Evidence based guidelines

for prevention of infection in

NICU
Dr. JP Dadhich MD,FNNF,PGD-DN
 Outline
 Relevance of infection control
 Out breaks in NICU and lessons
learnt from them
 Evidence based infection control
measures in NICU
 Nosocomial Infections
Relevance
70 67
60
56
50
44
40
31 EOS
30 LOS
20

10

0
IM EM

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  Delayed enteral
 Low birth weight feeding
 Invasive device  Formula feeding
• Intravascular device
• Mechanical
 Inadequate nursing
ventilation staff/overcrowding
• Urinary Catheter  Poor compliance
• VP shunt with hand washing
 Medication
• H2 Blockers
• Steroids
 Epidemics
 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
 Endemic Pseudomonas aeruginosa
Infection in a Neonatal Intensive Care
Unit
 Pseudomonas aeruginosa is a well-
known cause of nosocomial infections
among infants in neonatal intensive
care units.
 Environmental sources such as sinks
and respiratory-therapy equipment are
the most commonly described
reservoirs of P. aeruginosa
 Occasionally, health care workers have
been the reservoir
NEJM 2000; 343 (10):695-700.
 Surveillance
 An increased incidence of colonization and
infection with P. aeruginosa was noted
 Surveillance cultures were performed to
identify all infants with colonization
 33 infants in the neonatal intensive care
unit, 6 of whom were identified as being
colonized or infected with P. aeruginosa
 Surveillance cultures were obtained from
the other 27 infants – GA, ET secretions,
nasopharyngeal swabs – twice a month till
all babies in the cohort were discharged,
than once a month fo next two months
Detecting environmental reservoirs
 Cultures of environmental specimens
• tap water
• sink drains
• liquid medications
• respiratory-therapy equipment
• hand soaps
• hand creams
• water baths used to warm formula
 Moist and dry environmental surfaces were
swabbed with a cotton-tipped swab
 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
practitioner through the wall of the bag for 15 to
30 seconds
 samples were delivered to the microbiology
laboratory within 1 hour for processing
Risk Factors for Colonization of the
Hands with P. aeruginosa
 The hands of all health care workers were inspected by the infection-
control practitioner

 The presence of false nails, nail polish, and cracked or inflamed nail
beds was noted

 Possible exposures to P. aeruginosa and risk factors for infection,

such as use of antibiotics and a history of otitis externa, swimming in
the preceding year, skin lesions or dermatitis, latex allergy, nail or
nail-bed infections, and the use of artificial nails or nail wraps, were
assessed

 Risk factors for colonization of the hands of health care workers with
P. aeruginosa were determined by logistic-regression analysis with
the use of SAS software

 The association between exposure to a specific health worker and

infection or colonization with the endemic clone of P. aeruginosa was
assessed
 Results
 None of the cultures of environmental specimens
grew P. aeruginosa
 Among 165 health workers, 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
 Infection-Control Measures
 Contact isolation procedures were used for infants who were
colonized or infected with P. 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.
 At the beginning of each shift, 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, several care practices were changed:
• water baths were no longer used to heat formula,
• the number of supplies kept by the patients' bedsides was minimized
 Lessons
 Be vigilant to detect an increased
incidence of common organisms
 Adopt a systematic approach
 Be prepared to be surprised
 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,
prematurity, and respiratory distress

Morbidity & Mortality Weekly Report,

Report CDC.
 Cont…
 The infant had fever, tachycardia,
decreased vascular perfusion, and
neurologic abnormalities (e.g., suspected
seizure activity) at 11 days
 Cerebrospinal fluid (CSF) suggestive of
Meningitis
 Culture of CSF grew E. sakazakii
 The infant was treated with intravenous
antimicrobials for meningitis; however,
neurologic damage was progressive, and
the infant died 9 days later
 Cont…
 Because the organism was a rare
cause of neonatal meningitis,
hospital personnel, in collaboration
with the Tennessee Department of
Health and CDC, investigated the
source of infection
 Cont…
 During the study period, enhanced
case surveillance was performed to find
if other infants in the NICU were either
infected or colonized with E. sakazakii
 Patients were assessed for colonization
by stool culture
 Cont…
 Confirmed infection was defined as any E.
sakazakii-positive culture from a normally sterile
site
 Suspected infection was defined as an E.
sakazakii-positive culture from a nonsterile site
with documented deterioration in clinical status
(e.g., increased respiratory rate without other
evident cause) in the 24 hours before collection
of the specimen for culture
 Colonization was defined as an E. sakazakii-
positive culture from a nonsterile site without
documented deterioration in clinical status in the
24 hours before collection of the specimen for
culture.
 Cont…
 A total of 49 infants were screened
 Ten E. sakazakii infection or
colonization events were identified:
• one confirmed infection in the index
patient (culture-positive from CSF),
• two suspected infections (both culture-
positive from tracheal aspirate)
• seven colonization (six culture-positive
from stool, one from urine)
 A cohort study was performed on the
49 patients who were screened to
determine possible risk factors for
acquisition of E. sakazakii infection or
colonization
 A case-patient was defined as any
NICU patient with E. sakazakii
infection (confirmed or suspected) or
colonization during the study period
 Cont…
 Medical records were reviewed to assess
possible risk factors during the study period,
including
• gestational age and birth weight,
• mechanical ventilator use
• humidified incubator use
• oral medications
• feeding type (TPN, formula [e.g., powdered or
liquid], or breast milk)
• Feeding method (i.e., continuous or intermittent
administration)
 Of the 49 patients identified in the cohort,
• nine were case-patients
• 40 were non case-patients
 Analysis of risk factors identified only use
of a specific powdered infant formula
product (Portagen [Mead Johnson
Nutritionals, Evansville, Indiana]) to be
significantly associated with E. sakazakii
infection or colonization
 all case-patients received Portagen
compared with 21 of 40 non case-patients
(p<0.01)
 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
 Water and all environmental cultures were
negative
 Pulsed-field gel electrophoresis revealed
that isolates of 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
 Cont…
 To prevent additional infections, the hospital
made several policy changes
 Principal formula type for NICU patients was
changed from powdered formula to a
commercially sterile, ready-to-feed liquid formula
 Portagen use was stopped
 Other powdered formula products are reserved
for specific needs and, when necessary, 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
 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
 Neonatal Serratia marcescens
outbreak
 Observational study of microbiological and
epidemiological investigations
 Nine cases were observed in a 5 months
period. A Serratia outbreak was therefore
identified, and all the strains were
compared by pulsed-field gel
electrophoresis (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.
 PFGE revealed that three different strains were
present.
 Seven of the nine babies were infected by only
one of these strains.
 This same strain was found in a non-antimicrobial
soap bottle (NAS) that could be the source of
contamination
 The outbreak was controlled with cohorting,
contact isolation, surveillance cultures, and
careful review of cleaning procedures
 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

