Fakulteit Gesondheidswetenskappe

Faculty of Health Sciences

Protecting the most vulnerable:

IPC in the neonatal nursery

Dr Angela Dramowski (dramowski@sun.ac.za), Paediatrics and Child Health,

Stellenbosch University, Cape Town, South Africa

ICAN Harare 2014

Overview

• Why are neonates particularly vulnerable to HAI?

• Which organisms cause outbreaks in NNU?

• HAI outbreaks in NNU in South Africa

• Neonatal outbreaks & bloodstream infections over 6 years at

Tygerberg Children’s Hospital, Cape Town

• What can we do in Africa to reduce HAI rates in newborns?

Why are neonates vulnerable to HAI?

Contribution of infection to neonatal deaths

• UNAIDS: I million deaths/annum (25% of total NN mortality)

• SA 1 of 12 countries where U5MR has increased since 90’s

4

SA neonatal MR =

21/1000 live births

23000 deaths/year

? Contribution

of HAI

Which organisms cause outbreaks in NNU?

• Bacteria

- Klebsiella pneumonia, E coli (ESBL)

- Acinetobacter baumanni, Pseudomonas aeruginosa

- Staphylococcus aureus incl. MRSA

- Emerging pathogens: Serratia marcescens

• Viruses

- Rota virus, Noro virus

- RSV, parainfluenza, influenza

• Fungi

- mostly Candida spp

(Risk factors: low birth weight, broad spectrum antibiotics, central lines)

Outbreaks in Neonatal Nurseries

• a vulnerable population

• exposure to infections- in utero or postnatally

• HCW, parents, patients, hospital environment, equipment

• ID exposures microbial colonisation

infectious morbidity and mortality

nosocomial outbreaks

• high risk of outbreaks:

• overcrowding

• understaffing

• sharing and reuse of equipment

Enterobacter outbreak - Pelonomi FS 2004

Dirty hands... and six babies die

March 25 2004 at 04:45pm

A pharmacy assistant's dirty hands were the main reason why six babies died earlier this month in the Pelonomi Hospital in Bloemfontein.

Dr Victor Litlhakanyane, head of the Free State health department, said on Thursday that the assistant who prepared foodstuffs for the babies had washed his hands in a dirty basin.

"The results of forensic post mortem tests showed the babies died from septicaemia caused by Enterobacter bacteria. This caused the babies' organs to bleed, which led to their death

Klebsiella outbreak - Mahatma Ghandi KZN 2005

• Contaminated IV fluids

• Multi use of IV’s to limit cost

• Inadequate handwashing

• Understaffing

Norovirus outbreak – Charlotte Maxeke GP 2009

Contributing factors:

• Overcrowding

• Insufficient facilities &

equipment

• Poor IC practice

Recommendations:

• Support hospital managers

to encourage IC & QA

• In-service training of staff

Epidemic Gastroenteritis outbreak:

Sunday 16 May 2009 – cluster of 17

neonates with vomiting & diarrhoea –

7 deaths

Investigation yielded norovirus

Highly infectious GI virus

Contact and droplet spread

Source unknown - ? HCW/mother/visitor

10

Case study Acta Paediatrica, 2006; 95: 535-539

• 3 month old baby in Paeds ICU

• no household TB exposure

• ex-prem nursed in KMC ward for 3 weeks

• mother recalled sharing room with another

mom who looked ill & coughed continuously

• traced potential adult source case

• confirmed smear + pTB

• identical molecular fingerprint

• Of 8/11 infant contacts traced,

• 4/8 (50%) had TB Rx < 6months after KMC

• No known community TB contacts

The situation at Tygerberg NNU

• 6000 deliveries per year

• 8 bed NICU, 4 bed high care

• 3 acute wards + 1 KMC unit

• LBW rate = 37%

• Increasing survival of ELBW infants

43% in 1994, 55% in 2004, 76% in 2007, 85% in 2010

• No new facilities; no increase in capacity

• No increase in staffing ratios

• Insufficient isolation rooms (< 5% of beds)

