Nicu Infection Control

This is an evidence based presentation describing how to prevent and deal with the NICU infections outbreaks

1. Evidence based guidelines Evidence based guidelines
for prevention of infection in for prevention of infection in
NICUNICU
Dr. JP Dadhich Dr. JP Dadhich MD,FNNF,PGD-DNMD,FNNF,PGD-DN

2. OutlineOutline
Relevance of infection controlRelevance of infection control
Out breaks in NICU and lessons Out breaks in NICU and lessons
learnt from them learnt from them
Evidence based infection control Evidence based infection control
measures in NICUmeasures in NICU

3. Nosocomial Infections Nosocomial Infections
RelevanceRelevance
Significant cause of morbidity and Significant cause of morbidity and
mortalitymortality
Infants with nosocomial infectionsInfants with nosocomial infections
•Longer hospital staysLonger hospital stays
•Higher treatment costsHigher treatment costs
•Neurodevelopment impairmentNeurodevelopment impairment
67
31
56
44
0
10
20
30
40
50
60
70
IM EM
EOS
LOS
NNPD primary cause of death EM
NNPD – Time of onset of systemic infection

4. Risk factors for nosocomial Risk factors for nosocomial
infectionsinfections
PrematurityPrematurity
Low birth weightLow birth weight
Invasive deviceInvasive device
•Intravascular deviceIntravascular device
•Mechanical Mechanical
ventilationventilation
•Urinary CatheterUrinary Catheter
•VP shuntVP shunt
MedicationMedication
•H2 BlockersH2 Blockers
•SteroidsSteroids
Delayed enteral Delayed enteral
feedingfeeding
Formula feedingFormula feeding
Inadequate nursing Inadequate nursing
staff/overcrowdingstaff/overcrowding
Poor compliance Poor compliance
with hand washingwith hand washing

5. EpidemicsEpidemics
Cluster of infection with unusual pathogensCluster of infection with unusual pathogens
Continuous surveillance or monitoring of endemic Continuous surveillance or monitoring of endemic
infection rate to detect a change in baseline infection rate to detect a change in baseline
pattern pattern
Common sourceCommon source
•Contaminated equipmentsContaminated equipments
ThermometersThermometers
VentilatorsVentilators
StethoscopesStethoscopes
•Environmental reservoirsEnvironmental reservoirs
•Lapses in hand washingLapses in hand washing
Must be identified promptly and control measures Must be identified promptly and control measures
instituted immediatelyinstituted immediately

6. Endemic Pseudomonas aeruginosa Endemic Pseudomonas aeruginosa
Infection in a Neonatal Intensive Care Infection in a Neonatal Intensive Care
UnitUnit
PPseudomonas aeruginosaseudomonas aeruginosa is a well- is a well-
known cause of nosocomial infections known cause of nosocomial infections
among infants in neonatal intensive among infants in neonatal intensive
care units. care units.
Environmental sources such as sinks Environmental sources such as sinks
and respiratory-therapy equipment and respiratory-therapy equipment
are the most commonly described are the most commonly described
reservoirs of reservoirs of P. aeruginosaP. aeruginosa
Occasionally, health care workers Occasionally, health care workers
have been the reservoirhave been the reservoir
NEJM 2000; 343 (10):695-700.

7. SurveillanceSurveillance
An increased incidence of colonization and An increased incidence of colonization and
infection with infection with P. aeruginosaP. aeruginosa was noted was noted
Surveillance cultures were performed to Surveillance cultures were performed to
identify all infants with colonization identify all infants with colonization
33 infants in the neonatal intensive care 33 infants in the neonatal intensive care
unit, 6 of whom were identified as being unit, 6 of whom were identified as being
colonized or infected with colonized or infected with P. aeruginosaP. aeruginosa
Surveillance cultures were obtained from Surveillance cultures were obtained from
the other 27 infants – GA, ET secretions, the other 27 infants – GA, ET secretions,
nasopharyngeal swabs – twice a month till nasopharyngeal swabs – twice a month till
all babies in the cohort were discharged, all babies in the cohort were discharged,
than once a month fo next two monthsthan once a month fo next two months

