Infection Outbreaks Infection Outbreaks in a Neonatal Nurseryin a Neonatal Nursery
Dr Sandi HolgateDr Sandi HolgateDivision of NeonatologyDivision of NeonatologyDepartment of Paediatrics and Child HealthDepartment of Paediatrics and Child HealthTygerberg Children’s Hospital & University of StellenboschTygerberg Children’s Hospital & University of Stellenbosch
Overview Overview
OutbreaksOutbreaks– Rotavirus Rotavirus – MRSAMRSA
What we learntWhat we learnt How we managedHow we managed Hand washingHand washing For futureFor future
TBH NeonatologyTBH Neonatology
WARDWARD WHOWHO NUMBERNUMBER
A9 ICUA9 ICU ≥≥1000g1000g
≥≥28weeks28weeks88
G2G2 InbornInborn 4444
A9 EA9 E Stable Stable overflow G2overflow G2
1414
G1G1 ““out born”out born”
Ex - ICUEx - ICU3636
2 Outbreaks of 2 Outbreaks of InfectionInfection RotavirusRotavirus MRSAMRSA
Rotavirus – ClinicalRotavirus – Clinical
““Self limiting” diarrhoea & Self limiting” diarrhoea & vomitingvomiting
Infants & young children (<2yr)Infants & young children (<2yr)
Adults – mildAdults – mild
Immunity incompleteImmunity incomplete
Rotavirus - Rotavirus - EpidemiologyEpidemiology Seasonal: winterSeasonal: winter Incubation period 2-4 daysIncubation period 2-4 days SpreadSpread
– Faecal – oralFaecal – oral– Air borneAir borne– Stable in environmentStable in environment
Rotavirus - VirologyRotavirus - Virology
Double stranded RNADouble stranded RNA
Group A – infection in Group A – infection in humanshumans
Two outer protein Two outer protein layers:layers:– VP7 = G genotypesVP7 = G genotypes– VP4 = P genotypesVP4 = P genotypes
TBH rotavirus = G12 TBH rotavirus = G12 P6P6
Rotavirus - diagnosisRotavirus - diagnosis
DiagnosisDiagnosis– Antigen testAntigen test– Strains:Strains: not commonly done not commonly done
Enzyme immunoassayEnzyme immunoassay RT PCRRT PCR
www.cdc.gov/rotaviruswww.cdc.gov/rotavirus
Rotavirus – TBH CasesRotavirus – TBH Cases
Premature babyPremature baby Loose stoolsLoose stools No other features of NECNo other features of NEC Sent sample for virology screenSent sample for virology screen
– ROTAVIRUS +ROTAVIRUS + 22ndnd then 3 then 3rdrd baby with loose stools baby with loose stools Both Rotavirus positiveBoth Rotavirus positive
Rotavirus – at TBHRotavirus – at TBH
DurationDuration– 29 May – 30 June 200829 May – 30 June 2008
Total Cases – Total Cases – 5858– SymptomaticSymptomatic– Positive lab resultPositive lab result
Rotavirus at TBHRotavirus at TBH
Place of Origin of Rotavirus Infections
3%
10%
21%
66%
A9 NICU
A9 Ext
G1
G2
Rotavirus – Risk Rotavirus – Risk AssessmentAssessment
NumberNumber %%
AdmittedAdmitted 307307
Loose stoolsLoose stools 9494 30.630.6
Rotavirus +Rotavirus + 5858 18.918.9
RotavirusRotavirus
Number of new rotavirus cases: Weekly May to July 2008
1
7
1311
14
10
1
02468
10121416
22-25/05 26/05-01/06 02/06-08/06 09/06-15/06 16/06-22/06 23/06-29/06 30/06-06/07
Date
Cas
es
LegendLegend
Rotavirus positiveRotavirus positive
Rotavirus contactRotavirus contact
CleanClean
29 May 200829 May 2008A9A9
ExExtt
Room 5Room 5 Room 4Room 4
A9 A9 ICICUU
Room 5Room 5 Room 6Room 6 R7R7 R8R8
G2G2 Room 9Room 9 Room 10Room 10 Room 11Room 11 Room 12Room 12 R14R14 R15R15
G1G1 Room 1Room 1 R2R2 R3R3 R4R4 R5R5 Room 6Room 6 R7R7 R8R8
J5J5
Rotavirus – UIPC Rotavirus – UIPC findingsfindings OvercrowdingOvercrowding
