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Changing practice to prevent nosocomial infection in an immuno-compromised child
www.childnursepracticedevelopment.org.za
Lauren Rees 1 Oct 2012
Who is this child?
• Nomsa-second born child of Nokuthula
• Born: 03-11-2011 : 10 month old girl
• Discharge weight: 7.74kg
• Birth weight: 3.12kg
• Admission : 4 -17 September 2012
What does this family look like?
9 months 8 yrs 10 mo. 10 mo.
62 yrs
X
Presenting with…
• This admission - Acute gastroenteritis with metabolic acidosis
• 24 Feb-19 Mar 2012
– Chronic gastroenteritis – Moderate malnutrition – HIV positive – Klebsiella pneumonia infection
• 10-18 Apr 2012 - Failed challenge to Infacare soya from
Alimentum feeds
• 10-19 July 2012 - Challenge to Infacare soya successful
What is Klebsiella?
• Gram-negative, anaerobic bacteria • Normally present in the intestines • Associated with nosocomial infections of the
lungs, urinary tract, bloodstream, wounds and the meninges in immuno-compromised patients
• Developed antimicrobial resistance
Reference Centers for Disease Control and Prevention.2012.[Online] Available: http://ww.cdc.gov/HAI/organisms/klebsiella/klebsiella.html
[2012, September 29]
How is it spread?
• Person-to-person contact
• Contamination of the environment
• Host defences: patients on ventilators or with invasive lines and wounds are more susceptible
How did it present in Nomsa?
• 3 Mar: Vomiting and 10% dehydrated • 5 Mar: Irritable, peri-orbital oedema, abdominal
distension, subnormal temp Treated for entero colitis • 6 Mar: Pyrexial, mild subcostal recession,
Kelbsiella on culture • 7 Mar: Guarding, abdominal distension, decreased bowel
sounds but improved later that day • 9 Mar: Large blood-stained vomit. More
episodes vomiting. • 11 Mar: Peri-orbital and pedal oedema, hypothermic • 12-14 Mar: ?DIC picture
How was it managed?
• Numerous investigations
Bloods: U&E, FBC, blood cultures, liver function tests, clotting tests
Abdominal X-rays to rule out necrotising entero colitis
• Numerous antibiotics:
Gentamycin, Metronidazole, Penicillin G Ertapenem
• Numerous medical assessments with complex fluid management
• Increased nursing care
Support mother
Manage more pain and discomfort
Observation and administration of fluid therapies (hydration/nutrition)
More frequent observations of vital signs (regulatory system support)
NG and IV lines (skin and mucosal integrity/microbial load)
Administration of medications (microbial load)
Why should it be prevented?
• Health of the child further compromised
• Other children at risk
• Health personnel at risk
• Cost to state, taxpayer…you!
– Additional medications
– Further investigations
– Increased length of stay in hospital
How can it be prevented?
• Know the nature and mode of spread of the micro-organism
• Apply the correct infection control protocols • Isolation precautions • Equipment
• Enforce it with all health personnel and family • Ensure nursing care plan for microbial load is clear and
comprehensive • Infection control nurse • In-service education • Infection control more visible in nursing curricula
Discussion
• Know and implement infection control policies and protocols. Learning-practice gap huge.
• Change equipment (IV lines etc.) according to protocols. Funding available in private but not in public sector. Focus in these settings on affordable and achievable policies.
• Cannot eradicate nosocomial infections completely but reduce incidence
• Community-acquired infections impact on hospital-acquired infections due to traffic flow
• Examine teaching of infection control in nursing curricula including knowledge of microbiology
• Focus on planning, implementation and evaluating nursing care well
• Be creative in stimulating infection control practice change among health personnel and families in the clinical setting