8. Detecting environmental reservoirs
Cultures of environmental specimensCultures of environmental specimens
•tap watertap water
•sink drains sink drains
•liquid medications liquid medications
•respiratory-therapy equipmentrespiratory-therapy equipment
•hand soapshand soaps
•hand creams hand creams
•water baths used to warm formulawater baths used to warm formula
Moist and dry environmental surfaces Moist and dry environmental surfaces
were swabbed with a cotton-tipped swab were swabbed with a cotton-tipped swab

9. Cultures of the Hands of Health
Care Workers
The hands of health care workers who came in The hands of health care workers who came in
contact with infants hospitalized in the neonatal contact with infants hospitalized in the neonatal
intensive care unit during were cultured for intensive care unit during were cultured for P. P.
aeruginosaaeruginosa with use of a modification of the with use of a modification of the
"glove juice" method"glove juice" method
Both hands of each worker were sequentially put Both hands of each worker were sequentially put
into a sterile polyethylene bag containing 50 ml into a sterile polyethylene bag containing 50 ml
of sampling solution of sampling solution
One bag was used for each worker One bag was used for each worker
Each hand was massaged by an infection-control Each hand was massaged by an infection-control
practitioner through the wall of the bag for 15 to practitioner through the wall of the bag for 15 to
30 seconds30 seconds
samples were delivered to the microbiology samples were delivered to the microbiology
laboratory within 1 hour for processinglaboratory within 1 hour for processing

10. Risk Factors for Colonization of the
Hands with P. aeruginosa
The hands of all health care workers were inspected by the The hands of all health care workers were inspected by the
infection-control practitionerinfection-control practitioner

The presence of false nails, nail polish, and cracked or inflamed The presence of false nails, nail polish, and cracked or inflamed
nail beds was notednail beds was noted
Possible exposures to Possible exposures to P. aeruginosaP. aeruginosa and risk factors for infection, and risk factors for infection,
such as use of antibiotics and a history of otitis externa, such as use of antibiotics and a history of otitis externa,
swimming in the preceding year, skin lesions or dermatitis, latex swimming in the preceding year, skin lesions or dermatitis, latex
allergy, nail or nail-bed infections, and the use of artificial nails or allergy, nail or nail-bed infections, and the use of artificial nails or
nail wraps, were assessednail wraps, were assessed
Risk factors for colonization of the hands of health care workers Risk factors for colonization of the hands of health care workers
with with P. aeruginosaP. aeruginosa were determined by logistic-regression analysis were determined by logistic-regression analysis
with the use of SAS software with the use of SAS software
The association between exposure to a specific health worker and The association between exposure to a specific health worker and
infection or colonization with the endemic clone of infection or colonization with the endemic clone of P. aeruginosaP. aeruginosa
was assessed was assessed

11. Results Results
None of the cultures of environmental specimens None of the cultures of environmental specimens
grew grew P. aeruginosaP. aeruginosa
Among 165 health workers, 3 had positive hand Among 165 health workers, 3 had positive hand
cultures – risk factors were present – furloughed cultures – risk factors were present – furloughed
on full payon full pay
•The first health care worker wore nail extenders - The first health care worker wore nail extenders -
extenders were removed - hand cultures were extenders were removed - hand cultures were
subsequently negativesubsequently negative
•The second health care worker had candida The second health care worker had candida
onychomycosis – treated – negative culturesonychomycosis – treated – negative cultures
•The third health care worker had otitis externa – treated The third health care worker had otitis externa – treated
– negative cultures – negative cultures

12. Infection-Control MeasuresInfection-Control Measures

Contact isolation procedures were used for infants who were Contact isolation procedures were used for infants who were
colonized or infected with colonized or infected with P. aeruginosa:P. aeruginosa:
•gown and gloves were used during any contact with these patients, gown and gloves were used during any contact with these patients,
and and
•the patients were placed in a separate room and cared for by the patients were placed in a separate room and cared for by
designated nurses. designated nurses.
At the beginning of each shift, health care workers washed their At the beginning of each shift, health care workers washed their
hands with a preparation containing 4 percent chlorhexidine hands with a preparation containing 4 percent chlorhexidine
gluconate for two minutes gluconate for two minutes

during their shifts, the workers washed their hands with a during their shifts, the workers washed their hands with a
preparation containing 2 percent chlorhexidine gluconate preparation containing 2 percent chlorhexidine gluconate

Staff members were asked to wear no jewelry other than wedding Staff members were asked to wear no jewelry other than wedding
bands and wristwatches bands and wristwatches