– 30cm between 30cm between incubatorsincubators
Movement of Movement of babiesbabies– Progress Progress
through the through the wardswards
– Transfer to Transfer to other wardsother wards
Rotavirus – UIPC Rotavirus – UIPC findingsfindings Staff shortageStaff shortage
– Couldn’t dedicateCouldn’t dedicate– AgenciesAgencies– Understanding of precautionsUnderstanding of precautions– Waste bins not emptied regularlyWaste bins not emptied regularly
Rotavirus – UIPC Rotavirus – UIPC findingsfindings Shared utensils (feed preparation)Shared utensils (feed preparation)
Shared equipmentShared equipment
Supplies overstocked in patient Supplies overstocked in patient roomsrooms
Rotavirus – UIPC Rotavirus – UIPC ActionsActions Main suggestion was:Main suggestion was:
– WARD CLOSUREWARD CLOSURE
““Couldn’t” - full labour ward & Couldn’t” - full labour ward & tertiary referral centretertiary referral centre
Rotavirus – UIPC Rotavirus – UIPC ActionsActions Document “SOP”Document “SOP”
Outbreak warning Outbreak warning noticesnotices
SurveillanceSurveillance
Daily progress Daily progress reportsreports
Monitoring isolation Monitoring isolation precautionsprecautions
Training staff & Training staff & parentsparents
Availability of PPEAvailability of PPE
Assessment of ward Assessment of ward ventilationventilation
Checklist for ward Checklist for ward cleaningcleaning
Standard Operating Standard Operating ProcedureProcedure PatientsPatients WasteWaste SharpsSharps EquipmentEquipment EnvironmentEnvironment ParentsParents Health care workersHealth care workers
Standard Operating Standard Operating ProcedureProcedure
PatientsPatients– Closed incubatorsClosed incubators– Minimal Minimal
movementmovement
WasteWaste– InfectiousInfectious– Non infectiousNon infectious
Standard Operating Standard Operating ProcedureProcedure SharpsSharps
EquipmentEquipment– No sharingNo sharing– Labelling of Labelling of
incubatorsincubators
EnvironmentEnvironment– Clean (+) rooms lastClean (+) rooms last
– Separate equipmentSeparate equipment
– New cloths dailyNew cloths daily
– Soap & water – Soap & water – damp dusting damp dusting surfaces & floorssurfaces & floors
– Wipe surfaces 95% Wipe surfaces 95% ethyl alcoholethyl alcohol
Standard Operating Standard Operating ProcedureProcedure ParentsParents
– Hand washing & Hand washing & sprayspray
– MasksMasks– Reporting loose Reporting loose
stoolsstools– Their baby onlyTheir baby only– PamphletsPamphlets– Limit visitorsLimit visitors
Health Care Health Care WorkersWorkers– Limit staff Limit staff
exposureexposure– Limit studentsLimit students– Hand washing & Hand washing &
sprayspray– PPE per PPE per
procedureprocedure
Personal Protective Personal Protective EquipmentEquipmentProcedureProcedure MaskMask GlovesGloves ApronApron
Nappy Nappy changechange
√√ √√ √√
NG feedsNG feeds √√ √√
MedicationMedication √√ √√
Insert IVInsert IV √√ √√
Draw bloodDraw blood √√ √√
Hold babyHold baby √√ √√ √√
Examine Examine babybaby
√√ √√
Do dressingDo dressing √√ √√
Wash babyWash baby √√ √√ √√
Assessment of Ward Assessment of Ward Ventilation – smoke Ventilation – smoke testtest
1.1. No proper mechanical ventilation in No proper mechanical ventilation in rooms. Some air outlets closed.rooms. Some air outlets closed.
