Infection

International

ROUTINE
INFECTION
PREVENTION

Infection
International

ROUTINE INFECTION PREVENTION

Hand washing
Universal precautions
Safe handling of sharps

Infection
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STERILISATION
Instruments must be cleaned first
Sterilize with steam autoclave or hot-air oven
Preferable over disinfection for critical
instruments

Infection
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HIGH LEVEL DISINFECTION

Boiling for 20 minutes, completely covered

with water
Chemical: bleach 1:50 dilution for 20
minutes corrosive to stainless steel

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ANTISEPTICS
Patient skin prep
Wound cleanser
Hand washing/surgical scrub
Examples
isopropyl alcohol
chlorhexidine gluconate
iodine/iodophor

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DISINFECTING WORK AREAS

Clean dirty areas with detergent
Disinfect area with bleach 1:100
dilution
Wear gloves

Exam tables should be disinfected

daily

Infection
International

Infection

Infection
International

Objectives

definition
predisposing factors
pathophysiology
clinical features
sites of postpartum infection
treatment
prevention

Infection
International

Definition:
any patient with fever of 38.5C 48-72 hours
following a vaginal or forceps delivery with
uterine tenderness

Infection
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Incidence and scope:

- major cause of maternal death in emerging
countries
- less frequent with vaginal births
- complications include: shock, pelvic abscesses
and pelvic thrombosis

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Pathophysiology
- normal flora of genital tract contains potential
pathogens
- amniotic fluid and increase in white blood
cells during labour

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Predisposing factors
- trauma and tissue necrosis following deliver
creates a culture medium for ascending
- cesarean section is most important predisposing
- prolonged labour and ruptured membranes
- poverty and poor hygiene/nutrition

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Bacteria
- polymicrobial
- most common:
Escherichia coli, Kelbsiella, Proteus and
Bacteroides fragilis
- less common:
Clostridium, Staphylococcus aurea and
Pseudomona
- exogenous source:
Group A beta-hemolytic streptococci

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Clinical Features
- usually 2-3 days post partum
- low grade temperature, lower abdominal pain
and uterine tenderness
- also: malaise, anorexia, foul lochia
- if severe: high temperature and generalized
peritonitis

Infection
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Clinical Features
- Group A beta-hemolytic stretpococci may be
fulminant with peritonitis and septicemia

- if cultured, hospital personnel must be screened

to try and identify the source

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Diagnosis
- sites of infection to consider in post partum patient
(culture if able):
endomyometritis
urinary tract
episiotomy site
abdominal incision
breast
thrombophlebitis: legs, pelvis
appendicitis
other: upper respiratory infection

Infection
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Management - Prevention
- correct aseptic technique
- antibiotic use in women with cesarean section
or prolonged rupture of membranes (1g
ampicillin IV given prophylactically in
cesarean section reduces infection)

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International

Management -- Treatment
mild case: single broad spectrum antibiotic (eg.
ampicillin 1 g IV q6h Or orally)
if cesarean section:
flagyl 500 mg q8h + cefoxitin 2g q6h
OR
aminoglysocide (gentamycin or tobramycin) 60100 mg q8h +clindamycin 900 mg q8h

Infection
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Management - Treatment
if intravenous antibiotics used, continue for 48
hours after fever has stopped.
if fever continues and aminoglycoside-clindamycin
combination was used, add penicillin (5M units
q6h) to cover enterococci

oral antibiotics should be used for 5 days

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Other issues
- the more antibiotics used, > the higher the
chance of necrotizing colitis
- antibiotics do appear in breast milk but in most
cases are not clinically significant
(avoid
tetracyclines)

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Specific issues:
episiotomy infection: treat with antibiotics, baths
(clean water!), heat
- remove sutures if fluctuation or pus
- rarely needs debridement
necrotizing fascitis: rare, rapid progression of local
inflammation followed by gangrene -patient is toxic:
high dose antibiotics but MUST surgically
DEBRIDE

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Other issues
- Septic pelvic thrombophlebitis--usually anaerobic
sepsis
- usually patient is already on antibiotics but
continues to have high spiking fevers
- diagnosis of exclusion
- treatment is intravenous heparin
- > condition should respond to heparin

Infection
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Other issues
- Mastitis--penicillin G or penicillinase-resistant
(methicillin or cloxacillin)
for 7-10 days
continue breast feeding!
if breast abcess--drain

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International

Special case:
Postpartum or postabortal septic shock
definition: any toxic patient who has
hemodynamic or acid base changes with fever
38.5C (after abortion, vaginal or operative
delivery)

