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E i ith tb k i t lExperiences with outbreaks in neonatal intensive care units
Birgit RosslHospital Hygiene
University Hospital EssenGermany
Key facts
•Every year, an estimated 15 million babies are born preterm (before 37 completed weeks of gestation), and this number is rising.
•An estimated 1 million babies die annually from preterm birth complications.
•Preterm birth is the leading cause of newborn deaths (babies in the first four weeks of life) and the second leading cause of death after pneumonia in children under five years.in children under five years.
•Three‐quarters of them could be saved with current, cost‐effective interventions, even without intensive care facilities.,
•Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.
http://www.who.int/mediacentre/factsheets/fs363/en/index.html
Overview
Preterm is defined as babies born alive before 37 weeks of pregnancy are completed.
There are sub‐categories of preterm birth, based on gestational age:
extremely preterm (<28 weeks) very preterm (28 to <32 weeks) moderate to late preterm (32 to <37 weeks)
Highest risk:
Preterm babies with birth weight < 1500 g (VLBW = very low birth weight)
Source: WHO ‐ Preterm birth ‐ Fact sheet N°363, November 2012 http://www.who.int/mediacentre/factsheets/fs363/en/
Presentation from Dr. Joy Lawn
Special conditions in Neonatal Intensive Care Units (NICUs)
‐ Very vulnerable patient group‐ Breathing problems‐ Heart problems p‐ Brain problems‐ Temperature control problems‐ Gastrointestinal problems
High risk of hospital acquired infections!
‐ Blood problems‐ Metabolism problems
‐ Immature immune system
Hi hl b d d i h i !‐ Highly burdened with emotions!
Special conditions in Neonatal Intensive Care Units (NICUs)
‐ Very vulnerable patient group‐ Breathing problems‐ Heart problems p‐ Brain problems‐ Temperature control problems‐ Gastrointestinal problems‐ Blood problems‐ Metabolism problems
‐ Immature immune system
Hi hl b d d i h i !‐ Highly burdened with emotions!
Highly burdened with emotions!Highly burdened with emotions!
Preterm babies ‐ Care System in Germany:
i i i lMain principle:
Defining care levels according to the risk profile of preterm infants:
Level III:
Affiliation of pregnant women withAffiliation of pregnant women with
‐ Expected preterm birth 32 + 0 to 35 + 6 weeks of gestation‐ Other diseases with lower risk for the newbornOther diseases with lower risk for the newborn
Level II:
Affiliation of pregnant women with
‐ Expected preterm birth 29 + 0 to 31 + 6 weeks of gestationp p g‐ Pregnancy associated diseases like HELLP (Hemolysis, Elevated Liver
Enzymes, Low Platelet Count, or Fetal Growth Restriction‐ Diabetes mellitus with risk for the newborn
Level I:
Affiliation of pregnant women with
Expected preterm birth < 29 + 0 weeks of gestation‐ Expected preterm birth < 29 + 0 weeks of gestation‐ Expected birth of triplets (or more)‐ Expected birth of babies with prenatal diagnosis of severe diseases
Storage of incubators for emergency casesStorage of incubators for emergency cases
What do we know about outbreaks of nosocomial infections in NICUs?What do we know about outbreaks of nosocomial infections in NICUs?
Outbreak DatabaseWorldwide Database for Nosocomial OutbreakWorldwide Database for Nosocomial Outbreak
Your query was: neonatal
Query 2th September 2013:
q y298 Results of 2989 found. (Query date: 2013‐09‐02 05:55:29 (UTC+00:00:00))
Result: about 10 % of the outbreaks are related to neonatal units, allmost all in High income countries
Causative pathogens in outbreaks in NICUs and non ‐ NICUs
Gastmeier et al, Outbreaks in neonatal intensive care units‐They are not like others Am J Infect Control 2007; 35: 172‐6
Causative pathogens in outbreaks in NICUs and non ‐ NICUs
Gastmeier et al, Outbreaks in neonatal intensive care units‐They are not like others Am J Infect Control 2007; 35: 172‐6
lSome examples…
Exner 2012, Engelhart 2012, Martin 2012, Engelhart 2009, Seidenberg 2010
At least 28 infants were infected with Klebsiella oxytoca (Sepsis) 1996 – 1999 in an 12 bed NICU(Sepsis) 1996 1999 in an 12 bed NICU2 babies died, one survived sepsis with severe disability.Isolation of Klebsiella oxytoca from disinfectant solution used for surfaces.Bacterial investigations showed that K. oxytoca grew in a 0.25 % solution, not in 0.5 % solution (which was recommended).)The concentration of the solution was lowered in October 1996 from 0.5% to 0.25% because staff members felt irritation of mucosa.