Cosmetic nail treatments were not permitted Cosmetic nail treatments were not permitted
In addition, several care practices were changed: In addition, several care practices were changed:
•water baths were no longer used to heat formula, water baths were no longer used to heat formula,
•the number of supplies kept by the patients' bedsides was minimizedthe number of supplies kept by the patients' bedsides was minimized

13. Lessons Lessons
Be vigilant to detect an increased Be vigilant to detect an increased
incidence of common organismsincidence of common organisms
Adopt a systematic approachAdopt a systematic approach
Be prepared to be surprisedBe prepared to be surprised

14. E Sakazakii outbreakE Sakazakii outbreak
A male infant (1,270 grams) was A male infant (1,270 grams) was
delivered by cesarean section at 33.5 delivered by cesarean section at 33.5
weeks' gestation and was admitted weeks' gestation and was admitted
in NICU because of low birthweight, in NICU because of low birthweight,
prematurity, and respiratory distressprematurity, and respiratory distress
Morbidity & Mortality Weekly ReportMorbidity & Mortality Weekly Report, CDC.

15. Cont…Cont…
The infant had fever, tachycardia, The infant had fever, tachycardia,
decreased vascular perfusion, and decreased vascular perfusion, and
neurologic abnormalities (e.g., suspected neurologic abnormalities (e.g., suspected
seizure activity) at 11 daysseizure activity) at 11 days
Cerebrospinal fluid (CSF) suggestive of Cerebrospinal fluid (CSF) suggestive of
MeningitisMeningitis
Culture of CSF grew Culture of CSF grew E. sakazakiiE. sakazakii
The infant was treated with intravenous The infant was treated with intravenous
antimicrobials for meningitis; however, antimicrobials for meningitis; however,
neurologic damage was progressive, and neurologic damage was progressive, and
the infant died 9 days laterthe infant died 9 days later

16. Cont…Cont…
Because the organism was a rare Because the organism was a rare
cause of neonatal meningitis, cause of neonatal meningitis,
hospital personnel, in collaboration hospital personnel, in collaboration
with the Tennessee Department of with the Tennessee Department of
Health and CDC, investigated the Health and CDC, investigated the
source of infection source of infection

17. Cont…Cont…
During the study period, enhanced During the study period, enhanced
case surveillance was performed to find case surveillance was performed to find
if other infants in the NICU were either if other infants in the NICU were either
infected or colonized with infected or colonized with E. sakazakiiE. sakazakii
Patients were assessed for colonization Patients were assessed for colonization
by stool culture by stool culture

18. Cont…Cont…
Confirmed infection was defined as any Confirmed infection was defined as any E. E.
sakazakiisakazakii-positive culture from a normally -positive culture from a normally
sterile sitesterile site
Suspected infection was defined as an Suspected infection was defined as an E. E.
sakazakiisakazakii-positive culture from a nonsterile -positive culture from a nonsterile
site with documented deterioration in site with documented deterioration in
clinical status (e.g., increased respiratory clinical status (e.g., increased respiratory
rate without other evident cause) in the 24 rate without other evident cause) in the 24
hours before collection of the specimen for hours before collection of the specimen for
cultureculture
Colonization was defined as an Colonization was defined as an E. sakazakiiE. sakazakii--
positive culture from a nonsterile site positive culture from a nonsterile site
without documented deterioration in clinical without documented deterioration in clinical
status in the 24 hours before collection of status in the 24 hours before collection of
the specimen for culture. the specimen for culture.

19. Cont…Cont…
A total of 49 infants were screened A total of 49 infants were screened
Ten Ten E. sakazakiiE. sakazakii infection or infection or
colonization events were identified: colonization events were identified:
•one confirmed infection in the index one confirmed infection in the index
patient (culture-positive from CSF), patient (culture-positive from CSF),
•two suspected infections (both culture-two suspected infections (both culture-
positive from tracheal aspirate) positive from tracheal aspirate)
•seven colonization (six culture-positive seven colonization (six culture-positive
from stool, one from urine)from stool, one from urine)

20. A cohort study was performed on the A cohort study was performed on the
49 patients who were screened to 49 patients who were screened to
determine possible risk factors for determine possible risk factors for
acquisition of acquisition of E. sakazakiiE. sakazakii infection infection
or colonization or colonization
A case-patient was defined as any A case-patient was defined as any
NICU patient with NICU patient with E. sakazakiiE. sakazakii
infection (confirmed or suspected) or infection (confirmed or suspected) or
colonization during the study period colonization during the study period