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International

Etiology of postpartum/postabortal shock

- usually gram-negative bacteria (eg. E. Coli) and
occasionally gram positive
(staphylococci,
anaerobic streptococci, clostridium)

Infection
International

Pathophysiology of postpartum postabortal

shock
- not fully understood
- endotoxins from cell wall of bacteria initiate
vascular damage and vasodilatation
- hypotension / hypoperfusion

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Conclusions
- major problem
- proper diagnosis
- early and aggressive treatment
- prevention

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MALARIA IN PREGNANCY

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Objectives

Describe epidemiology of malaria

Describe maternal and fetal
complication
Principle of management and
preventive strategies

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International

Global Effect

Affects 300-500 million people yearly

Causes 1 to 2.7 million deaths
90% of deaths occur in Sub -Saharan
Africa
(approximately 3000 deaths each day)

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Size of problem in Africa

(WHO 1999)

Population: 564
Annual births: 24.7
Exposed to malaria: 93%
ANC coverage: 63%
Low birth weight: 16%
Malaria attributable fraction to LBW:1250%

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Effect of malaria on pregnancy

Related to Level of transmission and

immunity of individual exposed
In areas of high transmission
,endemic or stable malaria area.
In areas of low transmission or non
endemic or unstable areas

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Maternal complication

In Endemic areas
malaria related
anaemia
Febrile illness
Placental
sequestration

In non-Endemic
areas
Greater risk of
severe disease
Higher risk of
death
Anaemia,
hypoglycemia,
pulmonary
oedema, renal
failure

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Anaemia

Multi factorial:affects 50-60% pregnant women

in Sub-Saharan region
Haemolysis
Increased immune clearance of infected and
non infected RBCs
Malarial hyperactive splenomegaly
Nutritional & hookworm infestation
Increased risk in pregnancy to Post -partum
Hemorrhage & Heart failure

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International

Severe malaria

Cerebral malaria: Unrousable coma

with asexual peripheral parsitaemia or
placental infection.
Hypoglycemia
Pulmonary edema (ARDS)
Acute renal failure

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Fetal complications

In endemic areas
Low birth weight
Intra-uterine growth
retardation

In non-endemic areas
Abortions
preterm delivery
Congenital malaria
Low birth weight

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Management and Preventive

Strategies
Early diagnosis and effective treatment
Use of chemo-prophylaxis or
intermittent treatment presumptive
treatment.
Use of insecticide treated bed nets
Regular Antenatal care and health
education about malaria

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Early Diagnosis and

Treatment

Use of National treatment guideline for

treatment.
In uncomplicated malaria: Chloroquine,
SP,Mefloquine,Quinine (combination
therapy)
In Severe malaria: Parenteral Quinine,
Artemesinin derivatives and supportive
therapy

Infection
International

Studies on IPT

Results:
A decrease in febrile illness
A decrease in peripheral &placental
parasitemia
A increase in maternal hemoglobin
level
A lower proportion of Low birth
weights

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Chemoprophylaxis and Intermittent

Presumptive Treatment
In endemic areas ,use of intermittent
presumptive treatment (IPT):
Target population at Risk
Dosage: SP given in two doses;
1st dose: 16-24 weeks
2rd dose 28 to 36 weeks.
Alternative: Chloroquine Full dose than 2
tablets weekly dose till delivery or proguanil

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Use of Insecticide treated nets

YEAR

LOCATION

1993

MALARIA
TRANSMISSION

GRAVIDITY

PREVALENCE
OF ANAEMIA

Thai/Myanm 0.8
ar Border

All

56 to 27%

1996

Gambia

1-10

Primegravid

17 to 3%

1998

Kenya

10

Primegravid

20 to 15

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International

Conclusions

Improve implementation of existing

strategies and health delivery system
with emphasis on integration in existing
services
Improve on Health education to
community on dangers of malaria and
early ,regular ANC attendance.

