Infection control in neonatology pp.al

Infection Control inInfection Control in
Neonatology UnitsNeonatology Units
Dr Anjum Hashmi, MBBS,CCS(USA),MPH
Infection Prevention & Control Director,
Director Employee's Health,
Advisor Quality Management Department
East Najran Hospital
Najran, Saudi Arabia

PIONEERS IN INFECTION CONTROLPIONEERS IN INFECTION CONTROL
1815 - 1865
Childbed Fever caused by
physicians & medical
students washing hands
with lime water reduced
death rates From 18% to
<2%
Finding not accepted By peers
1827 - 1912
Using carbolic acid reduced
Nosocomial infections in the
Glasgow General Hospital
Findings well accepted by peers
Joseph Lister
Ignaz Semmelweiss
400 - 800BC
• Wrote a Treatise on surgery
• Used fumigation techniques
• Clip nails and hair
Clean and flamed surgical
instruments
Sushrutha
Considered the Father of SurgeryFather of Modern Surgery

TYPES OF INFECTIONSTYPES OF INFECTIONS
Patient may acquire infection before admission to an
hospital known as Community acquired infection.
Patient may get infected inside the hospital known as
Nosocomial infection/Healthcare Associated
Infection (HAIs).
They include:
1) Infections not present nor incubating at time of
admission
2) Infections that appear more than 48 hours after
admission
3) Infections acquired in the hospital but appear after
discharge
4) Occupational infections among staff

Of those infected…
1 in 20 will die…

Risk of Death is 1:400 from a HAI
X

PREVALENCE OF HAIsPREVALENCE OF HAIs
Developed countries: Even with sophisticated
treatments and technologies, HAIs continues to
account for complications in 5-10% of admissions
in acute-care hospitals. HAIs are the 4th leading
cause of death in the United States today
Developing countries:
The impact of HAIs is far greater, prevalence
studies report hospital-wide infection rates usually
higher than 15%.
In developing countries, over 4000 children die of
HAIs every day. (WHO 2013)

PREVALENCE OF HAIsPREVALENCE OF HAIs
IN NEONATESIN NEONATES
The rates of bloodstream infections among
neonates in developing countries are 3–20
times higher than those reported in
developed countries.
In developing countries, approximately one-
half of patients in neonatal ICUs (NICUs)
acquire infections, and more than 52% of
affected patients die.
• Zaidi AKM, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA. Hospital-acquired
neonatal infections in developing countries. Lancet 2005; 365:1175–88.
• Editorial Commentary • CID 2009:48

CHAIN OF INFECTIONCHAIN OF INFECTION

AIM OF INFECTION CONTROLAIM OF INFECTION CONTROL
Disease transmission can be
prevented by breaking one or more of
the links in the chain of transmission.
Basic infection control measures,
based on reducing the risk of
transmission of pathogens from
known, or unknown source.

BASICS OF INFECTION CONTROLBASICS OF INFECTION CONTROL
Hospital Infection Control policies and
procedures are applied to prevent
spread of infection in hospital.
Prevention of HAIs is the responsibility of
all individuals and services providers of
the healthcare setting.
To practice good asepsis, one should
know: what is dirty, what is clean, what
is sterile and how to keep them separate.

INFECTION CONTROL PRECAUTIONSINFECTION CONTROL PRECAUTIONS
Standard Precautions
– Should be applied for ALL patients
Transmission-based Precautions*
– Contact
– Droplet
– Airborne
*Transmission-based precautions are often used empirically, according to the clinical
syndrome and the likely etiological agent

POLICIES FOR INFECTIONPOLICIES FOR INFECTION
CONTROL IN NEONATOLOGYCONTROL IN NEONATOLOGY
All Neonatal Care Units staff shall be familiar with
the infection control practices that minimized the
infection risk in the staff and patients.
Strict Hand Hygiene compliance according to WHO 5
moments of hand hygiene.
Invasive procedure shall be used cautiously and with
appropriate aseptic technique.
Handling of neonates shall be minimized.
Equipment and supplies should not be shared
between infants.
Visitor management.

