NEONATAL SEPSIS AND PREVENTION

1. NEONATAL SEPSIS AND PREVENTION A PRESENTATION BY DR. GACHERI NYAMU-MUTUA CONSULTANT PAEDIATRICIAN/NEONATOLOGIST KENYATTA NATIONAL HOSPITAL

2. DEFINITION • Neonatal sepsis is defined as a clinical syndrome of bacteria with systemic signs and symptoms of infection in the first 4 weeks of life.

3. ETIOLOGY Common organisms identified:- • Coagulase negative staphylococcus aureus. • Escherichia coli • Strep.pneumoniae • Listeria monocytogenes • Klebsiella pneumoniae

4. EARLY ONSET NNS Early Onset: Infection occurring in the first 5 days of life. Usually sets in within less than 72 hours of birth. Exposure can occur:- Before delivery = Infected amniotic fluid = Untreated maternal sepsis During delivery = Organisms in maternal genital tract After delivery = Exposure to organisms in infants Environment (Suction tubes; ambubags, resuscitoire, 02 masks) • Early onset neonatal sepsis manifests frequently as pneumonia and less commonly as septicaemia or meningitis.

5. LATE ONSET NNS • Occurs 5-7 days after birth • Usually due to organisms thriving in the external environment. • Presents with septicaemia, pneumonia or meningitis.

6. Risk of exposure to late nns:- • Lack of hand hygiene by health care givers • Low birth weight • Lack of initiating breast feeding • Superficial infections (Pyoderma:umbilical sepsis) • Aspiration of feeds • Disruption of skin integrity with needle pricks and/or use of intravenous fluids • These enhance the chances of infection in the neonates (who have an already poor immune defense mechanism)

7. CLINICAL FEATURES Manifestations of neonatal sepsis are usually VAGUE and demand a HIGH INDEX OF SUSPICION for early diagnosis. Most common manifestations include:- • Respiratory distress in early onset neonatal sepsis • Altered feeding behavior in a well established feeding newborn (aspirate; vomiting etc) • Baby who was active/feeding suddenly or gradually becomes lethargic, inactive or unresponsive and refuses to suckle • Temperature instability

8. Signs of severe sepsis • Diarrhoea , vomiting and abdominal distension may occur. • Episodes of apnoiec attacks or gasping breaths in a baby who was otherwise stable • Others include:- • Sclerema • Prolonged capillary refill time more than 3 seconds. • Cyanosis • Shock • Bleeding/renal failure.

9. Current situation • Mortality is high in first 24-48hrs of life (24-45%) • At KNH newborn unit, average monthly admissions stand at approximately 250 per month • Majority of these (~50%) are preterm infants • Of this number: 60% survive, 40% succumb • Total mortality rate per month stands at ~40% (currently 32-50%)

10. NB: The chart has disregarded co-morbidities

11. PREVENTION OF NEONATAL SEPSIS • Good antenatal care • Maternal infections diagnosed early and treated adequately • Babies should be breastfed EARLY (or fed exclusively on EBM). Avoid pre-lacteal feeds (Offers cover with maternal flora to baby) • VERY IMPORTANT – Infection control policies applied in the unit.

12. GENERAL PRINCIPLES • Handling of neonates should be MINIMIZED • Measures should be taken to minimize the risk of transmission of pathogens from mother to infant. • Staff should perform hand washing between infants as well as upon entering and leaving the nursery. • Equipment and supplies should not be shared between infants. • Minimize invasive procedures and when carried out should be cautiously done and aseptic techniques observed. • Visitors should be minimized and should also observe the infection control measures set up in the unit .

13. NEONATAL CARE PRACTICES IV Cannular Insertion • Wash hands aseptically • Wear sterile (or clean) gloves • Disinfect neonate’s skin • Use a no - touch technique IV Therapy • Certain staff are designated to prepare IV fluids • An area should be dedicated for preparation of medications and IV fluids • Aseptic technique should be observed during these procedures

14. SKIN CARE • Cord should be cleaned/dried • Skin should be kept clean with warm water with or without mild soap • Daily washing has been shown to add no value in infection control. However soiled areas showed be cleaned gently but avoid damage to the skin. • Adhesive tapes that damage neonate’s skin should be avoided. • The only time whole body bathing and antiseptic soaps are indicated is during an infection outbreak.

