1. NICU Outbreaks Nawaf M. Al-Dajani

2. Disclosure

3. Infection Components Host Organisms Environment

5. MRSA

6. Infection Rates in NICUs / Up to 6-38 (25%) per 100 admissions. / 8.9 to 62 per 1000 patient days. / Up to 6-38 (25%) per 100 admissions. / 8.9 to 62 per 1000 patient days.

7. No. approved antibiotics

8. / Outbreak: An excess over the usual level of a disease within geographic area in certain period. Epidemic curve: Base line data: / Outbreak: An excess over the usual level of a disease within geographic area in certain period. Epidemic curve: Base line data:

10. Nosocomial infection Preventable Inevitable

11. What to do during outbreak? A - Prepare for investigation: - Develop knowledge about investigation techniques. - Review similar outbreak. - Team assembly. B - Confirm outbreak existence: - Case definition. - Case finding. - Early control measures. - Report to public health. - Appropriate consultations. A - Prepare for investigation: - Develop knowledge about investigation techniques. - Review similar outbreak. - Team assembly. B - Confirm outbreak existence: - Case definition. - Case finding. - Early control measures. - Report to public health. - Appropriate consultations.

12. Outbreak investigation cont… C - Verify diagnosis of reported cases: - Agent - Disease nature - Specimens D - Search for additional cases: E - Characterize cases of disease: - Time - Place - Person - Graph F - Formulate hypothesis: - Source - Epi curve C - Verify diagnosis of reported cases: - Agent - Disease nature - Specimens D - Search for additional cases: E - Characterize cases of disease: - Time - Place - Person - Graph F - Formulate hypothesis: - Source - Epi curve

13. Cont… G - Test hypothesis: H - Evaluate control measures efficacy: I - Review current practice: J- Communicate findings: G - Test hypothesis: H - Evaluate control measures efficacy: I - Review current practice: J- Communicate findings:

14. Examples / MRSA outbreak BCCH, Vancouver. / 1999, 33 cases were identified in NICU. / Task force team assembled. / Effective IC measures implemented. / Enhanced surveillance. / Isolation and cohorting. / MRSA outbreak BCCH, Vancouver. / 1999, 33 cases were identified in NICU. / Task force team assembled. / Effective IC measures implemented. / Enhanced surveillance. / Isolation and cohorting.

15. Weekly surveillance Glove & gown d/c’d Al-Dajani et al, IDSA 2006

16. Vanco stopped Daily tubing replacement

17. KAAUH / Eight cases of persistent CoNS in 1 wk. / Associated with thrombocytopenia. / One term baby? / Different allocations. / High dose of vancomycin +/- rifampin. / Worsening clinical condition. / One has PICC. / What to do?? / Eight cases of persistent CoNS in 1 wk. / Associated with thrombocytopenia. / One term baby? / Different allocations. / High dose of vancomycin +/- rifampin. / Worsening clinical condition. / One has PICC. / What to do??

18. ?common source / TPN might be ? / Culture from TPN sent. / Guess what? / Three +ve for CoNS. / TPN d/c’d for 5 days. / Sepsis well controlled. / No more new cases. / TPN might be ? / Culture from TPN sent. / Guess what? / Three +ve for CoNS. / TPN d/c’d for 5 days. / Sepsis well controlled. / No more new cases.

19. ESBL-KP / Klebsiella pneumonia outbreak / Macrae et al, J Hosp Infect 2001; 49: 183-92 / Outbreak control group. / Closed to transfer. / Cohort not feasible. / Hand hygiene etc… / Screening. / Antibiotic changed / But outbreak continued??? / Klebsiella pneumonia outbreak / Macrae et al, J Hosp Infect 2001; 49: 183-92 / Outbreak control group. / Closed to transfer. / Cohort not feasible. / Hand hygiene etc… / Screening. / Antibiotic changed / But outbreak continued???

20. / NICU closed. / Satellite unit opened. / Screen all new comers. / Outbreak over. / NICU closed. / Satellite unit opened. / Screen all new comers. / Outbreak over.

21. Cont… / Klebsiella pneumonia sepsis > 50%, 2001, PIDJ, 05. / 88/115 had clinical sepsis, MR 51%. / 24 pt develop sepsis in < 24hr, K-P 73%, ESBL 58%. / Reviewing their IC practice. / IVF prepared at bed side. / Inadequate hand hygiene & aseptic tech. / Cultures from IVF (65%) revealed KP. / Standard IC precautions improved sepsis rate & MR. / Klebsiella pneumonia sepsis > 50%, 2001, PIDJ, 05. / 88/115 had clinical sepsis, MR 51%. / 24 pt develop sepsis in < 24hr, K-P 73%, ESBL 58%. / Reviewing their IC practice. / IVF prepared at bed side. / Inadequate hand hygiene & aseptic tech. / Cultures from IVF (65%) revealed KP. / Standard IC precautions improved sepsis rate & MR.

22. Take home messages / Team work. / Epi-curve. / Think of the source. / Reinforce IC measures. / Appropriate allocation. / Review antibiogram. / Re-evaluate efficacy of IC. / Prevention vs therapy / Team work. / Epi-curve. / Think of the source. / Reinforce IC measures. / Appropriate allocation. / Review antibiogram. / Re-evaluate efficacy of IC. / Prevention vs therapy