The Carriers of Top Ten
Infectious Diseases Germs
In US 20,000 cases of HAIs are directly related to poor hand hygiene annually.

Ignaz Semmelweis
1815 - 1865
Hand Hygiene – Not a New ConceptHand Hygiene – Not a New Concept
Hungarian obstetrician, Ignaz
Semmelweis is considered the
father of infection control.
He noted that in his ward up to
18% of women died due to
puerperal infections K/A
“Childbed Fever” after
delivery but death rate was
less in home delivery cases.
He also noted that doctors &
medical students did not wash
their hands between patients
& after autopsies'.

Hand Hygiene – Not a NewHand Hygiene – Not a New
ConceptConcept
Maternal Mortality due to Postpartum Infection
General Hospital, Vienna, Austria, 1841-1850
0
2
4
6
8
10
12
14
16
18
184118421843 1844 18451946 18471848 1849 1850
MaternalMortality(%)
MD's Midwives
Semmelweis’ Hand
Hygiene Intervention
He enforced
hand washing
with lime water
before & after
patients contact,
and the mortality
rate in his ward
dropped to 1-2%.

Hand hygiene is the
single most
effective measureto reduce health
care-associated
infections

There are five steps in Hand
transmission
1. Presence of Germs
2. Transmission to Hands
3. Survival Germs on Hands
4. Defective Hand Hygiene
5. Cross Transmission of Germs
Hand TransmissionHand Transmission

Hand Transmission:Hand Transmission:
Step 1Step 1
Nearly 1 million skin
squames cells
containing viable
germs sheds daily
from normal skin.
Patient immediate
surroundings (bed
linen, furniture,
objects) become
contaminated
(especially by
staphylococci and
enterococci). Germs present on patients skin
and environmental surfaces
The Lancet Infectious Diseases
2006

Step 2Step 2
Nurses can
contaminate hands
with 100-1,000 CFU of
Klebsiella spp. during
“clean” activities
(lifting patients, taking
the patient's pulse,
blood pressure, or oral
temperature).
15% of nurses working
in an isolation unit
carried a median of
10,000 CFU of S. aureus
on their hands. Germ transfer on health-care workers’
hands
2006

Step 3Step 3
Following contact with
patients and/or
contaminated
environment, germs
can survive on hands
for differing lengths of
time (2-60 minutes)
In the absence of hand
hygiene, the longer
the duration of care,
the higher the degree
of hand contamination
Germs survival on hands
2006

Step 4Step 4
Insufficient amount
of soap and/or
insufficient duration
of hand hygiene
leads to poor hand
decontamination.
Use of alcohol hand
rub has been proven
more effective for
visibly clean hands.
2006
Defective hand cleansing

TYPES OF HAND HYGIENETYPES OF HAND HYGIENE
 Routine hand hygiene: Washing hands with
ordinary soap and warm water for at least
40-60 seconds, then drying with a disposable
paper towel. (CDC 2005)
 Alcohol-based hand rub 20-30 Sec
Can be used instead of hand washing, if hands
are not visibly soiled.
(CDC, 2005)

Antiseptic hand wash:
An adequate volume of antiseptic
soap should be applied to wet skin
for at least 60 seconds, and then
rinsed and dry hands with a
disposable paper towel. (CDC, 2005)

Surgical hand antisepsis should be performed prior
to all surgical procedures, with the aim of removing
all transient flora and substantially reducing resident
flora.
Duration of pre-operative surgical scrub varies
between 3 and 5 minutes, as per manufacturers
recommended guidelines. (CDC, 2005)
The antiseptic agent used must provide broad-
spectrum microbiocidal activity, act rapidly, and
persist on the skin over several hours, and ideally
also provide a cumulative effect after repeated use.

Surgical hand antisepsis should be performed prior
to all surgical procedures, with the aim of removing
all transient flora and substantially reducing resident
flora.
Duration of pre-operative surgical scrub varies
between 3 and 5 minutes, as per manufacturers
recommended guidelines. (CDC, 2005)
The antiseptic agent used must provide broad-
spectrum microbiocidal activity, act rapidly, and
persist on the skin over several hours, and ideally also
provide a cumulative effect after repeated use.