21. Cont…Cont…
Medical records were reviewed to Medical records were reviewed to
assess possible risk factors during assess possible risk factors during
the study period, including the study period, including
•gestational age and birth weight, gestational age and birth weight,
•mechanical ventilator use mechanical ventilator use
•humidified incubator use humidified incubator use
•oral medicationsoral medications
•feeding type (TPN, formula [e.g., feeding type (TPN, formula [e.g.,
powdered or liquid], or breast milk) powdered or liquid], or breast milk)
•Feeding method (i.e., continuous or Feeding method (i.e., continuous or
intermittent administration) intermittent administration)

22. Of the 49 patients identified in the cohort, Of the 49 patients identified in the cohort,
•nine were case-patients nine were case-patients
•40 were non case-patients 40 were non case-patients
Analysis of risk factors identified only use Analysis of risk factors identified only use
of a specific powdered infant formula of a specific powdered infant formula
product (Portagen [Mead Johnson product (Portagen [Mead Johnson
Nutritionals, Evansville, Indiana]) to be Nutritionals, Evansville, Indiana]) to be
significantly associated with significantly associated with E. sakazakiiE. sakazakii
infection or colonization infection or colonization
all case-patients received Portagen all case-patients received Portagen
compared with 21 of 40 non case-patients compared with 21 of 40 non case-patients
(p<0.01) (p<0.01)

23. Cont…Cont…
To determine the source of infection, To determine the source of infection,
microbiologic studies were performed microbiologic studies were performed
on samples of commercially sterile on samples of commercially sterile
water used for formula preparation water used for formula preparation
and from samples of formula taken and from samples of formula taken
from opened cans of Portagen from from opened cans of Portagen from
the same two batches used in the the same two batches used in the
NICU during the study period NICU during the study period

24. Cont…Cont…
Environmental swab cultures were taken Environmental swab cultures were taken
from surfaces on which the product had from surfaces on which the product had
been preparedbeen prepared
Cultures also were performed on Cultures also were performed on
unopened containers of Portagen supplied unopened containers of Portagen supplied
by the manufacturer with batch codes by the manufacturer with batch codes
matching those of opened cansmatching those of opened cans

25. Cont…Cont…
Cultures of formula taken from both Cultures of formula taken from both
opened and unopened cans of Portagen opened and unopened cans of Portagen
from a single batch grew from a single batch grew E. sakazakiiE. sakazakii
Water and all environmental cultures were Water and all environmental cultures were
negative negative
Pulsed-field gel electrophoresis revealed Pulsed-field gel electrophoresis revealed
that isolates of that isolates of E. sakazakiiE. sakazakii from the CSF from the CSF
culture of the neonate with meningitis and culture of the neonate with meningitis and
from the culture of formula from both from the culture of formula from both
opened and unopened containers were opened and unopened containers were
indistinguishableindistinguishable

26. Cont…Cont…
To prevent additional infections, the To prevent additional infections, the
hospital made several policy changes hospital made several policy changes
Principal formula type for NICU patients Principal formula type for NICU patients
was changed from powdered formula to a was changed from powdered formula to a
commercially sterile, ready-to-feed liquid commercially sterile, ready-to-feed liquid
formula formula
Portagen use was stoppedPortagen use was stopped
Other powdered formula products are Other powdered formula products are
reserved for specific needs and, when reserved for specific needs and, when
necessary, are prepared in a designated necessary, are prepared in a designated
formula preparation room in the pharmacy formula preparation room in the pharmacy
No additional episodes of infection or No additional episodes of infection or
colonization have been detected at the colonization have been detected at the
reporting hospital reporting hospital

27. LessonsLessons
Be vigilant for presence of unusual Be vigilant for presence of unusual
pathogenspathogens
Powdered formula is not a sterile Powdered formula is not a sterile
productproduct
Always include PIF in surveillance in Always include PIF in surveillance in
case of E sakazakiicase of E sakazakii