OVERCROWDING

INFECTION

Outbreaks: 1 May 2008 - 30 April 2014

Pathogen Year Infections Deaths

Rotavirus 1 2008 58 0

H1N1 influenza 2009 5 0

Rotavirus 2 2010 16 0

Measles 2010 1 0

Serratia marcescens 2012 12 4 (25% CFR)

Vancomycin-resistant

Enterococci (VRE)

2013 4(+ 7 colonized)

0

Rotavirus

Context well-recognised cause of nosocomial gastroenteritis

Outbreak1

Outbreak 2

May 2008: 58 babies; contained in 12 weeks

January 2010: 16 babies; contained in 6 weeks

Investigation Line list, Gannt charts, daily outbreak meetings

Precautions contact AND droplet precautions

restricted staff movement; designated staffing

stop movement of babies

education parents & staff: - sick HCW to stay at home

- reinforce handwashing with soap and water

Lessons Prompt institution of IPC precautions shortened 2nd outbreak

H1N1 influenza

Context Pandemic H1N1 (>12000 cases in SA; 91 deaths in 2009)

TBH situation Additional ventilator beds/wards opened (obstetrics)

TCH: 26 paeds cases; 1 child died from multi-organ failure

Neonates 5 infected; 4 prophylaxis (all LBW/premature), all survived

Precautions Droplet precautions, cough etiquette, hand hygiene compliance

Cohort isolation

Visitor restriction & excluded ill staff members

Oseltamivir to exposed and infected neonates

Lessons Need for better isolation facilities

Need for staff and high-risk patient immunisation

Congenital measles

Context Countrywide outbreak 2009/2010 (>30000 cases)

Referral to ID D4 of life, 33 weeks, 1900g, spotty rash otherwise well…

Diff. diagnosis Congenital measles; Enterovirus infection; Phototherapy rash

Investigations Blood enteroviral PCR;

Urine + throat swab: measles PCR (+)

Measles serology on mom & baby (Both IgM +)

Precautions Airborne precautions

Cohort isolation with designated staffing

Intragam to all exposed babies – no further cases

Measles vaccine to all non-immune parents and staff

Lessons Maternal history; alert clinicians

Serratia marcescensContext opportunistic pathogen; immunocompromised patients,

Referral to IPC Email: 2 babies died from S. marcescens sepsis…? outbreak

Investigation Data reviewed: identified 10 additional cases

Line list for common risk factors; Gannt chart for patient movement

Common RF = ventilation (IPPV & CPAP) 11/12

Re-use of ventilator circuits; swabbed clean circuits : many GNB isolated

PFGE on 12 samples: single strain

Visit to SSD: washer disinfector out of order; inappropriate disinfection

Source Inappropriately disinfected single-use vent. circuits

Intervention TBH management agreed to purchase single use circuits for paeds

Lessons Alert clinician; good outbreak investigation; risks of re-use

Vancomycin-resistant Enterococci (VRE)

Context immunocompromised patients, surgical procedures

Referral to IPC 2 cases of VRE in the NICU (CLABSI)

Investigation 2 rounds of rectal screening in NICU, 1 month apart

Initial 3/19 colonized (16%) increasing to 8/12 (67%)

Ongoing transmission despite contact precautions + staff education

2 babies went to operating theatre – no communication of risk

Source Uncertain, propagated by poor hand hygiene

Intervention Education!! Adherence to HH and contact precautions

Lessons Need for better communication and more education

Neonatal hospital-acquired bloodstream infections

3.2

3.73.9

2.4

3.1

2.4

0

1

2

3

4

5

2008 2009 2010 2011 2012 2013

BS

I ra

te p

er

1000 I

PD

Neonatal service HAI BSI rate

TREND

NICU CLABSI

bundle started!

95%CI:

2.4-4.0 3.1-4.3 3.2-4.6 1.9-2.9 2.5-3.7 1.8-3.0

Statistically significant reduction in HA-BSI rates 2009 - 2013

Automated

alcohol

dispensers

Endemic bacteraemia: the big four!