THE 5 STEPS OF HAND TRANSMISSION
Pittet D et al, Lancet Infect Dis, Oct 2006

5 MOMENTS FOR HAND HYGIENE5 MOMENTS FOR HAND HYGIENE
Clean hands before
touching a patient!
To protect the patient
against harmful germs
carried on HCW hands!
Clean hands immediately after an
exposure risk to body fluids and
after glove removal)!
To protect HCW and the health-
care environment from harmful
germs!
Clean hands immediately before
an aseptic task!
To protect the patient against
harmful germs, including the
patient’s own one! Clean hands after touching a
patient and immediate
surroundings, when leaving the
patient’s side!
To protect HCW and the health-
care environment from harmful
germs!
Clean hands after touching any object or
furniture in the patient’s immediate
surroundings, when leaving-even if the
patient has not been touched!
To protect HCW and the health-care
environment from harmful germs!

The Main Examples of this Indication DuringThe Main Examples of this Indication During
Everyday Practice of Health Care?Everyday Practice of Health Care?
Some examples may be:
Shaking hands,
Helping a patient to
move around,
Cleaning & washing of
patients,
Taking pulse, blood
pressure, chest
auscultation,
abdominal palpation

Suction of secretion
Skin lesion care,
Wound dressing,
Catheter insertion,
Opening a vascular
access system or a
draining system
Preparation of
medication/dressing
sets.

oral/dental care, giving eye
drops, secretion aspiration
Skin lesion care, wound
dressing, subcutaneous injection
Drawing and manipulating any
fluid sample, opening a draining
system,
Endotracheal tube insertion
and removal
Cleaning urines, faeces, vomit,
handling waste (bandages,
napkin, incontinence pads),
Cleaning of contaminated and
visibly soiled material or areas
(lavatories, medical or surgical
instruments)

•Shaking hands,
•Helping a patient to
move around,
•Cleaning & washing of
patients,
•Taking pulse, blood
pressure, chest
auscultation,
abdominal palpation

Some examples may
be:
•Changing bed linen
•Monitoring alarm
•Holding a bed rail
•Clearing the bedside
table

To effectively
reduce germs on
hands,
HANDWASHING
must last
40-60 secs
and should be
performed by
following all steps
illustrated in figure.

Gloves
are not
substitute
hand
washing,
it must be
done
before
putting on
gloves
and after
their
removal.

FEW FACTSFEW FACTS
A surface as small as a pinhead may contain up to
10 million bacteria.
Bacteria can double their number in 20 minutes.
We can eliminate 90% of germs through proper hand
washing.
Wet hands spread 60,400 bacteria, while dry hand can
only spread 200.
Residual moisture left on improperly dried hands is the
key factor for
Bacterial Contamination & Transmission.
Thus drying of hands is a key factor in reducing the risk

To effectively reduce
germs on hands,
ALCOHAL
HANDRUBBING
must last for 20-30
secs & should be
performed by
following all steps
illustrated in figure.
Take 2cc of gel, as less
amount dries within 15 secs
which is non compliance

PROCEDURESPROCEDURES
USEDUSED
NEONATOLOGYNEONATOLOGY
UNITSUNITS

Techniques Used for InfectionTechniques Used for Infection
ControlControl
Clean Technique
Aseptic Technique
Sterile Technique
All these techniques includes:
1. HCW
2. Patient
3. Environment
4. Instrument / Equipment

CLEAN TECHNIQUECLEAN TECHNIQUE
Clean technique is used for routine patient care
procedures; e.g., patient exam, taking pulse
temperature, BP, feeding, social touch.
1. HCW should use routine hand wash / Alcohol
hand rub before & after patient contact.
No need of developing barrier between HCW &
patient (CDC & WHO).
2. No skin preparation as patient skin is intact.
3. Environment should be clean.
4. Instrument / Equipment should cleaned or
disinfected by low level disinfectant.

