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

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Presentation on theme: "Infection Outbreaks in a Neonatal Nursery Dr Sandi Holgate Division of Neonatology Department of Paediatrics and Child Health Tygerberg Children’s Hospital."— 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 Outbreaks –Rotavirus –MRSA What we learnt What we learnt How we managed How we managed Hand washing Hand washing For future For future

3 TBH Neonatology WARDWHONUMBER A9 ICU ≥1000g ≥28weeks 8 G2Inborn44 A9 E Stable overflow G2 14 G1 “out born” Ex - ICU 36

4 2 Outbreaks of Infection Rotavirus Rotavirus MRSA MRSA

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

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

7 Rotavirus - Virology Double stranded RNA Double stranded RNA Group A – infection in humans Group A – infection in humans Two outer protein layers: Two outer protein layers: –VP7 = G genotypes –VP4 = P genotypes TBH rotavirus = G12 P6 TBH rotavirus = G12 P6

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

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

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

11 Rotavirus at TBH

12 Rotavirus – Risk Assessment Number% Admitted307 Loose stools Rotavirus

13 Rotavirus

14 Legend Rotavirus positive Rotavirus contact Clean

15 29 May 2008 A9Ext Room 5 Room 4 A9 IC U Room 5 Room 6 R7R8 G2 Room 9 Room 10 Room 11 Room 12 R14R15 G1 Room 1 R2R3R4R5 Room 6 R7R8 J5

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

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

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

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

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

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

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

23 Standard Operating Procedure Sharps Sharps Equipment Equipment –No sharing –Labelling of incubators Environment 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 Parents –Hand washing & spray –Masks –Reporting loose stools –Their baby only –Pamphlets –Limit visitors Health Care Workers Health Care Workers –Limit staff exposure –Limit students –Hand washing & spray –PPE per procedure

25 Personal Protective Equipment ProcedureMaskGlovesApron Nappy change √√√ NG feeds √√ Medication√√ Insert IV √√ Draw blood √√ Hold baby √√√ Examine baby √√ Do dressing √√ Wash baby √√√

26 Assessment of Ward Ventilation – smoke test 1.No proper mechanical ventilation in rooms. Some air outlets closed. 2.Circulation of air b/w the incubators - ↑ likelihood of aerosol transmission of the rotavirus. 3.Smoke particles remained suspended in far corners of the rooms, ↑ the risk of aerosol transmission in these areas. 4.There was no real movement of air from the rooms into the passages.

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

28 11 June 2008 A9Ext Room 5 Room 4 A9 IC U Room 5 Room 6 R7R8 G2 Room 9 Room 10 Room 11 Room 12 R14R15 G1 Room 1 R2R3R4R5 Room 6 R7R8 J5

29 20 June 2008 A9Ext Room 5 Room 4 A9 ICU Room 5 Room 6 R7R8 G2 Room 9 Room 10 Room 11 Room 12 R14R15 G1 Room 1 R2R3R4R5 Room 6 R7R8 J5

30 20 June WARDS G1 & G2 CLOSED TO NEW ADMISSIONS WARDS G1 & G2 CLOSED TO NEW ADMISSIONS

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

32 23 June 2008 A9Ext Room 5 Room 4 A9 IC U Room 5 Room 6 R7R8 G2 Room 9 Room 10 Room 11 Room 12 R14R15 G1 Room 1 R2R3R4R5 Room 6 R7R8 J5

33 10 July 2008 A9Ext Room 5 Room 4 A9 IC U Room 5 Room 6 R7R8 G2 Room 9 Room 10 Room 11 Room 12 R14R15 G1 Room 1 R2R3R4R5 Room 6 R7R8 J5

34 Rotavirus Literature Chen et al. J of Formosan Med Assoc Taiwan, 1997, Nov 96(11):884-9 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 TestedPositive Sympto matic (16%) 94 (57%)

35 Rotavirus Literature Infection Control & Hospital Epidemiology; Nov 2002, Vol 23, No 11, p665. Widdowson et al 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: 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) Ramani et al: Journal of Medical Virology 80: 1099 – 1105 (2008) –Difference in clinical & epidemiology in neonates vs older children –Neonates: Unusual strains Unusual strains Single strains persist long time Single strains persist long time High transmission, less virulence High transmission, less virulence

38 Rotavirus Literature cont Ramani et al: Journal of Medical Virology 80: 1099 – 1105 (2008) 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 Grey et al. JPGN 2008

40 METHACILLIN RESISTANT STAPH AUREUS - Background Staph infections common in hospitals Staph infections common in hospitals MRSA previously “hospital pathogen” MRSA previously “hospital pathogen” Recently “community acquired” MRSA Recently “community acquired” MRSA –Equally – if not more - pathogenic

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

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

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

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

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

46 MRSA Removed UVC Removed UVC Vancomycin IV Vancomycin IV Bactroban (Mupiricin) topical Bactroban (Mupiricin) topical

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

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

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

50 MRSA – Contact precautions Hand disinfection Hand disinfection –Wash –Alcohol spray Gloves Gloves Masks not needed Masks not needed Isolate Isolate ProcedureGlovesApron NappyYes NG feed Yes MedsYes Insert IV Yes Draw blood Yes Hold baby YesYes Exam baby Yes DressingYes WashingYesYes

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

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

54 HAND WASHING

55 What does the Evidence show? Problem  Tertiary hospital, Argentina Problem  Tertiary hospital, Argentina –Low hand washing compliance –High nosocomial infection rate Intervention Intervention –Education, training & performance feedback Results 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 Visibly soiled Before & after patient contact Before & after patient contact Before & after gloves Before & after gloves Invasive procedures Invasive procedures Surgical invasive procedure – nail brush Surgical invasive procedure – nail brush Alcohol-based hand sprays Alcohol-based hand sprays No artificial nails or polish No artificial nails or polish MMWR, 2002; 51: 1-56

57 Dissemination & Impact on Infection Rates Guidelines published in 2002 Guidelines published in 2002 –Implementation & compliance 44.2% DID NOT follow guideline recommendations 44.2% DID NOT follow guideline recommendations Compliance - 24% & 89% (mean 56.6%) Compliance - 24% & 89% (mean 56.6%) Implementation needs to be driven within the ward & management 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 Rate:1000 P value Central Line Assoc Blood Stream Infection <.001 Ventilator Assoc Pneumonia <.001

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

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

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

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

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

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

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

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

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


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