28. Neonatal Serratia marcescens Neonatal Serratia marcescens
outbreak outbreak
Observational study of microbiological and Observational study of microbiological and
epidemiological investigations epidemiological investigations
Nine cases were observed in a 5 months Nine cases were observed in a 5 months
period. A Serratia outbreak was therefore period. A Serratia outbreak was therefore
identified, and all the strains were identified, and all the strains were
compared by pulsed-field gel compared by pulsed-field gel
electrophoresis (PFGE)electrophoresis (PFGE)
Data from medical notes were gathered Data from medical notes were gathered
retrospectivelyretrospectively
Environmental samples were gathered Environmental samples were gathered
prospectivelyprospectively
Acta Pædiatrica 97(10):2008

29. Cont…Cont…
Four infants were colonized and five infants were Four infants were colonized and five infants were
infected by S. marcescens. infected by S. marcescens.
PFGE revealed that three different strains were PFGE revealed that three different strains were
present. present.
Seven of the nine babies were infected by only Seven of the nine babies were infected by only
one of these strains. one of these strains.
This same strain was found in a non-antimicrobial This same strain was found in a non-antimicrobial
soap bottle (NAS) that could be the source of soap bottle (NAS) that could be the source of
contaminationcontamination
The outbreak was controlled with cohorting, The outbreak was controlled with cohorting,
contact isolation, surveillance cultures, and contact isolation, surveillance cultures, and
careful review of cleaning procedurescareful review of cleaning procedures

30. Flow Chart for outbreak Flow Chart for outbreak
investigationinvestigation
Incident Cases and Infection Rate
Surveillance Cultures
Processing of Specimens
Pulse-field gel electrophoresis
Identifying risk factors for colonization
Infection control measures

31. Infection Control in the NICU –Infection Control in the NICU –
Recommended StandardsRecommended Standards
NICU C2CE414Dd01.pdfNICU C2CE414Dd01.pdf
Adapted mainly from Adapted mainly from “Guidelines for
Perinatal Care, 4
th
Edition by AAP and
ACOG
Focuses on the following areas:-Focuses on the following areas:-
•Physical SetupPhysical Setup
•Administrative arrangementAdministrative arrangement

32. Prevention of Nosocomial Prevention of Nosocomial
InfectionsInfections
Each unit has a baseline rate of infection due to inherent Each unit has a baseline rate of infection due to inherent
modifiable risk factorsmodifiable risk factors
Effective strategy focus on Effective strategy focus on modifiablemodifiable risk factors risk factors
•Strategic nursery design – space, sinks, soaps, paper towelStrategic nursery design – space, sinks, soaps, paper towel
•Adequate staffingAdequate staffing
•Hand hygiene complianceHand hygiene compliance
•Minimization of catheter daysMinimization of catheter days
•Sterile preparation of all fluids to be administeredSterile preparation of all fluids to be administered
•Promoting enteral feeding esp. with EBM/breastfeedingPromoting enteral feeding esp. with EBM/breastfeeding
•Monitoring/ surviellance of nosocomial infectionMonitoring/ surviellance of nosocomial infection
•Education and frequent feedback from staffEducation and frequent feedback from staff

33. General HousekeepingGeneral Housekeeping
Cleaning should be performed in the following Cleaning should be performed in the following
order – patient areas, accessory areas and then order – patient areas, accessory areas and then
adjacent hallsadjacent halls
In the cleaning procedure, dust should not be In the cleaning procedure, dust should not be
dispersed into the airdispersed into the air
Once dust has been removed, scrubbing with a Once dust has been removed, scrubbing with a
mop and a disinfectant/detergent solution should mop and a disinfectant/detergent solution should
be performedbe performed
Cabinet counters, work surfaces etc should be Cabinet counters, work surfaces etc should be
cleaned once a day and between patient use with cleaned once a day and between patient use with
a disinfectant/detergent and clean clothsa disinfectant/detergent and clean cloths
Walls, windows, storage shelves and similar non-Walls, windows, storage shelves and similar non-
critical surfaces should be scrubbed periodically critical surfaces should be scrubbed periodically
with a disinfectant/detergent solutionwith a disinfectant/detergent solution
Sinks should be scrubbed clean at least daily with Sinks should be scrubbed clean at least daily with
a detergenta detergent

