Infection Outbreaks in a Neonatal Nursery

1
Infection Outbreaks in a Neonatal Nursery

• Dr Sandi Holgate
• Division of Neonatology
• Department of Paediatrics and Child Health
• Tygerberg Childrens Hospital University of
  Stellenbosch

2
Overview

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

3
TBH Neonatology
4
2 Outbreaks of Infection

• Rotavirus

• MRSA

5
Rotavirus Clinical

• Self limiting diarrhoea vomiting
• Infants young children (lt2yr)
• 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

8
Rotavirus - diagnosis

• Diagnosis
• Antigen test
• Strains not commonly done
• Enzyme immunoassay
• RT PCR
• www.cdc.gov/rotavirus

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
• 29 May 30 June 2008
• Total Cases 58
• Symptomatic
• Positive lab result

11
Rotavirus at TBH
12
Rotavirus Risk Assessment
13
Rotavirus
14
Legend

• Rotavirus positive

Rotavirus contact
Clean
15
29 May 2008
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
• Couldnt 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
• Couldnt - 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
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
Rota Notices
28
11 June 2008
29
20 June 2008
30
20 June

• WARDS G1 G2 CLOSED TO NEW ADMISSIONS

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
33
10 July 2008
34
Rotavirus Literature

• 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

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 ? 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
• 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
• 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

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 days
  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

54
HAND WASHING
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 33 392-397

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 35 666-675

58
Implementation CDC guidelines

59
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 gt 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
• OG
• 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