Reduce risk for sepsis in NICU

1. Reducing risk of sepsis in nicu Dr C.S.N.Vittal

2. neonatal nosocomial infections • Nosocomial or hospital acquired infections threaten the survival and neurodevelopmental outcomes of infants admitted to the neonatal intensive care unit, and increase cost of care. • Premature infants are particularly vulnerable since they often undergo invasive procedures and are dependent on central catheters to deliver nutrition and on ventilators for respiratory support. • Prevention of nosocomial infection is a critical patient safety imperative, and invariably requires a multidisciplinary approach. 

3. What is a nosocomial infection? • Infection not present nor incubating at the time of admission • Infections that appear more than 48 hours after admission\inf • Infections acquired in the hospital but appear after discharge • Occupational infections amongst the staff

4. Centers for Disease Control (CDC) estimates that HAIs account for an estimated 1.7 million infections and 99,000 associated deaths each year.  • 32 percent of all healthcare acquired infection are urinary tract infections • 22 percent are surgical site infections • 15 percent are pneumonia (lung infections) • 14 percent are bloodstream infections • A multicenter study conducted by Turkish Neonatal Society (TNS), it was reported that the prevalence of HAI among NICUs varied from 2.6% to 17% • Incidence of HAI was reported to vary between 6.2 and 50.7 infections per 100 admissions, and between 4.8 and 62 infections per 1000 patient days at various centers in the previous studies

5. Risk of neonatal nosocomial infections • 20–25% of very low birth weight (VLBW, birth weight ≤ 1500 g) infants who survived beyond 3 days were found to have one or more episodes of blood culture proven sepsis, with the majority being caused by gram-positive organisms, predominantly coagulase-negative staphylococci (CONS)  • The rate of infections was inversely related to birth weight and gestational age, with 50% of the infections occurring in infants born at <25 weeks or weighing less than 750 g at birth.  • National Institute of Child Health and Human Development (NICHD) Neonatal Network USA

6. Risk factors • prematurity, • prolonged duration of parenteral alimentation with delayed enteral nutrition, • intravascular catheterization, • extended respiratory support on ventilators, • gastrointestinal surgery, and • use of broad spectrum antibiotics • contamination of equipment, environment, medications, and even breast milk   • Bed space less than 1 meter (3 feet) apart • Limited resources for isolation or co-horting (grouping babies with the same condition together) • High patient-to-nurse ratio • Lack of trained IPC practitioners and limited opportunities for staff training • Increasing use of complex medical and surgical procedures • Allegranzi et al. 2011

7. Organisms responsible for infections • Gram-positive • Staphylococcus- coagulase negative • Staph aureus • Enterococcus group • Group b streptococcus • Gram-negative • Enterobactor • Esch coli • Klebsiella • Pseudomonas • Fungi • Candida albicans • Candida parapsilosis

8. Infection control precautions • Stndard precautions • Applied to all • Transmission based precautions • Contatc • Droplet • airborn

9. Overview of preventive measures to reduce risk for sepsis in nicu Neonatal management • Early enteral breast-feeding with fresh human milk • Promotion of enteral feeding • hand Hygiene measures • CVC management policies • CVC bundles • In-line Enteric microbiota composition enhancement with the use of probiotics • H2 blockers and steroids restrictions • Antibiotic stewardship • Stewardship in TPN use • Prevention of VAP American Journal of Perinatology30(2) · January 2013

10. Overview of preventive measures to reduce risk for sepsis in nicu Pharmacological prophylactic interventions • General anti-infective prophylaxis: bioactive substances, probiotics, lactoferrin Specific anti- fungal prophylaxis: fluconazole, nystatin Specific anti- rsv prophylaxis: palivizumab • Fluconazole prophylaxis • reduces colonization of the skin, gastrointestinal and respiratory tracts and prevents invasive candida infection in high risk preterm infants  • Use of topical emollients • Veg oil or Aquaphor – to improve skin integrity and barrie function American Journal of Perinatology30(2) · January 2013

11. Physical Design of Neo-Natal Nursery • The nursery design should have adequate space for necessary equipment • Traffic through the other services should not pass through the unit • 30 square feet per neonate approximately three feet between bassinets is currently recommended • For infant who require extensive nursing care 50-60 square feet working space with at least four feet between incubators or bassinets and five feet wide aisles. • For Neonatal intensive care units 80-100 square feet per infant with at least six feet between incubators or bassinets and eight feet between aisles

12. There should be at least one elbow operated hand washing sink for every 4-6 basinettes • Each single room shall be provided with an elbow operated stand alone sink • Hand washing posters with clear washing instructions should be provided above all sinks • Hand washing sinks should be scoured and cleaned daily using a detergent.

13. Ventilation • Positive pressure airflow from a ceiling entry to a floor return pulling dust downwards and out is recommended • Filters with efficiency of at least 90-100% must be used • Minimum of 10-15 air charges per hour • Access to at least one isolation room with negative air pressure discharging air vented to the outside to accommodate newborns with airborne infections • Interventions to prevent ventilator associated pneumonia (VAP) • Caregiver education • Hand hygiene • Wearing gloves when in contact with secretions • Minimize days of ventilation • Prevent unexpected extubation – avoid reintubation • Suction orophayrynx • Prevent gastric distention • Change ventilator circuit only when visibly soiled or malfunctioning • Remove condensate from ventilator circuit frequently

