Download neonatal sepsis - Kenyatta National Hospital

NEONATAL SEPSIS
AND
PREVENTION
A PRESENTATION BY
DR. GACHERI NYAMU-MUTUA
CONSULTANT PAEDIATRICIAN/NEONATOLOGIST
KENYATTA NATIONAL HOSPITAL
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.
ETIOLOGY
Common organisms identified:• Coagulase negative staphylococcus aureus.
• Escherichia coli
• Strep.pneumoniae
• Listeria monocytogenes
• Klebsiella pneumoniae
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.
LATE ONSET NNS
• Occurs 5-7 days after birth
• Usually due to organisms thriving in the
external environment.
• Presents with septicaemia, pneumonia or
meningitis.
• Risk of exposure to late nns:1. Lack of hand hygiene by health care givers
2. Low birth weight
3. Lack of initiating breast feeding
4. Superficial infections (Pyoderma:umbilical sepsis)
5. Aspiration of feeds
6. 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)
CLINICAL FEATURES
Manifestations of neonatal sepsis are usually
VAGUE and demand a HIGH INDEX OF SUSPICION
for early diagnosis.
Most common manifestations include:1. Respiratory distress in early onset neonatal sepsis
2. Altered feeding behavior in a well established
feeding newborn (aspirate; vomiting etc)
3. Baby who was active/feeding suddenly or
gradually becomes lethargic, inactive or
unresponsive and refuses to suckle
4. Temperature instability
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.
Current situation
• Mortality is high in first 24-48hrs of life (2445%)
• 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%)
NB: The chart has disregarded co-morbidities
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.
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 .
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
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.
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.
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.
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 microorganisms and must be handled in very
aseptic ways
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.
• 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.
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.
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)
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.
GOWNS
• Several studies have shown no benefit in
reduction of neonatal infectious in gowning
and it is not cost-effective.
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
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 alcoholbased hand rub (ABHR)
• Decontaminate hands before and after each
patient.
• Decontaminate hands after contact with
inanimate object in the immediate vicinity of
the patient.
• 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
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.
Use of Aseptic or alcohol based handrub
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.
Hospital
Environment
NICU
Environment
Immediate Care
Environment
NICU Environment
Clean hands at initial entry
Immediate Care Environment
Clean hands on each entry into the
space and on leaving the space
Neonate
Environment
Neonate Environment
Clean hands at each entry to the space
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
• Way forward cont.
– Decongest the unit ( babies, mothers, staff,
caregivers)
– Proper handling of babies during referrals
– Adherence to the unit policies laid down
THANK YOU!
Questions? Comments?