Infection
International

PREVENTION OF MATERNAL
TO CHILD TRANSMISSION OF
HIV

Infection
International

Objectives

Describe relationship of HIV on

pregnancy
Factors affecting vertical transmission

Strategies to prevent maternal to child

transmission

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Introduction

UNAIDS about 25 million adults&

children living with HIV/AIDS in Sub
Saharan Africa.
4million new cases yearly
300,000 to 600,000 AIDS related deaths
in 1999 in children (0 -14yrs)

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International

HIV AND PREGNANCY

Effect of pregnancy on HIV progression

Effect of HIV on pregnancy outcome

Infection
International

Effects of pregnancy on HIV

infection
No effect on HIV progression.
Slight decline in absolute numbers of
CD4 count ( % of CD4 cells remains
stable
No overall significant in deaths rate

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Effect of HIV on pregnancy

course and outcome

Abortions

Possible increase risk

Perinatal deaths
IUGR

Developed: No association
Developing:Increased
Increased risk

Low birth weight

Increased risk

Preterm delivery

Increased risk

Fetal malformation

No evidence of increased
risk

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Maternal to Child
Transmission

Accounts to 15 % of all transmission in

Uganda
Accounts for > 90% of infection in children
In Africa rate of MTCT is 20 -40%
Overall risk at point estimate for transmission

During pregnancy: 5 -10%

In labour: 15 -20%
Breast feeding : 10-15%

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Factors affecting transmission

Viral
factors:(Load,strain
variation)*
Maternal: CD4 count
STD infections*
Substance abuse
Sexual behavior*
Placental disruption

Preterm deliveries
Duration of membrane
rupture.*
Invasive procedure in
Labour( Instrumental
vaginal
deliveries,episiotomies*
Mode of delivery
Fetal/neonatal factors
Breast feeding *

Infection
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Prevention of Maternal to
Child Transmission
Comprehensive MCH services (
antenatal,intrapartum,postnatal)
VCCT
Short course antiretroviral treatment
Modified and optimal obstetrical practice
Support for safe infant feeding
Family planning services & counseling

Infection
International

Comprehensive ANC
minimum package for PMTCT

Provision of quality ANC

Health education
Micro nutrient supplementation
Prevention and treatment of infections
Anti- retroviral drugs

Infection
International

Provision of Quality ANC-1

Early Attendance
Refocused ANC with at least 4 to 5 visits
Detailed history taking
Examination to rule out signs of HIV related illness
Baseline Investigation: Hemoglobin,RPR for
syphilis,Urine analysis
Voluntary confidential counseling and testing.

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Provision of Quality ANC-2

1st Visit:Detailed history, examination, investigation,
folic supplements,deworming and VCCT
2rd Visit:Monitor progress of pregnancy, Counsel on
pmtct and breast feeding option, 1st dose of
IPT,tetanus toxoid,iron/folic supplementation.
3rd Visit:Monitor progress of pregnancy,blood pressure
,Hb and urine analysis,2rd dose IPT,tetanus toxoid,
iron/folic supplementation.Counseling support
4th Visit: As above. Enrolment on the PMTCT
program,Give antiretroviral drugs

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Health education

Nutrition,personal hygiene,environmental sanitation

Normal Tetanus toxoid schedule
STI treatment
Benefits of VCCT
Condom usage and family planning
Male involvement
Breast feeding /other feeding options

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ANC-4

1.Micro-nutrient supplements
2.Prevention & treatment of infections
Intermittent presumptive treatment: 3 doses
of SP
identification& treatment of STI
3.Anti retroviral treatment
AZT
Neverapine

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Care during Labour and

Delivery

1. Good Obstetric practice

2. Ante retroviral drugs
3. Modified Obstetric practice

Delay ARM
ECV
Routine episiotomies
Instrumental deliveries
Traumatic suction of child
Universal precautions.

4. Mode of delivery

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Short course anti-retroviral

treatment

Options:
AZT after 36 weeks antepartum,intrapartum
amd post partum with neonatal treatment for
7 days. (%Reduction 50%) at 8weeks
Nevirapine In labour and neonatal treatment
for 48 to 72 hours. (% reduction 47%) at 8
weeks

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Oral Anti retroviral treatment

Antepartum

Intrapartum

Post partum
For mother

neonatal

1.AZT 300mgs
p.o B.D after 35
weeksgestation

AZT 300mgs p.o

3hourly till
delivery

AZT 300mgs p.o

B.D for 7 days

4mgs/kg p.o B.D

for 7 days

2.

NVP 200 mgs p.p

at onset of labour

None

none

2mgs/kg p.o 4872 hours

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Post natal care

Dual use of Contraception( Barrier&

contraception).
Ongoing Care
Counseling and support
Care of the Neonate,(Exclusive breast
feeding for 3/12 months or Artificial
infant feeding)

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Conclusion

Maternal to child transmission can be

reduced by 50%
Effective counseling ,support,treatment
of opportunistic infections and anti
retroviral treatment can improve quality
of life.