ASEPTIC TECHNIQUEASEPTIC TECHNIQUE
Medical Asepsis is a set of specific practices and
procedures done under carefully controlled conditions
mostly out side operation theater, e.g., IM/IV injections.
1. HCW should use antiseptic soap for hand wash / Alcohol
hand rub before & after patient contact.
Barrier between HCW hand & patient should be created by
using gloves (Non-sterile (CDC)/ sterile).
2. Patient skin needs disinfection by short acting
disinfectant like alcohol.
3. Environment should be clean and disinfected.
4. Instrument / Equipment should disinfected by high level
disinfectant or sterile.

STERILE TECHNIQUESTERILE TECHNIQUE
Surgical Asepsis is used in procedures designed to prevent
bloodstream infection & surgical site infection, e.g.,
insertion of umbilical line, PICC, Central line, surgeries.
1. HCW should use surgical scrub with antiseptic hand
wash solution / Avaguard ( Chlorohexadine 1% w/w in
61% w/w alcohol) hand rub lotion.
Barrier b/w HCW & pt created by using sterile PPE.
2. Patient skin needs disinfection by long acting
disinfectant like Chlorohexadine, Pyodine etc.
3. Environment: Sterile field should be created.
4. Instruments / Equipments should sterile.

ASEPTIC NEONATAL CAREASEPTIC NEONATAL CARE
PRACTICESPRACTICES
Peripheral Venous Catheter ( PVC)
Insertion:
IV Therapy:
Preparation of IV fluids:
IV Therapy - Umbilical Catheters:
Administration of IV medications/drugs

PERIPHERAL VENOUS CATHETERPERIPHERAL VENOUS CATHETER
(PVC) INSERTION(PVC) INSERTION
1) Do aseptic hand wash.
2) Wear sterile gloves
1) Disinfect the skin : Clean 5 cm of the skin at the
site, working from inside to outwards, with 2%
chlorhexidine / 70% alcohol swab with friction for
at least 60 seconds.
2) Leave the site to dry for 30 sec.
i ) Do not re-palpate the vein once the skin has
been cleaned.
ii) Use no-touch technique.

Use aseptic technique.
Establish a specific area for preparation of
medications and IV fluids.
1.This area should not be used to store /
place any biologic material (e.g., blood, milk
formula etc.).
2.All prepared fluids store in fridge at 2-8 C
( Portion of fluid which is not used should
to be disposed after 24 hours max.).
IV THERAPY & PREPARATION OFIV THERAPY & PREPARATION OF
IV FLUIDSIV FLUIDS

ADMINISTRATION OF IV MEDICATIONSADMINISTRATION OF IV MEDICATIONS
–Every step must follow strict aseptic techniques
–Maintain a closed system at all times.
–Do not mix medications together.
–If medications are not compatible with IV fluid, do the
following procedure :
»Stop the IV fluid first
»Flush the cannula with saline solution
»Infuse the medication
»Flush again
»If needed infuse the second medication and flush
again.
»Restart the routine IV fluid.

IV THERAPY - UMBILICAL CATHETERSIV THERAPY - UMBILICAL CATHETERS
–Insertion of umbilical catheter: Umbilical catheters should be
inserted using sterile techniques.
–Replacement of catheters:
»Replace umbilical venous catheters only if the catheter site
is infected.
»Remove and do not replace umbilical artery catheters if any
signs of CRBSI, vascular insufficiency, or thrombosis are
present.
–Catheter-site care:
»Clean the site with an antiseptic before catheter insertion.
»Do not use topical antibiotic ointment or creams on
umbilical catheter insertion sites.
»Umbilical venous catheter can be used up to 14 days if
managed aseptically.