15. INFANT FEEDING Maternal/Breast Milk • EBM should be collected and stored aseptically • Hands washed with an antiseptic and milk expressed into sterile containers. • Breast pump parts in contact with milk should be washed in hot soapy water after each use and sterilized or disinfected daily. • EBM should be stored for not more than 48hours in a refrigerator or below 20˚ C for up to 6 months • Avoid EBM if mother has transmittable diseases (those expressed through breast milk). • EBM can be cultured where contamination or infection is suspected.

16. INFANT FORMULAS • Formula once prepared should not be used more than 4 hours of uncupping • Sterile technique should be observed during preparation; sterilize the utensils/containers • Formula should be bottled in volumes for individual use for 4 hours of continuous feeding • Formulas can be refrigerated for 24 hours and used within 4 hours of opening.

17. OTHER INVASIVE PROCEDURES Umbilical catheters • If aseptic conditions have been maintained, they can stay for up to 3weeks Naso-gastric tubes • Should be kept clean and changed often Continuous IV infusions pumps Continuous b/feeding pumps • These allow an extra route of entry to micro-organisms and must be handled in very aseptic ways

18. EQUIPMENT • Schedules should be established for routine cleaning of all patient care equipment . • Incubators/ventilators should be cleaned and disinfected in between patients. • If a patient remains incubated for long, it is recommended that the incubator be disinfected every 5 – 7 days (Hydrogen peroxide or isopropyl alcohol 70 %). • Equipments in direct contact with mucous membranes of neonates should be disinfected and sterilized between patients.

19. Equipments assigned to a single patient use (respiratory masks; stethoscopes; thermometers) should be sterilized or replaced on a regular basis • Sterile water should be used in nebulizers and humidifiers. NB// Records should be kept of when done /due dates for the above.

20. ENVIRONMENTAL CLEANING • The nursery should be clean and dust free • Daily surface cleaning with water and detergent should be done routinely. • Blood spills should be removed immediately with a disinfectant. • Walls, windows, doors, curtains should be cleaned regularly.

21. ISOLATION • Studies have shown no need or added benefit for isolation rooms. • Most newborn care measures, if followed strictly, will prevent transmission of neonatal infections. • The need however only arises in:- • Airborne transmittable infections • Infants of mothers with perinatal varicella (Single room isolation)

22. BARRIER PRECAUTIONS GLOVES • Indicated in heavy microbial load such as infectious diarrhoea, draining skin lesions, enterovirus, Hepatitis A, rotavirus • Wear sterile gloves before performing invasive procedure and IV fluid preparation.

23. GOWNS • Several studies have shown no benefit in reduction of neonatal infectious in gowning and it is not cost-effective.

24. HAND HYGIENE • It has been shown that hand hygiene before and after every patient is the SINGLE most important means of reducing risk and preventing spread of infections in hospitals

25. Recommendations for hand hygiene (By CDC/WHO) guidelines • Wash hands with water and antiseptic soap when visibly soiled or contaminated. • If hands are not visibly soiled, use alcohol-based hand rub (ABHR) • Decontaminate hands before and after each patient. • Decontaminate hands after contact with inanimate object in the immediate vicinity of the patient.

26. There should be: • easy access to ABHR at points of care • programmes to monitor hand hygiene compliance with feed-back to care givers/staff • adequate sinks with soap and water to allow hand washing • NB: ABHR is the preferred method as it provides for a RAPID kill of most transient micro-organisms

27. HAND HYGIENCE TECHNIQUE • Roll up sleeves to the elbow • (It is recommended that all jewellery be removed). • Apply a good amount of soap and rub hands together vigorously for 20 seconds, covering hands and fingers. Rinse hands thoroughly and dry with disposable towels(Not dryers!). • Avoid hot water as repeated use may increase risk of dermatitis. • Advantage of bar to liquid soap is that the latter if not changed frequently and effectively can harbor micro-organisms.

28. Use of Aseptic or alcohol based hand-rub Should be performed:- • Before entering the neonatal unit • Before invasive procedures • Before mixing IV fluids • Before use of multidose drug vials • Before administration of IV fluids/medications Method: • Apply the hand rub on the palm • Rub hands together covering the hands and fingers. • Wait until its dry before handling the patient or the equipment • Repeat procedure in between patients.

30. In our facility • Challenges : • Increase in preterm babies • Late / complicated referral cases • Way forward : • Knowledge and practice ( both at KNH and the referring centres ) • Improved care/ equipment at the point of birth (obstetric/neonatal) • More research surveillance

31. Way forward cont. • Decongest the unit ( babies, mothers, staff, caregivers) • Proper handling of babies during referrals • Adherence to the unit policies laid down

32. THANK YOU! Questions? Comments?