Evidence based guidelines Evidence based guidelines for prevention of infection in for prevention of infection in

NICUNICU

Dr. JP Dadhich Dr. JP Dadhich MD,FNNF,PGD-DNMD,FNNF,PGD-DN

OutlineOutline

Relevance of infection controlRelevance of infection control Out breaks in NICU and lessons Out breaks in NICU and lessons

learnt from them learnt from them Evidence based infection control Evidence based infection control

measures in NICUmeasures in NICU

Nosocomial Infections Nosocomial Infections RelevanceRelevance

Significant cause of morbidity and mortalitySignificant cause of morbidity and mortality Infants with nosocomial infectionsInfants with nosocomial infections

• Longer hospital staysLonger hospital stays• Higher treatment costsHigher treatment costs• Neurodevelopment impairmentNeurodevelopment impairment

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IM EM

EOSLOS

NNPD primary cause of death EMNNPD – Time of onset of systemic infection

Risk factors for nosocomial Risk factors for nosocomial infectionsinfections

PrematurityPrematurity Low birth weightLow birth weight Invasive deviceInvasive device

• Intravascular deviceIntravascular device• Mechanical Mechanical

ventilationventilation• Urinary CatheterUrinary Catheter• VP shuntVP shunt

MedicationMedication• H2 BlockersH2 Blockers• SteroidsSteroids

Delayed enteral Delayed enteral feedingfeeding

Formula feedingFormula feeding Inadequate nursing Inadequate nursing

staff/overcrowdingstaff/overcrowding Poor compliance Poor compliance

with hand washingwith hand washing

EpidemicsEpidemics Cluster of infection with unusual pathogensCluster of infection with unusual pathogens Continuous surveillance or monitoring of endemic Continuous surveillance or monitoring of endemic

infection rate to detect a change in baseline infection rate to detect a change in baseline pattern pattern

Common sourceCommon source• Contaminated equipmentsContaminated equipments

ThermometersThermometers VentilatorsVentilators StethoscopesStethoscopes

• Environmental reservoirsEnvironmental reservoirs• Lapses in hand washingLapses in hand washing

Must be identified promptly and control measures Must be identified promptly and control measures instituted immediatelyinstituted immediately

Endemic Pseudomonas aeruginosa Endemic Pseudomonas aeruginosa Infection in a Neonatal Intensive Care Infection in a Neonatal Intensive Care

UnitUnit PPseudomonas aeruginosaseudomonas aeruginosa is a well- is a well-

known cause of nosocomial infections known cause of nosocomial infections among infants in neonatal intensive among infants in neonatal intensive care units. care units.

Environmental sources such as sinks Environmental sources such as sinks and respiratory-therapy equipment are and respiratory-therapy equipment are the most commonly described the most commonly described reservoirs of reservoirs of P. aeruginosaP. aeruginosa

Occasionally, health care workers have Occasionally, health care workers have been the reservoirbeen the reservoir

NEJM 2000; 343 (10):695-700.

SurveillanceSurveillance An increased incidence of colonization and An increased incidence of colonization and

infection with infection with P. aeruginosaP. aeruginosa was noted was noted Surveillance cultures were performed to Surveillance cultures were performed to

identify all infants with colonization identify all infants with colonization 33 infants in the neonatal intensive care 33 infants in the neonatal intensive care

unit, 6 of whom were identified as being unit, 6 of whom were identified as being colonized or infected with colonized or infected with P. aeruginosaP. aeruginosa

Surveillance cultures were obtained from Surveillance cultures were obtained from the other 27 infants – GA, ET secretions, the other 27 infants – GA, ET secretions, nasopharyngeal swabs – twice a month till nasopharyngeal swabs – twice a month till all babies in the cohort were discharged, all babies in the cohort were discharged, than once a month fo next two monthsthan once a month fo next two months

Detecting environmental reservoirs

Cultures of environmental specimensCultures of environmental specimens• tap watertap water• sink drains sink drains • liquid medications liquid medications • respiratory-therapy equipmentrespiratory-therapy equipment• hand soapshand soaps• hand creams hand creams • water baths used to warm formulawater baths used to warm formula