2.2. Circulation of air b/w the incubators - Circulation of air b/w the incubators - ↑↑ likelihood of aerosol transmission of the likelihood of aerosol transmission of the rotavirus.rotavirus.
3.3. Smoke particles remained suspended in Smoke particles remained suspended in far corners of the rooms, far corners of the rooms, ↑↑ the risk of the risk of aerosol transmission in these areas.aerosol transmission in these areas.
4.4. There was no real movement of air from There was no real movement of air from the rooms into the passages.the rooms into the passages.
Rota NoticesRota Notices
Rotavirus Outbreak in Progress
Please report to nurse in charge
upon entering the ward.
UIPC, June 2008
1111 June 2008 June 2008A9A9
ExExtt
Room 5Room 5 Room 4Room 4
A9 A9 ICICUU
Room 5Room 5 Room 6Room 6 R7R7 R8R8
G2G2 Room 9Room 9 Room 10Room 10 Room 11Room 11 Room 12Room 12 R14R14 R15R15
G1G1 Room 1Room 1 R2R2 R3R3 R4R4 R5R5 Room 6Room 6 R7R7 R8R8
J5J5
20 June 200820 June 2008A9A9
ExtExtRoom 5Room 5 Room 4Room 4
A9 A9 ICUICU
Room 5Room 5 Room 6Room 6 R7R7 R8R8
G2G2 Room 9Room 9 Room 10Room 10 Room 11Room 11 Room 12Room 12 R14R14 R15R15
G1G1 Room 1Room 1 R2R2 R3R3 R4R4 R5R5 Room 6Room 6 R7R7 R8R8
J5J5
20 June20 June
WARDS G1 & G2 WARDS G1 & G2 CLOSEDCLOSED TO TO NEW ADMISSIONSNEW ADMISSIONS
Rotavirus – Morbidity Rotavirus – Morbidity & Mortality& Mortality Only symptomatic babies Only symptomatic babies
screenedscreened– Loose stoolsLoose stools– DehydrationDehydration– Abdominal distensionAbdominal distension
3 deaths3 deaths– 2 NEC – possibly related2 NEC – possibly related– 1 epidermolysis bullosa - unrelated1 epidermolysis bullosa - unrelated
2233 June 2008 June 2008A9A9
ExExtt
Room 5Room 5 Room 4Room 4
A9 A9 ICICUU
Room 5Room 5 Room 6Room 6 R7R7 R8R8
G2G2 Room 9Room 9 Room 10Room 10 Room 11Room 11 Room 12Room 12 R14R14 R15R15
G1G1 Room 1Room 1 R2R2 R3R3 R4R4 R5R5 Room 6Room 6 R7R7 R8R8
J5J5
1010 July 2008 July 2008A9A9
ExExtt
Room 5Room 5 Room 4Room 4
A9 A9 ICICUU
Room 5Room 5 Room 6Room 6 R7R7 R8R8
G2G2 Room 9Room 9 Room 10Room 10 Room 11Room 11 Room 12Room 12 R14R14 R15R15
G1G1 Room 1Room 1 R2R2 R3R3 R4R4 R5R5 Room 6Room 6 R7R7 R8R8
J5J5
Rotavirus LiteratureRotavirus Literature
Chen et al. J of Chen et al. J of Formosan Med Assoc Formosan Med Assoc Taiwan, 1997, Nov Taiwan, 1997, Nov 96(11):884-996(11):884-9
– 91 same strain 91 same strain
– Different strain to 64 Different strain to 64 infants/toddlers in infants/toddlers in Paeds wardsPaeds wards
– Eradicated Eradicated 8 8 monthsmonths after onset after onset
TestedTested PositivPositivee
SymptSymptomaticomatic
10371037 164 164 (16%)(16%)
94 94 (57%)(57%)
Rotavirus LiteratureRotavirus Literature
Infection Control & Hospital Infection Control & Hospital Epidemiology; Nov 2002, Vol 23, No 11, Epidemiology; Nov 2002, Vol 23, No 11, p665. p665. Widdowson et alWiddowson et al
– Attack rate 40%Attack rate 40%
– Un-gloved NG feeds a Un-gloved NG feeds a significant significant risk factorrisk factor
