Gloves Apron Nappy Yes NG feed Meds Insert IV Draw blood Hold baby Exam baby Dressing Washing

51 MRSA – Treatment of Carriers
Nasal (8 hourly) Mupirocin (bactroban) Chlorhexidine nasal ointment Hair 4% Chlorhexidine gluconate – alternate days Skin 4% Chlorhexidine gluconate soap - daily

52 MRSA – Treatment of Neonatal Carriers
Skin decontamination - neonate Daily wipe the body and hair with 0.25% aqueous chlorhexidine (NOT 4% - skin burns) Do not rinse or wipe off – watch temperature Disposable cloth

53 MRSA – Treatment of Neonatal Carriers
Change bed linen daily after each day’s chlorhexidine application. Follow this procedure for 7 days. Repeat screening of baby 72 hours after stopping skin decontamination. Bactroban resistance and worry of nasal obstruction & apnoea – NO nasal treatment


55 What does the Evidence show?
Problem  Tertiary hospital, Argentina Low hand washing compliance High nosocomial infection rate Intervention Education, training & performance feedback Results Compliance improved from 23.1% to 64.5% Infection rate improvement of 41.3% Am J Infect Control, 2005; 33:

56 CDC Handwashing Guidelines, 2002
Visibly soiled Before & after patient contact Before & after gloves Invasive procedures Surgical invasive procedure – nail brush Alcohol-based hand sprays No artificial nails or polish MMWR, 2002; 51: 1-56

57 Dissemination & Impact on Infection Rates
Guidelines published in 2002 Implementation & compliance 44.2% DID NOT follow guideline recommendations Compliance - 24% & 89% (mean 56.6%) Implementation needs to be driven within the ward & management Am J Infect Control, 2007; 35:

58 Implementation CDC guidelines
Infection Site Pre – Guidelines Rate:1000 Post – Guidelines P value Central Line Assoc Blood Stream Infection 5.54 4.76 <.001 Ventilator Assoc Pneumonia 6.16 4.79

59 Sepsis rates dropped by 30% during time of Rotavirus outbreak
TBH Infection Rates Sepsis rates dropped by 30% during time of Rotavirus outbreak

60 Summary Infection not uncommon in neonatal nurseries
Overcrowding increase risk Staff shortages increase risk

61 Summary Infecting organisms “hardy” Difficult to eradicate
May be “dormant” Carriers may be asymptomatic often unaware

62 How do we “Better Our Best & Beat the Odds”?
Awareness Prevention

63 Better Our Best & Beat the Odds
Hand washing > 15sec Hand spray – before & after 70% alcohol 0.5% chlorhexidine Glycerine Proper disposal of waste Proper cleaning of equipment

64 Better Our Best & Beat the Odds
Education Mothers Medical staff (Doctors, nurses, other) Cleaning staff Administrative staff (superintendents/CEO)

65 Better Our Best & Beat the Odds
Limit / monitor use of antibiotics Peripheral line for antibiotics Limit access of central lines – STERILE Limit use of topical antibiotics

66 Better Our Best & Beat the Odds
Protocols Involve other colleagues O&G UIPC Microbiology & virology

67 Better Our Best & Beat the Odds
Involve management Help with staff Help with disposables Help with ward closures

68 Their Future is in Our Hands 
Thanks to: Sr Aucamp Dr Post TBH IPC team TBH neonatal team

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