Fakulteit Gesondheidswetenskappe Faculty of Health Sciences Protecting the most vulnerable: IPC in the neonatal nursery Dr Angela Dramowski ([email protected]), Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa ICAN Harare 2014
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Fakulteit Gesondheidswetenskappe
Faculty of Health Sciences
Protecting the most vulnerable:
IPC in the neonatal nursery
Dr Angela Dramowski ([email protected]), 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)
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