1. Klebsiella spp 1.84

2. Serratia marcescens 0.62

3. Acinetobacter spp 0.58

4. MRSA 0.43

(BSI per 1000 IPD)

Endemic bacteraemia: organism profilesB

SI

rate

per

1000 I

PD SERRA

PSEUD

MRSA

KLEB

ENTER

ACINE

2012

Serratia

outbreak

Resistance profiles

MSSA = Methicillin sensitive Staphylococcus aureus

MRSA = Methicillin resistant Staphylococcus aureus

ESBL = extended spectrum B-lacatamase producer

The ideal HAI-free neonatal nursery.....

• Population: - less deliveries, less premature infants

- well mothers (maternal HIV/TB)

- better social circumstances (early discharge)

• Facility: - more space (incl. isolation rooms)

- dedicated equipment

- optimal crib/incubator spacing

• Staff: - improved staffing ratios

- regular in-service IPC training

- optimal IPC practitioner: patient ratio (1:200)

- support of hospital management, DoH

One can only dream…

What do we need in Africa to prevent HAI?

• Low-cost

• Available technologies

• Evidence-based INTERVENTIONS

• Contextually appropriate (KNOW)

• Culturally acceptable

• Political will

• Supportive management structures (DO)

• HCW attitudinal & behavioural change MINDSHIFT

• Empowerment of mothers

So, what strategies can we use

to reduce HAI in African newborns?

25

Kangaroo Mother Care

• Skin to skin contact

• Thermo-stable

• Bonding

• Ease of breastfeeding

• Facilitates early discharge

• Decreases burden on nursing staff

• Opens up space for acutely ill neonates

• Decreased mortality & morbidity

from NEC, sepsis, pneumonia

Breastmilk

• 2010 WHO revised infant feeding guidelines

• SA again advocating breastfeeding for HIV-exposed infants

• Use flash or Pretoria pasteurisation of HIV+ mom’s EBM

• Where EBM not available use donor EBM

• Need strict SOP for management of EBM & DBM

• Outbreaks often associated with formula feeds

• Breastfeeding = decreased incidence & mortality

from gastroenteritis & pneumonia

Nasal CPAP

• Relatively cheap & widely available

• Minimal training required – suitable for Level 1 hospitals

• Can be used with in-out surfactant for ELBW

• Avoids risk of ventilator associated pneumonia

• Decreases bed pressure on NICU facilities & referral hospitals

Hand hygiene

• KNOW DO

• Low compliance globally – especially doctors!

• Lack of basins, soap, towels, water ?!?

• Personal alcohol handrub

• Bare below the elbows

• Improvement with re-training and feedback ? sustainability

Staffing

• All categories remain understaffed

• Nurses fulfil additional functions eg portering, cleaning

• High staff turnover; use of agency nurses to fill the gaps

• Often work in multiple clinical areas; often lack accountability

• BUT - very willing to learn

- safety-focused

- passionate about neonates

- willingness to work with link nurses/nurse educators

Facility Management – partners in IPC

• Sometimes adversarial relationship with staff

• Lack of insight into IPC priorities

• All about saving costs

• BUT willing to listen and assist!

“We need to train our managers to understand the basic

economics of infection control – the fewer infections the less cost

to health services. Investment in IC pays high dividends.”

Shaheen Mehtar

Political Will

• Recognition of the integral role of IPC in health services

• IPC one of the top priorities listed by Dr Motsoaledi

• Launch of the National Core Standards in South Africa

• In SA baseline audit only 50% national ave. IPC compliance

• IPC should capitalise on this momentum

(together with importance of IPC highlighted by Ebola)

32

Good IPC = vulnerable newborns to thriving babies

Acknowledgements

• Dr Theuns Avenant

• Dr Adrie Bekker

• Prof Ben Marais

• Colleagues at TCH

• Mothers & babies of TCH