Expression of breast milk may be necessary when a
sick infant is unable to suck.
Breast milk shall be collected and stored aseptically.
Hands shall be washed with an antiseptic and the
milk shall be expressed into sterile containers.
All breast pump components in contact with milk
should be washed with hot soapy water after each
use and disinfected daily.
Milk must be stored in a refrigerator for no more
than 48 hours.
INFANT FEEDING MATERNALINFANT FEEDING MATERNAL
BREAST MILKBREAST MILK

INFECTION CONTROLINFECTION CONTROL
PRECAUTIONSPRECAUTIONS
IN NEONATOLOGYIN NEONATOLOGY
UNITSUNITS

BARRIER PRECAUTIONSBARRIER PRECAUTIONS
Gloves : Single-use gloves are recommended during all patient
contacts (especially with septic neonates)
Indication for wearing gloves:
Infants with infectious diarrhea, draining skin lesions, purulent
conjunctivitis, infection with rotavirus, hepatitis A, or
enterovirus.
Care of infants with respiratory viral infections in order to
reduce the risk of accidental self-inoculation.
Wear sterile gloves before performing invasive procedures and
IV fluid preparation.
Single use gloves are recommended before any patient’s
contact.
Change gloves between patients or if gloves are visibly soiled
or contaminated even when handling the same patient.

BARRIER PRECAUTIONSBARRIER PRECAUTIONS
Gowns: A gown protects the infant from contact
with the wearer’s clothing and prevents
contamination of the healthcare worker’s
exposed skin with the infant’s flora.
A gown shall be worn if a newborn is to be
handled outside the incubator where direct
contact is expected and invasive procedures are
done. A single gown shall be used for one baby.
Gowns are recommended for contacts with
infants with certain infections like MRSA.

Newborn delivered in same hospital is admitted in
MAIN-NURSERY/ MAIN NICU.
Newborn delivered in same hospital is admitted
to ISO-NURSERY or ISO- NICU. If Newborn with
clinical or laboratory evidence of infection.
Newborn delivered outside is admitted to
ISO-NURSERY or ISO- NICU in following
situations:
1. Newborn admitted from ER, OPD.
2. Newborn referred from other hospital. In this
PREVENTION OF TRANSMISSION OFPREVENTION OF TRANSMISSION OF
INFECTIONS BETWEEN NEWBORNSINFECTIONS BETWEEN NEWBORNS

SINGLE ROOM ISOLATIONSINGLE ROOM ISOLATION
To prevent the spread of communicable diseases. Newborn
with documented or suspected infection with
communicable or epidemiologically important pathogen.
1- Infants of mothers with parental varicella or
varicella, measles, tuberculosis
( Airborne Precaution).
2- Infants with infections with droplet
transmission, such as, mumps, meningitis
( Droplet Precautions).
3- Infant with MRSA, MDRO
(Contact Precaution).

No visiting time.
Visitors should be treated on a
individual basis.
View babies through the viewing
box.
If mandatory to enter in the unit
allow only parents after rounds
with hand hygiene protocol and
use protective clothing.
VISITORS MANAGEMENTVISITORS MANAGEMENT

STAFFING NORMSSTAFFING 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.

LINEN HANDLINGLINEN HANDLING
Ensure that linen handling policy is adhered
to, to prevent cross-infection.
Enough clean linen must be made available
Clean linen should be transported in covered
carts or laundry bags.
Soiled linen should be discarded into leak
proof yellow bags, taken to the laundry twice
daily.
Nappy changes should be done wearing
disposable rubber gloves to prevent heavy
contamination and transient colonization of
the hands.

WASTE DISPOSALWASTE DISPOSAL
Handling and processing infectious waste
Waste must be placed in color coded,
leakage proof bags, collected with barrier
precautions like gloves.
Soiled diapers and medical waste should be
collected 3-6 hourly.
Proper disposal of sharps to be practiced to
prevent needle stick injuries.

NEONATOLOGY UNITNEONATOLOGY UNIT
EMPLOYEE HEALTHEMPLOYEE HEALTH
Personnel allocated to work in neonatology
should be immune to rubella, measles,
polio and chicken pox.
HBV and yearly influenza vaccination
should be offered.
Proper PPE should be readily available for
use, when blood splashes and body fluids
spillages are anticipated.
Infection safety & sharp disposal to be
practiced to prevent needle stick injuries.

THANK YOUTHANK YOU
Email:
anjumhashmi61@hotmail.com
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Editor's Notes