Moist and dry environmental surfaces were Moist and dry environmental surfaces were swabbed with a cotton-tipped swab swabbed with a cotton-tipped swab

Cultures of the Hands of Health Care Workers

The hands of health care workers who came in The hands of health care workers who came in contact with infants hospitalized in the neonatal contact with infants hospitalized in the neonatal intensive care unit during were cultured for intensive care unit during were cultured for P. P. aeruginosaaeruginosa with use of a modification of the with use of a modification of the "glove juice" method"glove juice" method

Both hands of each worker were sequentially put Both hands of each worker were sequentially put into a sterile polyethylene bag containing 50 ml into a sterile polyethylene bag containing 50 ml of sampling solution of sampling solution

One bag was used for each worker One bag was used for each worker Each hand was massaged by an infection-control Each hand was massaged by an infection-control

practitioner through the wall of the bag for 15 to practitioner through the wall of the bag for 15 to 30 seconds30 seconds

samples were delivered to the microbiology samples were delivered to the microbiology laboratory within 1 hour for processinglaboratory within 1 hour for processing

Risk Factors for Colonization of the Hands with P. aeruginosa

The hands of all health care workers were inspected by the infection-The hands of all health care workers were inspected by the infection-control practitionercontrol practitioner

The presence of false nails, nail polish, and cracked or inflamed nail The presence of false nails, nail polish, and cracked or inflamed nail beds was notedbeds was noted

Possible exposures to Possible exposures to P. aeruginosaP. aeruginosa and risk factors for infection, and risk factors for infection, such as use of antibiotics and a history of otitis externa, swimming in such as use of antibiotics and a history of otitis externa, swimming in the preceding year, skin lesions or dermatitis, latex allergy, nail or the preceding year, skin lesions or dermatitis, latex allergy, nail or nail-bed infections, and the use of artificial nails or nail wraps, were nail-bed infections, and the use of artificial nails or nail wraps, were assessedassessed

Risk factors for colonization of the hands of health care workers with Risk factors for colonization of the hands of health care workers with P. aeruginosaP. aeruginosa were determined by logistic-regression analysis with were determined by logistic-regression analysis with the use of SAS software the use of SAS software

The association between exposure to a specific health worker and The association between exposure to a specific health worker and infection or colonization with the endemic clone of infection or colonization with the endemic clone of P. aeruginosaP. aeruginosa was was assessed assessed

Results Results None of the cultures of environmental specimens None of the cultures of environmental specimens

grew grew P. aeruginosaP. aeruginosa Among 165 health workers, 3 had positive hand Among 165 health workers, 3 had positive hand

cultures – risk factors were present – furloughed cultures – risk factors were present – furloughed on full payon full pay

• The first health care worker wore nail extenders - The first health care worker wore nail extenders - extenders were removed - hand cultures were extenders were removed - hand cultures were subsequently negativesubsequently negative

• The second health care worker had candida The second health care worker had candida onychomycosis – treated – negative culturesonychomycosis – treated – negative cultures

• The third health care worker had otitis externa – treated The third health care worker had otitis externa – treated – negative cultures – negative cultures

Infection-Control MeasuresInfection-Control Measures

Contact isolation procedures were used for infants who were Contact isolation procedures were used for infants who were colonized or infected with colonized or infected with P. aeruginosa:P. aeruginosa: • gown and gloves were used during any contact with these patients, gown and gloves were used during any contact with these patients,

and and • the patients were placed in a separate room and cared for by the patients were placed in a separate room and cared for by

designated nurses. designated nurses. At the beginning of each shift, health care workers washed their At the beginning of each shift, health care workers washed their

hands with a preparation containing 4 percent chlorhexidine hands with a preparation containing 4 percent chlorhexidine gluconate for two minutes gluconate for two minutes

during their shifts, the workers washed their hands with a during their shifts, the workers washed their hands with a preparation containing 2 percent chlorhexidine gluconate preparation containing 2 percent chlorhexidine gluconate

Staff members were asked to wear no jewelry other than wedding Staff members were asked to wear no jewelry other than wedding bands and wristwatches bands and wristwatches

Cosmetic nail treatments were not permitted Cosmetic nail treatments were not permitted In addition, several care practices were changed: In addition, several care practices were changed:

• water baths were no longer used to heat formula, water baths were no longer used to heat formula, • the number of supplies kept by the patients' bedsides was minimizedthe number of supplies kept by the patients' bedsides was minimized

Lessons Lessons Be vigilant to detect an increased Be vigilant to detect an increased

incidence of common organismsincidence of common organisms Adopt a systematic approachAdopt a systematic approach Be prepared to be surprisedBe prepared to be surprised

E Sakazakii outbreakE Sakazakii outbreak

A male infant (1,270 grams) was A male infant (1,270 grams) was delivered by cesarean section at 33.5 delivered by cesarean section at 33.5 weeks' gestation and was admitted weeks' gestation and was admitted in NICU because of low birthweight, in NICU because of low birthweight, prematurity, and respiratory distressprematurity, and respiratory distress

Morbidity & Mortality Weekly ReportMorbidity & Mortality Weekly Report, CDC.

Cont…Cont… The infant had fever, tachycardia, The infant had fever, tachycardia,

decreased vascular perfusion, and decreased vascular perfusion, and neurologic abnormalities (e.g., suspected neurologic abnormalities (e.g., suspected seizure activity) at 11 daysseizure activity) at 11 days

Cerebrospinal fluid (CSF) suggestive of Cerebrospinal fluid (CSF) suggestive of MeningitisMeningitis

Culture of CSF grew Culture of CSF grew E. sakazakiiE. sakazakii The infant was treated with intravenous The infant was treated with intravenous

antimicrobials for meningitis; however, antimicrobials for meningitis; however, neurologic damage was progressive, and neurologic damage was progressive, and the infant died 9 days laterthe infant died 9 days later

Cont…Cont… Because the organism was a rare Because the organism was a rare

cause of neonatal meningitis, cause of neonatal meningitis, hospital personnel, in collaboration hospital personnel, in collaboration with the Tennessee Department of with the Tennessee Department of Health and CDC, investigated the Health and CDC, investigated the source of infection source of infection

Cont…Cont… During the study period, enhanced During the study period, enhanced

case surveillance was performed to find case surveillance was performed to find if other infants in the NICU were either if other infants in the NICU were either infected or colonized with infected or colonized with E. sakazakiiE. sakazakii

Patients were assessed for colonization Patients were assessed for colonization by stool culture by stool culture

Cont…Cont… Confirmed infection was defined as any Confirmed infection was defined as any E. E.

sakazakiisakazakii-positive culture from a normally sterile -positive culture from a normally sterile sitesite

Suspected infection was defined as an Suspected infection was defined as an E. E. sakazakiisakazakii-positive culture from a nonsterile site -positive culture from a nonsterile site with documented deterioration in clinical status with documented deterioration in clinical status (e.g., increased respiratory rate without other (e.g., increased respiratory rate without other evident cause) in the 24 hours before collection evident cause) in the 24 hours before collection of the specimen for cultureof the specimen for culture

Colonization was defined as an Colonization was defined as an E. sakazakiiE. sakazakii--positive culture from a nonsterile site without positive culture from a nonsterile site without documented deterioration in clinical status in the documented deterioration in clinical status in the 24 hours before collection of the specimen for 24 hours before collection of the specimen for culture. culture.

Cont…Cont… A total of 49 infants were screened A total of 49 infants were screened Ten Ten E. sakazakiiE. sakazakii infection or infection or

colonization events were identified: colonization events were identified: • one confirmed infection in the index one confirmed infection in the index

patient (culture-positive from CSF), patient (culture-positive from CSF), • two suspected infections (both culture-two suspected infections (both culture-

positive from tracheal aspirate) positive from tracheal aspirate) • seven colonization (six culture-positive seven colonization (six culture-positive

from stool, one from urine)from stool, one from urine)

A cohort study was performed on the A cohort study was performed on the 49 patients who were screened to 49 patients who were screened to determine possible risk factors for determine possible risk factors for acquisition of acquisition of E. sakazakiiE. sakazakii infection or infection or colonization colonization

A case-patient was defined as any A case-patient was defined as any NICU patient with NICU patient with E. sakazakiiE. sakazakii infection (confirmed or suspected) or infection (confirmed or suspected) or colonization during the study period colonization during the study period