14. Staffing Norms • Adequate staff is mandatory to allow for hand washing between patients’ contact • Normal nursery staffing ratio is: one professional nurse to every 6-8 infants • Intermediate care nursery staffing ratio is: one professional nurse for ever 2-3 patients • NICU- one professional nurse for every 1-2 patients 2 • Dedicated assistance is needed to mentor and support lodger mothers not to expose their babies to cross-infection

15. Isolation Rooms: • Adequate space of 13.94 square metres (150 square feet) should be available excluding the entry work area • Ideally single multi-bedded corners are appropriate? • Ventilation in isolation rooms to have negative pressure with our 100% exhausted to the outside • A hands free emergency communication system is required within the isolation room to minimize in and out movement • Choice and placement of windows an blinds should allow for care of operation and cleaning • All babies with Septicaemia should be isolated • Babies transferred from other hospitals or admitted from home must have swabs taken and sent for culture • Transfers must be nursed in an isolation unit

16. Hand Washing • Use antiseptic soap to thoroughly wash and rinse hands before entering the nursery • use paper towel to dry hands and dispose of in a plastic lined functional pedal bin.

17. Protective Attire: • A short sleeved gown should be worn over special clothing designated for nursery by the health care personnel and lodger mothers- this gown to be exclusively for one named neonate and hand hygiene strictly practiced before moving on to others.

18. Patient Care Equipment • Terminal disinfection of equipment done using soap and water and hypochlorite solution • ventilator tubing used in babies with negative bacilli to be discarded as medical waste • Ventilators used for infected babies to be left standing for 96hours after terminal disinfection before re-use • Incubators and bassinets should have the detachable parts removed and scrubbed meticulously • Incubator fans, where applicable should be cleaned and disinfected • Air filters in the incubator should be maintained as recommended by the manufacturer • Waterproofed mattresses replaced when waterproof covering is broken • Porthole cuffs are easily and often heavily contaminated, therefore need for daily cleaning with detergent and daily cleaning with disinfectant

19. Invasive Device: • Meticulous attention should be given to aseptic and maintenance of cannulae and to aseptic techniques of fluid administration • Parental nutrition fluids ordered direct from supplying company and no decanting at the facility level (even in the pharmacy) to prevent cross infections • Single dose medication vials are recommended for injections. • For handling of intravenous lines, this to be done according to relevant policy • Infection Control guidelines should be observed with the ff: - endotracheal tubes - urinary catheters

20. Implementation, Monitoring and Evaluation of this Policy • responsibility of the hospital manager, the nurse manager, the head of department and the nursery personnel (both day and night) the infection control manager and the matron in charge of the nursery to ensure that effective support, implementation, monitoring and evaluation systems are in place.

21. Adjuvant therapy • Immunoglobulin therapy Preterm infants are deficient in immunoglobulin G (IgG • Lactoferrin • Probiotics • Prebiotics • Synbiotics • Antibiotic sterwardship

22. Potential Better Practices for Preventing Nosocomial Infection • Handwashing ● • Meticulous attention to handwashing, with regular monitoring and surveillance of handwashing practice and reporting of compliance. • Nutrition • No alteration of hyperalimentation solutions after preparation. • Initiation of enteral feedings as early as possible. • Reduced exposure to intravenous lipids and hyperalimentation. • Promotion of the use of human milk, ensuring proper collection and storage. • Skin Care • Initiation of a skin care protocol for all neonates weighing <1,000 g to promote skin maturation and to prevent skin breakdown. • Reduced laboratory testing that requires venipuncture or heel stick. • Development of a systematic approach to intravenous therapy that reduces the frequency and number of skin punctures for placement of an intravenous catheter.

23. Potential Better Practices for Preventing Nosocomial Infection • Diagnosis • Establishment of a minimum sample size for a blood culture that is 1 mL per aerobic culture bottle. • Preference for two samples of 1 mL each in two aerobic culture bottles. ● Development of a method to distinguish true infection from a contaminated culture. • Respiratory Care • Minimization of intubation days. • Minimization of the interruption of the ventilator-endotracheal tube circuit.

24. Potential Better Practices for Preventing Nosocomial Infection • Vascular Access • Minimization of the use of central lines, and when used, minimization of the frequency of daily entries and the duration of use. • Prospective placement of central lines when intravenous therapy will be of long duration. • Establishment of sound policies and procedures for line care and access and regular monitoring of compliance. • Unit Culture • Promotion of developmentally supportive care, with an emphasis on minimal handling. • Development and maintenance of a culture of cooperation and teamwork that supports and encourages all team members to feel responsible for outcomes

25. Prevention of catheter-related bloodstream infections (CRBSI) • Use of injection ports instead of stopcocks • Minimum number of ports • Disinfection of injection port before line entry • Adherence to hand-washing hygiene • Clean technique when accessing system and when changing tubing

26. Central Line Associated Bloodstream Infection (CLABSI) • Antiseptic Non Touch Technique (ANTT) to prevent the contamination of wounds and other susceptible sites, by ensuring that only uncontaminated equipment or sterile fluids come into contact with susceptible or sterile body sites during clinical procedures. • ANTT: • Always wash hands effectively • Never contaminate Key parts • Touch non- key parts with confidence • Take appropriate infective precautions

27. “five moments for hand hygiene” • Adequate handwashing with water and soap requires 40– 60 seconds • Average time usually adopted by health-care workers: < 10 sec • Alcohol-based hand rubbing: 20–30 seconds

28. How to hand rub This takes only 20–30 seconds!

29. How to hand wash Must last at least 40–60 secs

30. five cleans • which must be followed to prevent infection in the newborn -  • Clean hands,  • clean cord tie,  • clean cord,  • clean surface and  • clean blade.