– Persistence on surfaces despite cleaningPersistence on surfaces despite cleaning
– Mothers with high antibodies Mothers with high antibodies not not necessarily protectivenecessarily protective
Rotavirus LiteratureRotavirus Literature
Widdowson et al:Widdowson et al:– Outbreak ended with in 7 days of Outbreak ended with in 7 days of
WARD CLOSURE, proper disinfection WARD CLOSURE, proper disinfection and gloved NG feedsand gloved NG feeds
Rotavirus LiteratureRotavirus Literature
Ramani et alRamani et al: Journal of Medical : Journal of Medical Virology 80: 1099 – 1105 (2008)Virology 80: 1099 – 1105 (2008)– Difference in clinical & epidemiology Difference in clinical & epidemiology
in neonates vs older childrenin neonates vs older children– Neonates:Neonates:
Unusual strainsUnusual strains Single strains persist long timeSingle strains persist long time High transmission, less virulenceHigh transmission, less virulence
Rotavirus Literature Rotavirus Literature contcont
Ramani et alRamani et al: Journal of Medical : Journal of Medical Virology 80: 1099 – 1105 (2008)Virology 80: 1099 – 1105 (2008)
– Virus detected in environment of Virus detected in environment of ⅓⅓ of neonatesof neonates
– Need STANDARD PROTOCOLS for Need STANDARD PROTOCOLS for cleaning, procedures etccleaning, procedures etc
Rotavirus - G Rotavirus - G genotypesgenotypes
Grey et al. JPGN 2008
METHACILLIN RESISTANT METHACILLIN RESISTANT STAPH AUREUS - STAPH AUREUS - BackgroundBackground Staph infections common in Staph infections common in
hospitalshospitals
MRSA previously “hospital MRSA previously “hospital pathogen”pathogen”
Recently “community acquired” Recently “community acquired” MRSAMRSA– Equally – if not more - pathogenicEqually – if not more - pathogenic
MRSAMRSA- Microbiology- Microbiology
Resistant to:Resistant to:– CephalosporinsCephalosporins– CloxacillinCloxacillin– ErythromycinErythromycin– TetracyclinesTetracyclines– Fusidic acidFusidic acid– GentamicinGentamicin
MRSAMRSA
Treatment of choice = Treatment of choice = GylcopeptideGylcopeptide– VancomycinVancomycin– TeichoplaninTeichoplanin
If resistance (GRSA or GISA)If resistance (GRSA or GISA)– Very difficult to treatVery difficult to treat– LinezolidLinezolid– RifampicinRifampicin
MRSA - ReservoirsMRSA - Reservoirs
NoseNose and groin and groin Skin lesionsSkin lesions Dust and enviromentDust and enviroment Linen and bed clothingLinen and bed clothing Clinical equipmentClinical equipment
MRSA – route of MRSA – route of spreadspread HandsHands of staff or mothers or of staff or mothers or
other patientsother patients Skin scales or excoriating skin Skin scales or excoriating skin
lesionslesions Air and environment (unusual)Air and environment (unusual) Equipment - clinical and non-Equipment - clinical and non-
clinical (rare)clinical (rare)
Methacillin Resistant Methacillin Resistant Staph AureusStaph Aureus
TBH index case:TBH index case: Term IDM with hypoglycaemiaTerm IDM with hypoglycaemia