34. Recommendations for Hand Recommendations for Hand
HygieneHygiene
Wash hands with soap and water when Wash hands with soap and water when
hands are visibly soiled contaminatedhands are visibly soiled contaminated
If hands are not visibly soiled, alcohol If hands are not visibly soiled, alcohol
based waterless antiseptic (ABWLAS) based waterless antiseptic (ABWLAS)
agents for routine decontamination of agents for routine decontamination of
hands in all clinical situationshands in all clinical situations
Before regular hand decontamination Before regular hand decontamination
begins all wrists and hand jewelry should begins all wrists and hand jewelry should
be removedbe removed
Cuts and abrasions must be covered with Cuts and abrasions must be covered with
waterproof dressings waterproof dressings
Fingernails should be kept short and cleanFingernails should be kept short and clean

35. Recommended technique for Hand Recommended technique for Hand
Hygiene Hygiene
ABWLAS agentsABWLAS agents
Apply enough of the product to cover Apply enough of the product to cover
all the surfaces of the hands and all the surfaces of the hands and
fingersfingers
Rub hands together until they are Rub hands together until they are
drydry
Enough volume should be applied – Enough volume should be applied –
such that it takes 15-25 seconds to such that it takes 15-25 seconds to
drydry

36. Recommended technique for Hand Recommended technique for Hand
HygieneHygiene
Hand WashingHand Washing

37. Hand Hygiene Practices in a Hand Hygiene Practices in a
Neonatal Intensive Care UnitNeonatal Intensive Care Unit
A problem-based and task-orientated A problem-based and task-orientated
education program can improve hand education program can improve hand
hygiene compliancehygiene compliance
Overall hand hygiene compliance Overall hand hygiene compliance
inincreased from 40% to 53% before creased from 40% to 53% before
patient contact and 39% to 59% after patient contact and 39% to 59% after
patient contact patient contact
There was improvement in most aspects There was improvement in most aspects
of hand-washing technique in the of hand-washing technique in the
postintervention stage. postintervention stage.
The health care–associated infection rate The health care–associated infection rate
decreased from 11.3 to 6.2 per 1000 decreased from 11.3 to 6.2 per 1000
patient-days patient-days
PEDIATRICS 2004;114 (5) :e565-e571

38. Use of Human-milk FeedingsUse of Human-milk Feedings
Neonates fed breast milk were less likely to Neonates fed breast milk were less likely to
become septic compared to formula-fed neonates become septic compared to formula-fed neonates
(Narayanan I et al. J Pediatr 1981)(Narayanan I et al. J Pediatr 1981)
human-milk feedings reduced the odds of sepsis/human-milk feedings reduced the odds of sepsis/
meningitis compared to preterm milk feedings meningitis compared to preterm milk feedings
(Hylander MA et al. Pediatrics 1998 )(Hylander MA et al. Pediatrics 1998 )
The efficacy of breast milk also appears to be The efficacy of breast milk also appears to be
dose dependent dose dependent (Schanler RJ. Pediatr Clin North Am 2001)(Schanler RJ. Pediatr Clin North Am 2001)

39. VentilationVentilation
A minimum of 6 air changes per hour A minimum of 6 air changes per hour
is required for the NICU, with a is required for the NICU, with a
minimum of 2 changes being outside minimum of 2 changes being outside
airair
Ventilation air delivered to the NICU Ventilation air delivered to the NICU
shall be filtered with at least 90 % shall be filtered with at least 90 %
efficiencyefficiency

40. Catheter related blood stream Catheter related blood stream
infections infections (CDC)(CDC)
Isolation of a recognized pathogen Isolation of a recognized pathogen
from one blood culture or isolation of from one blood culture or isolation of
a skin commensal from two blood a skin commensal from two blood
culture specimensculture specimens
One/more clinical signs of infectionOne/more clinical signs of infection
Presence of an intravascular devicePresence of an intravascular device
CDC’s National Nosocomial Infection Surveillance System (NNIS)
reported CABSIs - pooled means – 28.2/1000 catheter days in
VLBW babies

41. RECOMMENDATIONS FOR PLACEMENT OF RECOMMENDATIONS FOR PLACEMENT OF
INTRAVASCULAR CATHETERSINTRAVASCULAR CATHETERS
Category IACategory IA
Educate health-Educate health-
care workers care workers
Assess knowledge Assess knowledge
of and adherence of and adherence
to guidelines to guidelines
periodically periodically
Category IBCategory IB
Ensure appropriate Ensure appropriate
nursing staff levels nursing staff levels
in ICUs in ICUs
Health-care worker education and training

