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