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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

95th

3rd

25th

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