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Infection Outbreaks in a Neonatal Nursery

Infection Outbreaks in a Neonatal Nursery. Dr Sandi Holgate Division of Neonatology Department of Paediatrics and Child Health Tygerberg Children’s Hospital & University of Stellenbosch. Overview . Outbreaks Rotavirus MRSA What we learnt How we managed Hand washing For future.

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Infection Outbreaks in a Neonatal Nursery

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  1. Infection Outbreaks in a Neonatal Nursery Dr Sandi Holgate Division of Neonatology Department of Paediatrics and Child Health Tygerberg Children’s Hospital & University of Stellenbosch

  2. Overview • Outbreaks • Rotavirus • MRSA • What we learnt • How we managed • Hand washing • For future

  3. TBH Neonatology

  4. Rotavirus MRSA 2 Outbreaks of Infection

  5. Rotavirus – Clinical • “Self limiting” diarrhoea & vomiting • Infants & young children (<2yr) • Adults – mild • Immunity incomplete

  6. Rotavirus - Epidemiology • Seasonal: winter • Incubation period 2-4 days • Spread • Faecal – oral • Air borne • Stable in environment

  7. Rotavirus - Virology • Double stranded RNA • Group A – infection in humans • Two outer protein layers: • VP7 = G genotypes • VP4 = P genotypes • TBH rotavirus = G12 P6

  8. Rotavirus - diagnosis • Diagnosis • Antigen test • Strains:not commonly done • Enzyme immunoassay • RT PCR • www.cdc.gov/rotavirus

  9. Rotavirus – TBH Cases • Premature baby • Loose stools • No other features of NEC • Sent sample for virology screen • ROTAVIRUS + • 2nd then 3rd baby with loose stools • Both Rotavirus positive

  10. Rotavirus – at TBH • Duration • 29 May – 30 June 2008 • Total Cases – 58 • Symptomatic • Positive lab result

  11. Rotavirus at TBH

  12. Rotavirus – Risk Assessment

  13. Rotavirus

  14. Legend Rotavirus positive Rotavirus contact Clean

  15. 29 May 2008

  16. Overcrowding 30cm between incubators Movement of babies Progress through the wards Transfer to other wards Rotavirus – UIPC findings

  17. Rotavirus – UIPC findings • Staff shortage • Couldn’t dedicate • Agencies • Understanding of precautions • Waste bins not emptied regularly

  18. Rotavirus – UIPC findings • Shared utensils (feed preparation) • Shared equipment • Supplies overstocked in patient rooms

  19. Rotavirus – UIPC Actions • Main suggestion was: • WARD CLOSURE • “Couldn’t” - full labour ward & tertiary referral centre

  20. Document “SOP” Outbreak warning notices Surveillance Daily progress reports Monitoring isolation precautions Training staff & parents Availability of PPE Assessment of ward ventilation Checklist for ward cleaning Rotavirus – UIPC Actions

  21. Standard Operating Procedure • Patients • Waste • Sharps • Equipment • Environment • Parents • Health care workers

  22. Patients Closed incubators Minimal movement Waste Infectious Non infectious Standard Operating Procedure

  23. Sharps Equipment No sharing Labelling of incubators Environment Clean (+) rooms last Separate equipment New cloths daily Soap & water – damp dusting surfaces & floors Wipe surfaces 95% ethyl alcohol Standard Operating Procedure

  24. Parents Hand washing & spray Masks Reporting loose stools Their baby only Pamphlets Limit visitors Health Care Workers Limit staff exposure Limit students Hand washing & spray PPE per procedure Standard Operating Procedure

  25. Personal Protective Equipment

  26. Assessment of Ward Ventilation – smoke test • No proper mechanical ventilation in rooms. Some air outlets closed. • Circulation of air b/w the incubators - ↑ likelihood of aerosol transmission of the rotavirus. • Smoke particles remained suspended in far corners of the rooms, ↑ the risk of aerosol transmission in these areas. • There was no real movement of air from the rooms into the passages.

  27. Rotavirus Outbreak in Progress Please report to nurse in charge upon entering the ward. UIPC, June 2008 Rota Notices

  28. 11 June 2008

  29. 20 June 2008

  30. 20 June • WARDS G1 & G2 CLOSED TO NEW ADMISSIONS

  31. Rotavirus – Morbidity & Mortality • Only symptomatic babies screened • Loose stools • Dehydration • Abdominal distension • 3 deaths • 2 NEC – possibly related • 1 epidermolysis bullosa - unrelated

  32. 23 June 2008

  33. 10 July 2008

  34. Rotavirus Literature • Chen et al. J of Formosan Med Assoc Taiwan, 1997, Nov 96(11):884-9 • 91 same strain • Different strain to 64 infants/toddlers in Paeds wards • Eradicated 8 months after onset

  35. Rotavirus Literature • Infection Control & Hospital Epidemiology; Nov 2002, Vol 23, No 11, p665. Widdowson et al • Attack rate 40% • Un-gloved NG feeds a significant risk factor • Persistence on surfaces despite cleaning • Mothers with high antibodies not necessarily protective

  36. Rotavirus Literature • Widdowson et al: • Outbreak ended with in 7 days of WARD CLOSURE, proper disinfection and gloved NG feeds

  37. Rotavirus Literature • Ramani et al: Journal of Medical Virology 80: 1099 – 1105 (2008) • Difference in clinical & epidemiology in neonates vs older children • Neonates: • Unusual strains • Single strains persist long time • High transmission, less virulence

  38. Rotavirus Literature cont • Ramani et al: Journal of Medical Virology 80: 1099 – 1105 (2008) • Virus detected in environment of ⅓ of neonates • Need STANDARD PROTOCOLS for cleaning, procedures etc

  39. Rotavirus - G genotypes Grey et al. JPGN 2008

  40. METHACILLIN RESISTANT STAPH AUREUS - Background • Staph infections common in hospitals • MRSA previously “hospital pathogen” • Recently “community acquired” MRSA • Equally – if not more - pathogenic

  41. MRSA - Microbiology • Resistant to: • Cephalosporins • Cloxacillin • Erythromycin • Tetracyclines • Fusidic acid • Gentamicin

  42. MRSA • Treatment of choice = Gylcopeptide • Vancomycin • Teichoplanin • If resistance (GRSA or GISA) • Very difficult to treat • Linezolid • Rifampicin

  43. MRSA - Reservoirs • Nose and groin • Skin lesions • Dust and enviroment • Linen and bed clothing • Clinical equipment

  44. MRSA – route of spread • Hands of staff or mothers or other patients • Skin scales or excoriating skin lesions • Air and environment (unusual) • Equipment - clinical and non-clinical (rare)

  45. Methacillin Resistant Staph Aureus • TBH index case: • Term IDM with hypoglycaemia • UVC for 15% Dextrose infusion • Omphalitis • Cultured MRSA

  46. MRSA • Removed UVC • Vancomycin IV • Bactroban (Mupiricin) topical

  47. MRSA • Septic arthritis • “GISA” cultured… • Glycopeptide Intermediate Sensitivity Staph Aureus

  48. MRSA – UIPC investigation • Incorrectly given antibiotic doses • Low vancomycin trough levels • Overuse bactroban – resistance • “Incorrect” hand spray

  49. MRSA – Screening • Sterile swab – dipped in sterile saline • Patients • Esp if on antibiotics or steroids • Wounds, skin lesions • Urine catheters, venous access lines • Staff • Nose & 1 of: • Groin • Axilla • Hair line

  50. MRSA – Contact precautions • Hand disinfection • Wash • Alcohol spray • Gloves • Masks not needed • Isolate

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