Cont…Cont… Medical records were reviewed to assess Medical records were reviewed to assess

possible risk factors during the study period, possible risk factors during the study period, including including • gestational age and birth weight, gestational age and birth weight, • mechanical ventilator use mechanical ventilator use • humidified incubator use humidified incubator use • oral medicationsoral medications• feeding type (TPN, formula [e.g., powdered or feeding type (TPN, formula [e.g., powdered or

liquid], or breast milk) liquid], or breast milk) • Feeding method (i.e., continuous or intermittent Feeding method (i.e., continuous or intermittent

administration) administration)

Of the 49 patients identified in the cohort, Of the 49 patients identified in the cohort, • nine were case-patients nine were case-patients • 40 were non case-patients 40 were non case-patients

Analysis of risk factors identified only use Analysis of risk factors identified only use of a specific powdered infant formula of a specific powdered infant formula product (Portagen [Mead Johnson product (Portagen [Mead Johnson Nutritionals, Evansville, Indiana]) to be Nutritionals, Evansville, Indiana]) to be significantly associated with significantly associated with E. sakazakiiE. sakazakii infection or colonization infection or colonization

all case-patients received Portagen all case-patients received Portagen compared with 21 of 40 non case-patients compared with 21 of 40 non case-patients (p<0.01) (p<0.01)

Cont…Cont… To determine the source of infection, To determine the source of infection,

microbiologic studies were microbiologic studies were performed on samples of performed on samples of commercially sterile water used for commercially sterile water used for formula preparation and from formula preparation and from samples of formula taken from samples of formula taken from opened cans of Portagen from the opened cans of Portagen from the same two batches used in the NICU same two batches used in the NICU during the study period during the study period

Cont…Cont… Environmental swab cultures were taken Environmental swab cultures were taken

from surfaces on which the product had from surfaces on which the product had been preparedbeen prepared

Cultures also were performed on Cultures also were performed on unopened containers of Portagen supplied unopened containers of Portagen supplied by the manufacturer with batch codes by the manufacturer with batch codes matching those of opened cansmatching those of opened cans

Cont…Cont… Cultures of formula taken from both Cultures of formula taken from both

opened and unopened cans of Portagen opened and unopened cans of Portagen from a single batch grew from a single batch grew E. sakazakiiE. sakazakii

Water and all environmental cultures were Water and all environmental cultures were negative negative

Pulsed-field gel electrophoresis revealed Pulsed-field gel electrophoresis revealed that isolates of that isolates of E. sakazakiiE. sakazakii from the CSF from the CSF culture of the neonate with meningitis and culture of the neonate with meningitis and from the culture of formula from both from the culture of formula from both opened and unopened containers were opened and unopened containers were indistinguishableindistinguishable

Cont…Cont… To prevent additional infections, the hospital To prevent additional infections, the hospital

made several policy changes made several policy changes Principal formula type for NICU patients was Principal formula type for NICU patients was

changed from powdered formula to a changed from powdered formula to a commercially sterile, ready-to-feed liquid formula commercially sterile, ready-to-feed liquid formula

Portagen use was stoppedPortagen use was stopped Other powdered formula products are reserved Other powdered formula products are reserved

for specific needs and, when necessary, are for specific needs and, when necessary, are prepared in a designated formula preparation prepared in a designated formula preparation room in the pharmacy room in the pharmacy

No additional episodes of infection or colonization No additional episodes of infection or colonization have been detected at the reporting hospital have been detected at the reporting hospital

LessonsLessons Be vigilant for presence of unusual Be vigilant for presence of unusual

pathogenspathogens Powdered formula is not a sterile Powdered formula is not a sterile

productproduct Always include PIF in surveillance in Always include PIF in surveillance in

case of E sakazakiicase of E sakazakii

Neonatal Serratia marcescens Neonatal Serratia marcescens outbreak outbreak

Observational study of microbiological and Observational study of microbiological and epidemiological investigations epidemiological investigations

Nine cases were observed in a 5 months Nine cases were observed in a 5 months period. A Serratia outbreak was therefore period. A Serratia outbreak was therefore identified, and all the strains were identified, and all the strains were compared by pulsed-field gel compared by pulsed-field gel electrophoresis (PFGE)electrophoresis (PFGE)