42. Surveillance Surveillance
Monitor the catheter sites visually or Monitor the catheter sites visually or
by palpation through the intact by palpation through the intact
dressing on a regular basis - dressing on a regular basis - IBIB
Record the operator, date, and time Record the operator, date, and time
of catheter insertion and removal, of catheter insertion and removal,
and dressing changes on a and dressing changes on a
standardized form - IIstandardized form - II

43. Aseptic technique during catheter Aseptic technique during catheter
insertion and care insertion and care
Maintain aseptic technique for the Maintain aseptic technique for the
insertion and care of intravascular insertion and care of intravascular
catheters - catheters - Category IACategory IA
Use either sterile gauze or sterile, Use either sterile gauze or sterile,
transparent, semipermeable dressing to transparent, semipermeable dressing to
cover the catheter site - cover the catheter site - Category IACategory IA
Promptly remove any intravascular Promptly remove any intravascular
catheter that is no longer essential - catheter that is no longer essential -
Category IACategory IA
Clean injection ports with 70% alcohol or Clean injection ports with 70% alcohol or
an iodophor before accessing the system - an iodophor before accessing the system -
Category IACategory IA

44. Strategies that do not Appear to Strategies that do not Appear to
WorkWork
Ventilator circuit changes more often than Ventilator circuit changes more often than
one time per week were not associated one time per week were not associated
with a decrease in pneumonia or sepsiswith a decrease in pneumonia or sepsis
(Long M et al. Infection Control & Hospital (Long M et al. Infection Control & Hospital
Epidemiology,1996)Epidemiology,1996)
Gowning before entering the NICU has no Gowning before entering the NICU has no
effect on reducing HAI effect on reducing HAI (Tan S et al. International (Tan S et al. International
J of Nursing Practice 1995)J of Nursing Practice 1995)
Changing the frequency of tracheal Changing the frequency of tracheal
suctioning from every 4 hours to 8 hours suctioning from every 4 hours to 8 hours
did not change pneumonia or blood did not change pneumonia or blood
stream infection rate stream infection rate (Cordero I et al. Journal (Cordero I et al. Journal
ofPerinatolgy 2000)ofPerinatolgy 2000)

45. Prophylactic IVIGProphylactic IVIG
Meta analysis of IVIG in preterms Meta analysis of IVIG in preterms
Only 3% reduction in nosocomial Only 3% reduction in nosocomial
infectioninfection
No reduction in mortalityNo reduction in mortality
(Modi and Carr, 2000)(Modi and Carr, 2000)

46. Haemopoietic Colony Stimulating Haemopoietic Colony Stimulating
Factor (G-CSF, GM-CSF)Factor (G-CSF, GM-CSF)
Effective in raising neutrophil countEffective in raising neutrophil count
Not consistent in decreasing Not consistent in decreasing
nosocomial infections or mortalitynosocomial infections or mortality
(Modi and Carr 2000)(Modi and Carr 2000)

47. GownsGowns
Routine use does not help in Routine use does not help in
reducing endemic nosocomial reducing endemic nosocomial
infection rateinfection rate
Should be used Should be used
•In specific circumstances in which the In specific circumstances in which the
risk of contamination is highrisk of contamination is high
•The infant is being heldThe infant is being held

48. ConclusionsConclusions
HAIs/NCIs could be prevented with a HAIs/NCIs could be prevented with a
systematic, evidence based approachsystematic, evidence based approach
Outbreaks need prompt identification Outbreaks need prompt identification
and remedial actionsand remedial actions
Do not hesitate to report and Do not hesitate to report and
document the outbreaks document the outbreaks

49. Their Future is in Our Hands Their Future is in Our Hands 
Thanks !!!!
[email protected]

50. Antibiotics for preterm rupture of Antibiotics for preterm rupture of
membranes membranes (Cochrane Review -(Cochrane Review - 2005)2005)
1.98 to 10.724.60Co-amoxiclav -
NNEC
0.72 to 0.960.83use of surfactant
0.53 to 0.87 0.68neonatal infection
0.71 to 0.90 0.80born within seven
days of
randomisation
0.58 to 0.870.71born within 48
hours of
randomisation
0.37 to 0.860.57chorioamnionitis
95% CIRRParameter