INFECTION CONTROL IN NICU

DR RHISHIKESH THAKREDM ( Neonatology )

MD, DNB, DCH, FCPS, MB

+NEO CLINIC+27, Samarth Nagar, Aurangabad

Risk factors for infections

• Birth weight• Inadequate space• Under - staffing• Duration of hospitalization• Duration of antibiotics• Invasive procedures• Mechanical ventilation

COMMON SOURCES

• Hands• Stethoscopes• Thermometer• Suction bottles / catheters• Ambu bag / Laryngoscopes• Linen• Drugs / Fluids

PREVENTIVE MEASURES

�Hand Washing�Disinfectants�Antiseptics�Gloves / Gowns

�Housekeeping�Fumigation�Surveillance�Antimicrobials

BASIC CONCEPTS

• CLEANING :Physical removal.

• STERILIZATION :Destruction of all forms of microbial life.

• DISINFECTION :Intermediate measures between physical cleaning and sterilization.

HAND WASHING

• Types : 1. Mechanical : Use of soap & water.2. Chemical : Use of antimicrobial.

• Micro-organisms on skin :1. Resident : Coagulase –ve staph,

Acinetobacter, Corynebacterium2. Transient : Gram negative coliforms and

Staphylococcus aureus.

: PURPOSE OF HAND WASHING :

• Remove all dirt and debris.• Reduce cross contamination.• Interrupt fecal oral route of infection.• Reduce risk of hands acting as vectors.• Break link in chain of infections.• Increase image of cleanliness of health

providers

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• Remove jewelry, watch etc on hands. Roll up the sleeves.

• Rinse under running water.• Lather with soap using friction both the hands.

(Minimum 10 – 20 sec). • Frequently missed areas are nails, nail bed,

under surface of nails, thumbs, web spaces, back of fingers and hands.

• Turn off the water soap by foot or elbow.• Dry hands thoroughly.

HANDWASHING BASICS

� DO’S� Keep basins, dryers,

soap at convenient sites.

� Educate and demonstrate hand wash

� Keep vigilance� Use sink for hand wash

only and not for any other purpose

� DONT’So Do not use nail polish or

artificial nails o Do not use washed

hands for turning off the water source.

o Do not substitute hand washing by gloves.

Soaps for hand washing

Types : Liquid, Bar, Tissue impregnated

Precautions :• Disposable container.• Thorough cleansing.• No adding to the partially filled. • Keep bar soap on racks.

SOAP OR ANTISEPTICHAND WASH ?

Antimicrobial handwashing :• In high risk patients : ICU, NICU, Casualty.• Before any invasive procedure.• In immunocompromised patients.• In barrier nursing leaving an isolation room. • Before contact with patients having invasive

devices.

NoYes� Hexachlorophene

NoYes� Sodium hypochlorite

No Yes� > 50 % Alcohol

YesYes� Chlorhexidine gluconate (4%)

YesYes� Ipodophor iodine

NoYes� Plain Soap

RESIDUALEFFECT

IMMEDIATEEFFECT

AGENT

Alcohol based handwash

• ADVANTAGE– Rapid reduction in

microbial counts.– Easy to use.– Time saving.– Better compliance.– Eliminates use of

water and drying.– Does not need

sink, dryers.

• DISADVANTAGE- Skin irritation.- Sensitive to dilution

with water.- Costly.

HAND DRYING

• Wiping to personal wears / towel• Hand dryers• Autoclaved napkins• Autoclaved papers

Improving Handwashing

• Policing each other• Educating the need for hand washing .• Demonstrating the technique• Convenient placement of infrastructure

like sinks, dryers etc • Senior staff should serve as role models.