Data from medical notes were gathered Data from medical notes were gathered retrospectivelyretrospectively

Environmental samples were gathered Environmental samples were gathered prospectivelyprospectively

Acta Pædiatrica 97(10):2008

Cont…Cont… Four infants were colonized and five infants were Four infants were colonized and five infants were

infected by S. marcescens. infected by S. marcescens. PFGE revealed that three different strains were PFGE revealed that three different strains were

present. present. Seven of the nine babies were infected by only Seven of the nine babies were infected by only

one of these strains. one of these strains. This same strain was found in a non-antimicrobial This same strain was found in a non-antimicrobial

soap bottle (NAS) that could be the source of soap bottle (NAS) that could be the source of contaminationcontamination

The outbreak was controlled with cohorting, The outbreak was controlled with cohorting, contact isolation, surveillance cultures, and contact isolation, surveillance cultures, and careful review of cleaning procedurescareful review of cleaning procedures

Flow Chart for outbreak Flow Chart for outbreak investigationinvestigation

Incident Cases and Infection Rate

Surveillance Cultures

Processing of Specimens

Pulse-field gel electrophoresis

Identifying risk factors for colonization

Infection control measures

Infection Control in the NICU –Infection Control in the NICU –Recommended StandardsRecommended Standards

NICU C2CE414Dd01.pdfNICU C2CE414Dd01.pdf

Adapted mainly from Adapted mainly from “Guidelines for Perinatal Care, 4th Edition by AAP and ACOG

Focuses on the following areas:-Focuses on the following areas:-• Physical SetupPhysical Setup• Administrative arrangementAdministrative arrangement

Prevention of Nosocomial Prevention of Nosocomial InfectionsInfections

Each unit has a baseline rate of infection due to inherent Each unit has a baseline rate of infection due to inherent modifiable risk factorsmodifiable risk factors

Effective strategy focus on Effective strategy focus on modifiablemodifiable risk factors risk factors• Strategic nursery design – space, sinks, soaps, paper towelStrategic nursery design – space, sinks, soaps, paper towel• Adequate staffingAdequate staffing• Hand hygiene complianceHand hygiene compliance• Minimization of catheter daysMinimization of catheter days• Sterile preparation of all fluids to be administeredSterile preparation of all fluids to be administered• Promoting enteral feeding esp. with EBM/breastfeedingPromoting enteral feeding esp. with EBM/breastfeeding• Monitoring/ surviellance of nosocomial infectionMonitoring/ surviellance of nosocomial infection• Education and frequent feedback from staffEducation and frequent feedback from staff

General HousekeepingGeneral Housekeeping Cleaning should be performed in the following order – Cleaning should be performed in the following order –

patient areas, accessory areas and then adjacent hallspatient areas, accessory areas and then adjacent halls In the cleaning procedure, dust should not be In the cleaning procedure, dust should not be

dispersed into the airdispersed into the air Once dust has been removed, scrubbing with a mop Once dust has been removed, scrubbing with a mop

and a disinfectant/detergent solution should be and a disinfectant/detergent solution should be performedperformed

Cabinet counters, work surfaces etc should be cleaned Cabinet counters, work surfaces etc should be cleaned once a day and between patient use with a once a day and between patient use with a disinfectant/detergent and clean clothsdisinfectant/detergent and clean cloths

Walls, windows, storage shelves and similar non-Walls, windows, storage shelves and similar non-critical surfaces should be scrubbed periodically with a critical surfaces should be scrubbed periodically with a disinfectant/detergent solutiondisinfectant/detergent solution

Sinks should be scrubbed clean at least daily with a Sinks should be scrubbed clean at least daily with a detergentdetergent

Recommendations for Hand Recommendations for Hand HygieneHygiene

Wash hands with soap and water when hands Wash hands with soap and water when hands are visibly soiled contaminatedare visibly soiled contaminated

If hands are not visibly soiled, alcohol based If hands are not visibly soiled, alcohol based waterless antiseptic (ABWLAS) agents for waterless antiseptic (ABWLAS) agents for routine decontamination of hands in all clinical routine decontamination of hands in all clinical situationssituations

