INFECTION CONTROL IN NICUS

HANY ALY, MD, FAAP

Professor of Pediatrics, Obstetrics &
Gynecology
Director, Newborn Services
The George Washington University
 SEPSIS IN VLBW INFANTS
Vermont-Oxford Network
40

20
%

0
1998 1999 2000 2001
 SEPSIS IN VLBW INFANTS…. NICHD

Incidence of ≥ 1 episode of late onset

sepsis: 21%
……”strategies to reduce late infections in
VLBW neonates...are urgently needed. The
use of collaborative quality improvement
strategies to reduce nosocomial infections
among VLBW NICU patients warrants
additional study.”
Stoll et al; Pediatrics, 2000
 INFECTIONS AT GWU
20
Infection/1000 line
Aly et al., 2005 - Aly & Herson 2006

15
days

10

0
98 99 0 1 2 3 4 5 6 7 8
 FACTORS THAT INCREASE
RISK OF INFECTION IN NICU
• Immature immune system in the newborn
• Overcrowding and understaffing
• Inadequate numbers or placement of
sinks
• Neonates may be colonized with
pathogens without overt symptoms
• Invasive procedures
 THE NURSERY: LOCATION
• It should be in a low traffic area
• Access to the unit should be restricted
• No open windows to the outside
• Nursing station should be away from
patient care area
 THE NURSERY: SINKS
A sink should be within 8 steps from each patient

NURSERY LEVEL NUMBER OF SINKS

Level 1 1 Sink / 6-8 Neonates

Level 2 1 Sink / 3-4 Neonates

Level 3 1 Sink / 3-4 Neonates

a
THE NURSERY: SPACE DESIGN

NURSERY LEVEL SPACE / NEONATE

Level 1 30 ft2 / Neonate

Level 2 50 ft2 / Neonate

2
Level 3 80- 100 ft / Neonate
 THE NURSERY STRUCTURE
• Entrance: Foot operated sink
Gowns (?)
Disposable trash cans

• Isolation rooms: For airborne infections

For home admissions
(72 hours)
 PERSONNEL: STAFFING
NURSERY LEVEL NUMBER OF NURSES

Level 1 1 Nurse / 6-8 Infants

Level 2 1 Nurse / 2-3 Infants

Level 3 1 Nurse / 1-2 Infants

a
 PERSONNEL: GLOVES
• Use gloves for any contact with body
fluids
• Use masks, head covers, sterile gloves
and sterile gowns for procedures:
– PCVL
– UAC / UVC
PERSONNEL: OVERSHOES

?
 PERSONNEL: OTHERS
• Foods and drinks are not allowed
• Live plants and flowers are not allowed
• Sterile solutions, flushes should not be
kept longer than 24 hours
– Label all solutions with date and time of
opening
 HANDWASHING
• It the MOST important infection control
measure
• Remove all jewelry
• Roll sleeves up to elbows
• Use a wet sponge or scrub brush with an
antiseptic: Chlorhexidine Gluconate
Povidone Iodine
 HAND WASHING
• P.S. Liquid soap dispensers and their
contents can become contaminated