UVC for 15% Dextrose infusionUVC for 15% Dextrose infusion
OmphalitisOmphalitis
Cultured MRSACultured MRSA
MRSAMRSA
Removed UVCRemoved UVC Vancomycin IVVancomycin IV Bactroban (Mupiricin) topicalBactroban (Mupiricin) topical
MRSAMRSA
Septic arthritisSeptic arthritis
““GISA” cultured…GISA” cultured…– Glycopeptide Intermediate Glycopeptide Intermediate
Sensitivity Staph AureusSensitivity Staph Aureus
MRSA – UIPC MRSA – UIPC investigationinvestigation
Incorrectly given antibiotic dosesIncorrectly given antibiotic doses
Low vancomycin trough levelsLow vancomycin trough levels
Overuse bactroban – resistanceOveruse bactroban – resistance
““Incorrect” hand sprayIncorrect” hand spray
MRSA – ScreeningMRSA – Screening
Sterile swab – dipped in sterile salineSterile swab – dipped in sterile saline PatientsPatients
– Esp if on antibiotics or steroidsEsp if on antibiotics or steroids– Wounds, skin lesionsWounds, skin lesions– Urine catheters, venous access linesUrine catheters, venous access lines
StaffStaff– NoseNose & 1 of: & 1 of:– GroinGroin– AxillaAxilla– Hair lineHair line
MRSA – Contact MRSA – Contact precautionsprecautions Hand Hand
disinfectiondisinfection– WashWash– Alcohol sprayAlcohol spray
GlovesGloves Masks not Masks not
neededneeded IsolateIsolate
ProcedurProceduree
GlovesGloves AproApronn
Nappy Nappy YesYes
NG feedNG feed YesYes
MedsMeds YesYes
Insert IVInsert IV YesYes
Draw Draw bloodblood
YesYes
Hold babyHold baby YesYes YesYes
Exam Exam babybaby
YesYes
DressingDressing YesYes
Washing Washing YesYes YesYes
MRSA – Treatment of MRSA – Treatment of CarriersCarriers Nasal (8 hourly)Nasal (8 hourly)
– Mupirocin (bactroban)Mupirocin (bactroban)– Chlorhexidine nasal ointmentChlorhexidine nasal ointment
HairHair– 4% Chlorhexidine gluconate – 4% Chlorhexidine gluconate –
alternate daysalternate days SkinSkin
– 4% Chlorhexidine gluconate soap - 4% Chlorhexidine gluconate soap - dailydaily
MRSA – Treatment of MRSA – Treatment of Neonatal CarriersNeonatal Carriers
Skin decontamination - neonateSkin decontamination - neonate– Daily wipe the body and hair with Daily wipe the body and hair with
0.25%0.25% aqueous chlorhexidine (NOT aqueous chlorhexidine (NOT 4% - skin burns) 4% - skin burns)
– Do not rinse or wipe off – watch Do not rinse or wipe off – watch temperaturetemperature
– Disposable clothDisposable cloth
MRSA – Treatment of MRSA – Treatment of Neonatal CarriersNeonatal Carriers Change bed linen daily after each day’s Change bed linen daily after each day’s
chlorhexidine application.chlorhexidine application.
Follow this procedure for 7 days.Follow this procedure for 7 days.
Repeat screening of baby 72 hours after Repeat screening of baby 72 hours after stopping skin decontamination.stopping skin decontamination.
Bactroban resistance and worry of nasal Bactroban resistance and worry of nasal obstruction & apnoea – NO nasal obstruction & apnoea – NO nasal treatmenttreatment
HAND WASHINGHAND WASHING
What does the Evidence What does the Evidence show?show?