Before regular hand decontamination begins Before regular hand decontamination begins all wrists and hand jewelry should be removedall wrists and hand jewelry should be removed

Cuts and abrasions must be covered with Cuts and abrasions must be covered with waterproof dressings waterproof dressings

Fingernails should be kept short and cleanFingernails should be kept short and clean

Recommended technique for Hand Recommended technique for Hand Hygiene Hygiene

ABWLAS agentsABWLAS agents Apply enough of the product to cover Apply enough of the product to cover

all the surfaces of the hands and all the surfaces of the hands and fingersfingers

Rub hands together until they are dryRub hands together until they are dry Enough volume should be applied – Enough volume should be applied –

such that it takes 15-25 seconds to such that it takes 15-25 seconds to drydry

Recommended technique for Hand Recommended technique for Hand HygieneHygiene

Hand WashingHand Washing

Hand Hygiene Practices in a Hand Hygiene Practices in a Neonatal Intensive Care UnitNeonatal Intensive Care Unit

A problem-based and task-orientated A problem-based and task-orientated education program can improve hand education program can improve hand hygiene compliancehygiene compliance

Overall hand hygiene compliance Overall hand hygiene compliance inincreased creased from 40% to 53% before patient contact from 40% to 53% before patient contact and 39% to 59% after patient contact and 39% to 59% after patient contact

There was improvement in most aspects of There was improvement in most aspects of hand-washing technique in the hand-washing technique in the postintervention stage. postintervention stage.

The health care–associated infection rate The health care–associated infection rate decreased from 11.3 to 6.2 per 1000 decreased from 11.3 to 6.2 per 1000 patient-days patient-days

PEDIATRICS 2004;114 (5) :e565-e571

Use of Human-milk FeedingsUse of Human-milk Feedings

Neonates fed breast milk were less likely to Neonates fed breast milk were less likely to become septic compared to formula-fed neonates become septic compared to formula-fed neonates (Narayanan I et al. J Pediatr 1981)(Narayanan I et al. J Pediatr 1981)

human-milk feedings reduced the odds of human-milk feedings reduced the odds of sepsis/meningitis compared to preterm milk sepsis/meningitis compared to preterm milk feedings feedings (Hylander MA et al. Pediatrics 1998 )(Hylander MA et al. Pediatrics 1998 )

The efficacy of breast milk also appears to be The efficacy of breast milk also appears to be dose dependent dose dependent (Schanler RJ. Pediatr Clin North Am 2001)(Schanler RJ. Pediatr Clin North Am 2001)

VentilationVentilation A minimum of 6 air changes per hour A minimum of 6 air changes per hour

is required for the NICU, with a is required for the NICU, with a minimum of 2 changes being outside minimum of 2 changes being outside airair

Ventilation air delivered to the NICU Ventilation air delivered to the NICU shall be filtered with at least 90 % shall be filtered with at least 90 % efficiencyefficiency

Catheter related blood stream Catheter related blood stream infections infections (CDC)(CDC)

Isolation of a recognized pathogen Isolation of a recognized pathogen from one blood culture or isolation of from one blood culture or isolation of a skin commensal from two blood a skin commensal from two blood culture specimensculture specimens

One/more clinical signs of infectionOne/more clinical signs of infection Presence of an intravascular devicePresence of an intravascular deviceCDC’s National Nosocomial Infection Surveillance System (NNIS) reported CABSIs - pooled means – 28.2/1000 catheter days in VLBW babies

RECOMMENDATIONS FOR PLACEMENT OF RECOMMENDATIONS FOR PLACEMENT OF

INTRAVASCULAR CATHETERSINTRAVASCULAR CATHETERS

Category IACategory IA Educate health-Educate health-

care workers care workers Assess knowledge Assess knowledge

of and adherence of and adherence to guidelines to guidelines periodically periodically

Category IBCategory IB Ensure appropriate Ensure appropriate

nursing staff levels nursing staff levels in ICUs in ICUs

Health-care worker education and training

Surveillance Surveillance Monitor the catheter sites visually or Monitor the catheter sites visually or

by palpation through the intact by palpation through the intact dressing on a regular basis - dressing on a regular basis - IBIB

