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
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 (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
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 Room 5 Room 5 Room 4 Room 4
A9 ICU Room 5 Room 5 Room 6 Room 6 R7 R8
G2 Room 9 Room 9 Room 10 Room 10 Room 11 Room 11 Room 12 Room 12 R14 R15
G1 Room 1 Room 1 R2 R3 R4 R5 Room 6 Room 6 R7 R8
J5
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
Procedure Mask Gloves Apron
Nappy change v v v
NG feeds v v
Medication v v
Insert IV v v
Draw blood v v
Hold baby v v v
Examine baby v v
Do dressing v v
Wash baby v v v
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
28
11 June 2008
A9 Ext Room 5 Room 5 Room 4 Room 4
A9 ICU Room 5 Room 5 Room 6 Room 6 R7 R8
G2 Room 9 Room 9 Room 10 Room 10 Room 11 Room 11 Room 12 Room 12 R14 R15
G1 Room 1 Room 1 R2 R3 R4 R5 Room 6 Room 6 R7 R8
J5
29
20 June 2008
A9 Ext Room 5 Room 5 Room 4 Room 4
A9 ICU Room 5 Room 5 Room 6 Room 6 R7 R8
G2 Room 9 Room 9 Room 10 Room 10 Room 11 Room 11 Room 12 Room 12 R14 R15
G1 Room 1 Room 1 R2 R3 R4 R5 Room 6 Room 6 R7 R8
J5
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
A9 Ext Room 5 Room 5 Room 4 Room 4
A9 ICU Room 5 Room 5 Room 6 Room 6 R7 R8
G2 Room 9 Room 9 Room 10 Room 10 Room 11 Room 11 Room 12 Room 12 R14 R15
G1 Room 1 Room 1 R2 R3 R4 R5 Room 6 Room 6 R7 R8
J5
33
10 July 2008
A9 Ext Room 5 Room 5 Room 4 Room 4
A9 ICU Room 5 Room 5 Room 6 Room 6 R7 R8
G2 Room 9 Room 9 Room 10 Room 10 Room 11 Room 11 Room 12 Room 12 R14 R15
G1 Room 1 Room 1 R2 R3 R4 R5 Room 6 Room 6 R7 R8
J5
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

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 ? 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

Procedure Gloves Apron
Nappy Yes
NG feed Yes
Meds Yes
Insert IV Yes
Draw blood Yes
Hold baby Yes Yes
Exam baby Yes
Dressing Yes
Washing Yes Yes
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
Infection Site Pre Guidelines Rate1000 Post Guidelines Rate1000 P value
Central Line Assoc Blood Stream Infection 5.54 4.76 lt.001
Ventilator Assoc Pneumonia 6.16 4.79 lt.001

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