Problem Problem Tertiary hospital, Argentina Tertiary hospital, Argentina– Low hand washing complianceLow hand washing compliance– High nosocomial infection rateHigh nosocomial infection rate
InterventionIntervention– Education, training & performance feedbackEducation, training & performance feedback
ResultsResults– Compliance improved from 23.1% to 64.5%Compliance improved from 23.1% to 64.5%– Infection rate improvement of 41.3%Infection rate improvement of 41.3%
Am J Infect Control, 2005; 33: 392-397Am J Infect Control, 2005; 33: 392-397
CDC Handwashing CDC Handwashing Guidelines, 2002Guidelines, 2002
Visibly soiledVisibly soiled Before & after patient contactBefore & after patient contact Before & after glovesBefore & after gloves Invasive proceduresInvasive procedures Surgical invasive procedure – nail Surgical invasive procedure – nail
brushbrush Alcohol-based hand spraysAlcohol-based hand sprays No artificial nails or polishNo artificial nails or polish
MMWR, 2002; 51: 1-56MMWR, 2002; 51: 1-56
Dissemination & Dissemination & Impact on Infection Impact on Infection RatesRates Guidelines published in 2002Guidelines published in 2002
– Implementation & complianceImplementation & compliance 44.2% DID NOT44.2% DID NOT follow guideline follow guideline
recommendationsrecommendations Compliance - 24% & 89% (mean 56.6%)Compliance - 24% & 89% (mean 56.6%)
Implementation needs to be Implementation needs to be driven within the ward & driven within the ward & managementmanagement
Am J Infect Control, 2007; 35: 666-675Am J Infect Control, 2007; 35: 666-675
Implementation CDC Implementation CDC guidelinesguidelines
Infection SiteInfection Site Pre – Pre – GuidelinGuidelinesesRate:1000Rate:1000
Post – Post – GuidelinGuidelinesesRate:1000Rate:1000
P P valuvaluee
Central Line Central Line Assoc Blood Assoc Blood Stream Stream InfectionInfection
5.545.54 4.764.76 <.00<.0011
Ventilator Assoc Ventilator Assoc PneumoniaPneumonia
6.166.16 4.794.79 <.00<.0011
TBH Infection RatesTBH Infection Rates
Sepsis rates dropped Sepsis rates dropped by 30% during time by 30% during time
of Rotavirus outbreakof Rotavirus outbreak
SummarySummary
Infection Infection not uncommon not uncommon in in neonatal nurseriesneonatal nurseries
Overcrowding increase riskOvercrowding increase risk Staff shortages increase riskStaff shortages increase risk
SummarySummary
Infecting organisms “hardy”Infecting organisms “hardy” Difficult to eradicateDifficult to eradicate May be “dormant” May be “dormant” Carriers may be asymptomatic Carriers may be asymptomatic
– often unawareoften unaware
How do we “Better Our How do we “Better Our Best & Beat the Best & Beat the Odds”?Odds”?
AwarenessAwareness
PreventionPrevention
Better Our Best & Beat Better Our Best & Beat the Oddsthe Odds Hand washing > 15secHand washing > 15sec Hand spray – before & after Hand spray – before & after
– 70% alcohol70% alcohol– 0.5% chlorhexidine0.5% chlorhexidine– GlycerineGlycerine
Proper disposal of wasteProper disposal of waste Proper cleaning of equipmentProper cleaning of equipment
Better Our Best & Beat Better Our Best & Beat the Oddsthe Odds EducationEducation
– MothersMothers– Medical staff (Doctors, nurses, other)Medical staff (Doctors, nurses, other)– Cleaning staffCleaning staff– Administrative staff Administrative staff
(superintendents/CEO)(superintendents/CEO)
Better Our Best & Beat Better Our Best & Beat the Oddsthe Odds Limit / monitor use of antibioticsLimit / monitor use of antibiotics
Peripheral line for antibioticsPeripheral line for antibiotics
Limit access of central lines – Limit access of central lines – STERILESTERILE
Limit use of topical antibioticsLimit use of topical antibiotics
Better Our Best & Beat Better Our Best & Beat the Oddsthe Odds ProtocolsProtocols Involve other colleagues Involve other colleagues
– O&GO&G– UIPCUIPC– Microbiology & virologyMicrobiology & virology
Better Our Best & Beat Better Our Best & Beat the Oddsthe Odds Involve managementInvolve management
– Help with staffHelp with staff– Help with disposablesHelp with disposables– Help with ward closuresHelp with ward closures
Their Future is in Our Their Future is in Our Hands Hands
Thanks to:Thanks to:
– Sr AucampSr Aucamp– Dr PostDr Post– TBH IPC teamTBH IPC team– TBH neonatal TBH neonatal
teamteam