Record the operator, date, and time Record the operator, date, and time of catheter insertion and removal, of catheter insertion and removal, and dressing changes on a and dressing changes on a standardized form - IIstandardized form - II

Aseptic technique during catheter Aseptic technique during catheter insertion and care insertion and care

Maintain aseptic technique for the Maintain aseptic technique for the insertion and care of intravascular insertion and care of intravascular catheters - catheters - Category IACategory IA

Use either sterile gauze or sterile, Use either sterile gauze or sterile, transparent, semipermeable dressing to transparent, semipermeable dressing to cover the catheter site - cover the catheter site - Category IACategory IA

Promptly remove any intravascular Promptly remove any intravascular catheter that is no longer essential - catheter that is no longer essential - Category IACategory IA

Clean injection ports with 70% alcohol or Clean injection ports with 70% alcohol or an iodophor before accessing the system - an iodophor before accessing the system - Category IACategory IA

Strategies that do not Appear to Strategies that do not Appear to WorkWork

Ventilator circuit changes more often Ventilator circuit changes more often than one time per week were not than one time per week were not associated with a decrease in pneumonia associated with a decrease in pneumonia or sepsisor sepsis (Long M et al. Infection Control & Hospital (Long M et al. Infection Control & Hospital Epidemiology,1996)Epidemiology,1996)

Gowning before entering the NICU has no Gowning before entering the NICU has no effect on reducing HAI effect on reducing HAI (Tan S et al. International J (Tan S et al. International J of Nursing Practice 1995)of Nursing Practice 1995)

Changing the frequency of tracheal Changing the frequency of tracheal suctioning from every 4 hours to 8 hours suctioning from every 4 hours to 8 hours did not change pneumonia or blood did not change pneumonia or blood stream infection rate stream infection rate (Cordero I et al. Journal (Cordero I et al. Journal ofPerinatolgy 2000)ofPerinatolgy 2000)

Prophylactic IVIGProphylactic IVIG Meta analysis of IVIG in preterms Meta analysis of IVIG in preterms Only 3% reduction in nosocomial Only 3% reduction in nosocomial

infectioninfection No reduction in mortalityNo reduction in mortality

(Modi and Carr, 2000)(Modi and Carr, 2000)

Haemopoietic Colony Stimulating Haemopoietic Colony Stimulating Factor (G-CSF, GM-CSF)Factor (G-CSF, GM-CSF)

Effective in raising neutrophil countEffective in raising neutrophil count Not consistent in decreasing Not consistent in decreasing

nosocomial infections or mortalitynosocomial infections or mortality

(Modi and Carr 2000)(Modi and Carr 2000)

GownsGowns Routine use does not help in Routine use does not help in

reducing endemic nosocomial reducing endemic nosocomial infection rateinfection rate

Should be used Should be used • In specific circumstances in which the In specific circumstances in which the

risk of contamination is highrisk of contamination is high• The infant is being heldThe infant is being held

ConclusionsConclusions HAIs/NCIs could be prevented with a HAIs/NCIs could be prevented with a

systematic, evidence based systematic, evidence based approachapproach

Outbreaks need prompt identification Outbreaks need prompt identification and remedial actionsand remedial actions

Do not hesitate to report and Do not hesitate to report and document the outbreaks document the outbreaks

Their Future is in Our Hands Their Future is in Our Hands

Thanks !!!!

jpdadhich@gmail.com

Antibiotics for preterm rupture of Antibiotics for preterm rupture of membranes membranes (Cochrane Review -(Cochrane Review - 2005)2005)

ParameterParameter RRRR 95% CI95% CIchorioamnionitis chorioamnionitis 0.570.57 0.37 to 0.860.37 to 0.86

born within 48 born within 48 hours of hours of

randomisation randomisation

0.710.71 0.58 to 0.870.58 to 0.87

born within seven born within seven days of days of

randomisationrandomisation

0.800.80 0.71 to 0.90 0.71 to 0.90

neonatal infection neonatal infection 0.680.68 0.53 to 0.87 0.53 to 0.87

use of surfactantuse of surfactant 0.830.83 0.72 to 0.960.72 to 0.96

Co-amoxiclav - Co-amoxiclav - NNECNNEC

4.604.60 1.98 to 10.721.98 to 10.72