• Alcohol-containing foams and gel kill

bacteria when applied to clean hands. It
does not work when hands are physically
soiled
• Alcohol-containing products require 15
seconds to 2 minutes of contact
 HAND WASHING: DURATION
CONDITION DURATION
At the start 2-3 minute scrub
Before procedures 2-3 minute scrub
Other consultants 2-3 minute scrub
Hospital technicians 2-3 minute scrub
Between patients 15-30 seconds
 HAND HYGIENE
• Fingernails should be trimmed short
• Artificial fingernails or extenders should
not be permitted
• Clear nail polish on natural nails appear to
have no effect , but dark colors may
obscure the subungual space and reduce
the likelihood of careful cleaning
 HAND WASHING
• Poor hand washing increases the risk of
transmitting infections (Infec Control hospital
Epidemiology 1988)
• Transmission of Staphylococci between
newborns is more likely to occur by personnel
who are less compliant about hand washing
(Mortimer et al AMJ. DIS chil.104 1950)
• Compliance with hand washing is poor
HAND WASHING SAVES LIVES
 WHY IS COMPLIANCE SO POOR?
• Hand washing takes too much time (44%)
• Hand washing is not important if an infant
is receiving antibiotics (10%)
• One thorough wash/ day is sufficient
(26%)
• Gloves can substitute for hand washing
(25%including 50% of physician )
• Lack of soap (54%) and towels (65%)
Wharton et al Ped Res 1998
 HAND WASHING
• Six nurses were assigned to monitor hand
washing techniques without their
coworkers awareness.
1. Was there a 15 second wash prior to
handling an infant?
2. Was an inanimate object or one’s own
body touched while examining the
infant?
3. Were bracelets and rings removed ?
Raju & Kobler Am J Med SCI 1991
 HAND WASHING
Compliance Rate

Item #1 Item #2 Item #3

Doctors 37.5% 29.2% 72.7%
Nurses 53.9% 29.2% 75.3%
Ancillary staff 48.5% 25.0% 85.7%
Initial overall compliance 28.2% Vs 62.6% (after an
educational process)
Raju & Kobler Am J Med SCI 1991
 ROUTINE GOWNS !!!
• Practice transferred from policies
developed for surgical asepsis during
operations
• Very limited data to support its efficacy
and much data to say it is ineffective*
*Forfar & McCabe BJM 1958,Williams&Oliver Pediatrics
1969,Donowitz Pediatrics 1986, Pelke Arch Ped &Adol
Med 1994
 ROUTINE GOWNS !!!

• Does the gown serve as a reminder to

wash hands? No! (Donowitz et al
Pediatrics 1986)
• The risk of transmission infection through
clothing is less than 2/10,000
(Larson JOGNN 1987)
 EMPLOYEE HEALTH
• ILLNESS:
– Respiratory: Use masks
– Conjunctivitis: Do not enter the unit
– Skin lesions: Do not touch patients or
equipment
• VACCINES:
– Hepatitis B
– Td (every 10 years)
 INFECTION CONTROL
EDUCATION
• Infection control course review every 2
years for all staff and nurses
• A written test may be conducted
• Conferences
• Flyers
 VISITORS
• They must do 2-3 minute scrub
• Visitation should be restricted during URI
outbreaks
• Only 2 visitors at a time
• They should not contact any equipment or
any other infant
• Visitors to well babies should be in
mothers’ rooms
 ENVIRONMENT: FLOORS

• Dust sweep every 8 hours

• Wet cleaning at least once a day
• Use any of the following:
– Quaternary ammonium compounds
– Chlorine
– Alcohol
• Walls, curtains
and windows should be
cleaned every week
 ENVIRONMENT: ISOLETTES
• Should be cleaned in a designated room
with a quaternary ammonia product
• Should be replaced every 7 days
• Should be wiped form outside every 8
hours
• Should be wiped from inside once a day
 ENVIRONMENT: ISOLETTES
• Humidifier reservoirs should be cleaned
and filled with sterile water
• Linens should be replaced every day
• Soiled linens will be kept in covered
containers until removed by laundry
personnel
 ENVIRONMENT: OTHERS
• Waste should be collected in plastic bags
and placed in soiled utility room
• Needle containers should be placed in
each room and replaced when they are 3/4
full
• Room temperature at 24-27 0C
• Relative humidity at 30-60 %
 EQUIPMENT: RESPIRATORY
• Ventilator circuit should be replaced every
week (?)
• Water condensate in the tubing should be
drained periodically
• Use only sterile water for the humidifier
• Ventilators should be replaced and
disinfected every week
ENVIRONMENT: RESPIRATORY
• Each infant should have his own
resuscitation bag and mask
• They should be kept clean away form the
floor
• They should be replaced and disinfected
every week (?)
ENVIRONMENT: RESPIRATORY
• Suction catheters should be discarded
after single use (? Re-sterilization ?)
• Suction tubing should be changed every
day or when soiled
• Suction reservoir liner should be changed
when it is full
• Sterile gloves and sterile saline bullets (5
ml) should be used with suction
CPAP AND SEPSIS (GNS)