DECONTAMINATION

• CRITICAL ITEMS :Come in contact with sterile tissues

• SEMI CRITICAL ITEMS :Contact with mucosa but does not breach

• NON CRITICAL ITEMS : In the vicinity of patient

CLEANING IS MUST PRIOR TO DISINFECTION( Washing + Rinsing + Drying )

�

•All reusable equipment•Environmental surfaces•Stethoscopes, Ear specula•BP cuffs, Bed pans, Urinals

•Blood spillsMicrobial spills•Thermometers

•Semicriticalitems.Scopes, •Nebulizer cups•Nasal specula, Breast pump accessories

Phenol, Iodophors,1 : 500 bleach water

Ethanol, PhenolIodophors, 1: 64 bleach water

2% Glutardehyde6% H2O21 : 64 Bleach water

Low levelIntermediate level

High level

200ml/l 14 g/l10% 10% 10%

20 ml/l 1.4 g/l

5% 5 %

4%

Sodium hypochlorite Calcium hypochloritePhenol Formalin 4.8% Chlorxylenol(dettol)

Articles, Wares, Stainless steel, Plastic eg: Bed pan, bowls, etc

200ml/l

14 g/l

10%

20 ml/l

1.4 g/l

5 %

Sodium hypochlorite 5% Calcium hypochlorite Phenol

Floor, Walls, Sinks, Trolley, Furniture, Basins

DIRTYCLEAN AGENTARTICLE

DIRTYCLEANAGENTARTICLE

70%

70%

70%

70%

Alcohol (Ethyl / Isopropyl) Methylated spirit

Ampoule

No chemical disingection.

Syringes / Needles

Wash with detergent solution. Keep in boiling water for 10 mts

Cutlery / Crockery

Glutardehyde, Chlorhexidine + cetrimide (Savlon). (Keep for 10 mtsbefore next use

Thermometer

2.5 % 10%

2.5% 5%

GlutardehydeChlorhexidine + Cetrimide

Instruments, Cheatleforceps, Sharp instruments

Gloves / Gowns

• Does not replace handwashing• Sterile gloves :

�Open wounds�Invasive procedures

• Non sterile gloves : �Handling of secretions / excretions.

• Sterile gowns for invasive procedures.

HOUSE KEEPING ( Daily )

• Thorough cleaning & scrubbing• Wet mopping of floors• Mopping of dust bins / plastic bags• Nursery slippers• Cleaning of sinks• No dry dusting & sweeping• Open care system / Stethoscope / Non critical

appratus / Hood / Mask / Tubing / Utensils

ISOLATION

• Acute gastroenteritis• Draining abscesses• Congenital CMV, Rubella, Chickenpox,

Syphilis, Tetanus• Babies with meningitis / pneumonia do not

need isolation• Cohort babies with documented sepsis

Antimicrobial Prophylaxis

• IVIG• GM – CSF• Colistin / Neomycin• Nystatin / Clotrimozole• Eye drops• Umbilical cord• Anti - fungal

FUMIGATION

• No additional benefit if good house keeping & aseptic routines

• Definitely following an epidemic• 500 ml formaldehyde ( 40 % ) + 250 g

KMNO4 : 30 m3 for 12 hours• Shut off central O2 / Suction / Vent outlets

/ AC vents / Doors / Windows.• ? UV radiation

Drug Preparation

• Change cannula 48 – 72 hrs• Change infusion set every alternate day• Use disposable syringe / needle• Wipe neck of ampoule / inj. water with alcohol• Top of the vial be wiped with alcohol• Do not stock open ampoules• Use new disposable needle each time fluid is

withdrawn

Feeding Precautions

• Wash utensils with soap / water daily.• Preferably autoclave / boiled for 15 mts• Keep the formulas in dry place & intact• Discard unused feeds immediately• Do not reuse same spoon / syringe• Shift to breast milk at the earliest

What can be done ?

• Do not bathe baby in hospital• Restrict handling babies to minimum• Ensure hand washing strictly• Ensure nails are short / no nail polish• Use gauze underneath while collecting blood• Limit traffic in nursery• Involve mother in baby care at earliest• Cohort infected babies together• Ensure cleaning before disinfection• Watch for ants, flies, and cockroaches.

Practical Tips

• Screen for fungus weekly in urine in preterms

• Use freshly prepared disinfectant solutions• Restrict handling the babies to minimum• Determined & conscious efforts for

asepsis• Involve mother in baby care at the earliest• Use breast milk for feeding

CONCLUSIONS

• Hand washing & common sense are the best disinfectants.

• Breast milk is the best antidote.• Mother is the best nurse of the baby.• Masterly inactivity on our part is the key.• Conscious, determined efforts & health

education is our moral responsibility.