Reiss et al. The Lancet, Volume 356, Issue 9226, Page 310, 22 July 2000
Outbreak in Bremen, Germany
Large Outbreak on NICU with Klebsiella pneumoniae (ESBL)Level I Neonatal Intensive Care Unit28 babies involved, 3 Babies died in 2011New related cases in 2012 after complete refurbishment of the ward
Fact‐finding‐committee („Untersuchungsausschuss der Bremischen Bürgerschaft“) stated:
‐ lack of staff‐ Insufficient cleaning procedures
Lack of education in cleaning stuff‐ Lack of education in cleaning stuff‐ „Authorities focussed on economic situation of the hospitals“
Outbreak in Bremen, Germany
Large Outbreak on NICU with Klebsiella pneumoniae (ESBL)Level III Neonatal Intensive Care Unit28 babies involved, 3 Babies died in 2011New related cases in 2012 after complete refurbishment of the ward
Fact‐finding‐committee („Untersuchungsausschuss der Bremischen Bürgerschaft“) stated:
‐ lack of staff‐ Insufficient cleaning procedures
Lack of education in cleaning stuff‐ Lack of education in cleaning stuff‐ „Authorities focussed on economic situation of the hospitals“
Critical understaffing (1)
Understaffing is well known to be related with the number of hospital acquired infections (see 1‐5)
A low level of staffing (realized/planned) on a NICU was associated with an increased risk„A low level of staffing (realized/planned) on a NICU was associated with an increased riskfor CVC‐associated BSI.“ (2)
German Guidelines (6) recommend staffing related to level of care (1, 2a, 2b, 3)
1Nurse Staffing and NICU Infection Rates Rogowski et al. JAMA Pediatr. 2013;167(5)2The impact of staffing on central venous catheter associated bloddstream infectons in preterm neonates –results of a nation wide cohort study in Germany2The impact of staffing on central venous catheter‐associated bloddstream infectons in preterm neonates –results of a nation‐wide cohort study in GermanyLeistner et al. Antimicrobial Resistance and Infection Control 2013, 2:113Haley RW, Bregman DA: The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal specialcare unit. J Infect Dis 1982, 145:875–885.4Nursing resources ‐ a major determinant of nosocomial infection? S. Hugenett et al Arch Pediatr Adolesc Med. 2006 August; 160(8): 832–836. 5Impact of staffing on bloodstream infections in the neonatal intensive care unit Cimiotti et al Arch Pediatr Adolesc Med 2006 Aug;160(8):832‐65Impact of staffing on bloodstream infections in the neonatal intensive care unit. Cimiotti et al. Arch Pediatr Adolesc Med. 2006 Aug;160(8):832 6.6Empfehlungen für die strukturellen Voraussetzungen der perinatologischen Versorgung in Deutschland http://www.dgpm‐online.org/Publikationen/Leitlinien.html
Critical understaffing (2)
The medical and nursing care must be ensured by a 24‐hour shift work with a permanent presence of a in the medical intensive care unit.
Recommendation
Nurse : Patient Ratio 1 : 3 to 1 : 2
Beginning of 2017
Nurse : Patient Ration 1 : 1
Bremen Clinics had up to 1 : 6 Nurse:Patient Ratio !
Empfehlungen für die strukturellen Voraussetzungen der perinatologischen Versorgung in Deutschland http://www.dgpm‐online.org/Publikationen/Leitlinien.html
Outbreak in Bremen, Germany
Large Outbreak on NICU with Klebsiella pneumoniae (ESBL)Level III Neonatal Intensive Care Unit28 babies involved, 3 Babies died in 2011New related cases in 2012 after complete refurbishment of the ward
Fact‐finding‐committee („Untersuchungsausschuss der Bremischen Bürgerschaft“) stated:
‐ lack of staff‐ Insufficient cleaning procedures
Lack of education in cleaning staff‐ Lack of education in cleaning staff‐ „Authorities focussed on economic situation of the hospitals“
Figure 1 Dynamic transmission cycle of MRSA
Stephanie J DancerStephanie J Dancer
Importance of the environment in meticillin‐resistant <ce:italic>Staphylococcus aureus</ce:italic> acquisition: the case for hospital cleaning
The Lancet Infectious Diseases Volume 8, Issue 2 2008 101 ‐ 113
http://dx.doi.org/10.1016/S1473‐3099(07)70241‐4
l h b kCloth buckets
Might be critical
‐ Often filled with quaternary ammonium compounds ‐ effectiveness against q y p ggramnegatives might be reduced
‐ Often the bucket is not closed ‐ clothes are dry and not effective
‐ Biofilms may cause remains unclear (concentration of the disinfectant)
‐ Clothes and disinfectant must be compatible – often not tested
Hyg Med 2012, 37 ‐ 11
Outbreak in Bremen, Germany
Large Outbreak on NICU with Klebsiella pneumoniae (ESBL)Level III Neonatal Intensive Care Unit28 babies involved, 3 Babies died in 2011New related cases in 2012 after complete refurbishment of the ward
Fact‐finding‐committee („Untersuchungsausschuss der Bremischen Bürgerschaft“) stated:
‐ lack of staff‐ Insufficient cleaning procedures
Lack of education in cleaning stuff‐ Lack of education in cleaning stuff‐ „Authorities focussed on economic situation of the hospitals“
Result of the Bremen Outbreak
‐ Loss of 25 Million Euro25 Million Euro(Patients refused the clinic because of the „Hygiene scandal“)
Results of outbreaks….
Infection protection changing act
P i P li t i J 2011Passing Parliament in June 2011
Passing also States Chamber without problemsg p
Conclusions:
Outbreaks in Neonatology are common – the patients are at high risk for infections
Structures (hospital construction/staffing) are often difficult, even in high income countries
Outbreaks in Neonatology lead to high public interest
Outbreaks in Neonatology may change the public view on infection controlgy y g p