Graham et al, 2006

 CPAP AND SEPSIS
20
Infection/1000 line days

15

10

0
98 99 0 1 2 3 4 5 6 7 8
Aly et al., 2005 - Aly & Herson 2006
NASAL COLONIZATION AND CPAP

• 829 cultures from 170 premature infant

• Only one infant had GN bacteremia
• BW, Gender, race, Prenatal steroids,
PROM, Maternal infection did not affect
colonization
• GN colonization was associated with
– CPAP (P=0.04)
– Vaginal delivery (p=0.02)
TRACHEAL COLONIZATION AND ETT
TRACHEAL COLONIZATION AND ETT
Supine Lateral P
(n=30) (n=30)

Cultures on day 5 26 (87) 9 (30) <0.01

• Gram negative rods: 18 (60) 6 (20)
Klebsiella 10 (33) 4 (13)
Pseudomonus 6 (20) 2 (7)
Enterobacter 2 (7) 0 (0)

• Gram positive cocci: 0 (0) 2 (7)

Staphylococcus 0 (0) 1 (3)
Streptococcus 0 (0) 1 (3)

• Candida 2 (7) 0 (0)

• Mixed 6 (20) 1 (3)
ABSTINENCE IS THE KEY

During intubation think about

Ventilator Associated
Pneumonia
 ENVIRONMENT: FEEDING
• Nasogastric tubes should be changed
every 3 days
• Feeding syringes should be replaced
every 4 hours
• Once out, gavage feeding tubes should be
re-inserted again
 ENVIRONMENT: IV LINES
• Document the date of insertion of any line
• UAC/UVC should not remain >15 days (?)
• Apply betadine or alcohol if the umbilical
site is moist
• Central lines dressing should be
evaluated daily and changed weekly
 ENVIRONMENT: IV LINES
• If blood culture remains positive after 48
hours of antibiotics treatment, PICC
should be removed
• Continuous infusion of heparinized fluids
should run all times in central lines
• Sterile fluids should be replaced daily
 ENVIRONMENT: IV LINES
• IV tubing should be replaced every 24
hours
• IV medications should be administered
maintaining aseptic technique (closed
medication system)
• IV pumps should be cleaned every 8
hours and when soiled
 BLOOD INFECTIONS-NICUs
Infections/1000 line days
25
20
15
10
5
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Medical Management Planning, Inc. 1999
 INFECTIONS AT GWUH
CCMC GWUH
35

30

25
B
20
S
I
/

15
1
0
0
0
10
l
i
n
e
5
d
a
y
s
0
'95 '96 '97 '98 '99 '00 '01
 INFECTIONS AT GWU
U Con GWU NNN
20

15

10

0
1999 2000 2001
 INFECTIONS AT GWU
20
Infection/1000 line
Aly et al., 2005 - Aly & Herson 2006

15
days

10

0
98 99 0 1 2 3 4 5 6 7 8
 SEPSIS IN VLBW INFANTS
Vermont-Oxford Network
40

20
%

0
1998 1999 2000 2001
 SEPSIS IN VLBW INFANTS…. NICHD

Incidence of ≥ 1 episode of late onset

sepsis: 21%
……”strategies to reduce late infections in
VLBW neonates...are urgently needed. The
use of collaborative quality improvement
strategies to reduce nosocomial infections
among VLBW NICU patients warrants
additional study.”
Stoll et al; Pediatrics, 2000
 ENVIRONMENT:
SCALES, MONITORS & SUPPLIES