 Infection Control in the NICU –
Recommended Standards
NICU C2CE414Dd01.pdf

 Adapted mainly from “Guidelines for

Perinatal Care, 4th Edition by AAP and
ACOG
 Focuses on the following areas:-
• Physical Setup
• Administrative arrangement
 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, sinks, soaps, paper towel
• Adequate staffing
• Hand hygiene compliance
• Minimization of catheter days
• Sterile preparation of all fluids to be administered
• Promoting enteral feeding esp. with EBM/breastfeeding
• Monitoring/ surviellance of nosocomial infection
• Education and frequent feedback from staff
 General Housekeeping
 Cleaning should be performed in the following order –
patient areas, accessory areas and then adjacent halls
 In the cleaning procedure, dust should not be
dispersed into the air
 Once dust has been removed, scrubbing with a mop
and a disinfectant/detergent solution should be
performed
 Cabinet counters, work surfaces etc should be cleaned
once a day and between patient use with a
disinfectant/detergent and clean cloths
 Walls, windows, storage shelves and similar non-
critical surfaces should be scrubbed periodically with a
disinfectant/detergent solution
 Sinks should be scrubbed clean at least daily with a
detergent
 Recommendations for Hand
Hygiene
 Wash hands with soap and water when hands
are visibly soiled contaminated
 If hands are not visibly soiled, 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
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
dry
Recommended technique for Hand
Hygiene
Hand Washing
 Hand Hygiene Practices in a
Neonatal Intensive Care Unit
 A problem-based and task-orientated
education program can improve hand
hygiene compliance
 Overall hand hygiene compliance 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
postintervention stage.
 The health care–associated infection rate
decreased from 11.3 to 6.2 per 1000
patient-days

PEDIATRICS 2004;114 (5) :e565-e571

 Use of Human-milk Feedings

 Neonates fed breast milk were less likely to

become septic compared to formula-fed neonates
(Narayanan I et al. J Pediatr 1981)
 human-milk feedings reduced the odds of
sepsis/meningitis compared to preterm milk
feedings (Hylander MA et al. Pediatrics 1998 )
 The efficacy of breast milk also appears to be
dose dependent (Schanler RJ. 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 Category IB
 Educate health-  Ensure appropriate
care workers nursing staff levels
 Assess knowledge in ICUs
of and adherence
to guidelines
periodically
 Surveillance
 Monitor the catheter sites visually or
by palpation through the intact
dressing on a regular basis - IB
 Record the operator, date, and time
of catheter insertion and removal,
and dressing changes on a
standardized form - II
 Aseptic technique during catheter
insertion and care
 Maintain aseptic technique for the
insertion and care of intravascular
catheters - 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
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. Infection Control & Hospital
Epidemiology,1996)
 Gowning before entering the NICU has no
effect on reducing HAI (Tan S et al. 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. Journal
ofPerinatolgy 2000)
 Prophylactic IVIG
 Meta analysis of IVIG in preterms
 Only 3% reduction in nosocomial
infection
 No reduction in mortality

(Modi and Carr, 2000)

 Haemopoietic Colony Stimulating
Factor (G-CSF, GM-CSF)

 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
Antibiotics for preterm rupture of
membranes (Cochrane Review - 2005)

Parameter RR 95% CI
chorioamnionitis 0.57 0.37 to 0.86

born within 48 0.71 0.58 to 0.87

hours of
randomisation
born within seven 0.80 0.71 to 0.90
days of
randomisation
neonatal infection 0.68 0.53 to 0.87

use of surfactant 0.83 0.72 to 0.96

Co-amoxiclav - 4.60 1.98 to 10.72

NNEC