• Dinamaps, stethoscopes and diaper

weighing scales should be wiped with
disinfectant between infants
• Cardiac monitors and POX should be
disinfected daily
• Supplies should not be shared between
infants
• Soiled and clean items should not be
mixed
 INFANTS
• Remove infants from radiant warmers as
soon as possible
• Infants admitted from community should
be admitted to isolation area with contact
precautions for 72 hours
• Umbilical stumps should be cleaned with
alcohol with each diaper change
 INFANTS
• If omphalitis is endemic use triple dye
routinely to to reduce Staph. aureus
colonization
• Triple dye: 2.29g brilliant green + 1.14g
profavine hemisulfate + 2.29g crystal
violet in a letter of sterile water
• Infants should be bathed 3 times a week.
Do not apply soap to the face
 INFANTS
• Erythromycin eye ointment to all infants
on admission
• Use only CMV-antibody negative blood
(via Leukopoor filtration) for all infants’
transfusions
 NUTRITION: FORMULA
• Formula should be discarded after 24
hours from preparation
• Sterile water should be used for
preparation
• Fortification with non-cow protein
formulas only
 NUTRITION: FORMULA
• Formula should be discarded after 24
hours from preparation
• Sterile water should be used for
preparation
• Fortification with non-cow protein
formulas only
 NUTRITION: BM EXPRESSION
• Give proper instructions to mothers
– Careful washing of nipple and hand
– Pumps should be sterilized by boiling for 10-
15 minutes every day
– Pumps should be cleaned with hot soapy
water after each use
– HBsAG positive mother can breast feed if the
infant received the HBIG and vaccine
 NUTRITION: BM STORAGE
• BM should be stored in sterile bags
labeled with date and name on it
• It can be refrigerated for 24 hours
• It can be frozen for 2-3 weeks
• It can be stored in deep freezers (-18 0
C)
for months
• Do not use microwave for thawing frozen
milk
 CPAP and NEC (n=342)
Variables OR 95% CI P
Birth weight 0.99 0.99 1.0 0.05
Gender (Male) 2.42 0.93 6.27 0.07
Prenatal steroids 1.58 0.57 4.35 0.38
Duration of CPAP 1.04 0.47 2.33 0.92
PaO2 0.99 0.97 1.0 0.08
FiO2 during CPAP 0.99 0.98 1.02 0.92
Umbilical artery Catheter 2.4 0.82 6.99 0.11
Patent ductus arteriosus 0.18 0.06 0.52 0.002
Early sepsis 1.12 0.10 12.494 0.93
Delivery room intubation 1.37 0.39 4.84 0.62
Hospital site 0.86 0.34 2.21 0.76
Aly et al Pediatrics 2009
 NUTRITION: CANDIDA
PROPHYLAXIS
• Nystatin is given to all ELBW infants
<1000 g after the first week of life
• Oral swab Q 8 hours
• Prophylaxis continues until infants are on
full enteral feed and weighs >1 kg
• Infants on steroid nebulization also
receives nystatin
ZANTAC IS ASSOCIATED WITH
INCREASED SEPSIS
60

30 Sepsis %
OR=6.99

0
Zantac No Zantac J Perinatal Med 2007:35:147-150
 ANTIBIOTIC CHOICE
• The use of cephlosporins as the primary
choice of antibiotics are associated with
significantly increased mortality
• Mortality is explained by increased
Candida sepsis
 IMMUNIZATION

• In accordance to the postnatal age

• OPV only at discharge, otherwise use IPV
• BCG can be given at discharge
 ISOLATION: NON-NEONATAL
• Respiratory
– Meningitis due to H. influenzae or N.
meningitidis
– Measles
– Pertussis

• Tuberculosis
 ISOLATION
TYPES OF ISOLATION EXAMPLES
Strict Varicella
Contact URI, C. Rubella, HSV,
Staph wounds
Enteric NEC, Gastroenteritis,
viral meningitis
Drainage/Secretions Non-Staph wounds
None CMV, GBS