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 What we learnt How we managed Hand washing Rotavirus MRSA What we learnt How we managed Hand washing For future

TBH Neonatology WARD WHO NUMBER A9 ICU ≥1000g ≥28weeks 8 G2 Inborn 44 A9 E Stable overflow G2 14 G1 “out born” Ex - ICU 36

2 Outbreaks of Infection Rotavirus MRSA

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

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

Rotavirus - Virology Double stranded RNA Group A – infection in humans Two outer protein layers: VP7 = G genotypes VP4 = P genotypes TBH rotavirus = G12 P6 VP 7 and VP 4 - are the 2 major antigens of this virus Group A Rotavirus are classified accordingly, for eg. the strain we encountered was identified as G12P [6] 7

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

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

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

Rotavirus at TBH

Rotavirus – Risk Assessment Number % Admitted 307 Loose stools 94 30.6 Rotavirus + 58 18.9

Rotavirus

Legend Rotavirus positive Rotavirus contact Clean

29 May 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

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

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

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

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

Rotavirus – UIPC Actions 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

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

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

Standard Operating Procedure 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 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

Personal Protective Equipment Procedure Mask Gloves Apron Nappy change √ NG feeds Medication Insert IV Draw blood Hold baby Examine baby Do dressing Wash baby

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.

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

11 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

20 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

20 June WARDS G1 & G2 CLOSED TO NEW ADMISSIONS

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

23 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

10 July 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

Rotavirus Literature Tested Positive Symptomatic 1037 164 (16%) 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 Tested Positive Symptomatic 1037 164 (16%) 94 (57%)

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

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

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

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

Rotavirus - G genotypes This slide illustrates the distribution of circulating Group A rotavirus amongst children in European countries. It demonstrates very nicely the high prevalence of G1,G2,G3 and G4 strains. ( Therefore one can also understand why these strains are covered by the new rotavirus vaccine rotateq. I would like to use this opportunity to show you the novel G12 strain. Although rare, it is occuring more frequenty and also especially in newborn nurseries. We have encountered the G12P[6] in our unit. Grey et al. JPGN 2008 39

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

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

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

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

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)

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

MRSA Removed UVC Vancomycin IV Bactroban (Mupiricin) topical

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

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

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

MRSA – Contact precautions Hand disinfection Wash Alcohol spray Gloves Masks not needed Isolate Procedure Gloves Apron Nappy Yes NG feed Meds Insert IV Draw blood Hold baby Exam baby Dressing Washing

MRSA – Treatment of Carriers Nasal (8 hourly) Mupirocin (bactroban) Chlorhexidine nasal ointment Hair 4% Chlorhexidine gluconate – alternate days Skin 4% Chlorhexidine gluconate soap - daily

MRSA – Treatment of Neonatal Carriers Skin decontamination - neonate Daily wipe the body and hair with 0.25% aqueous chlorhexidine (NOT 4% - skin burns) Do not rinse or wipe off – watch temperature Disposable cloth

MRSA – Treatment of Neonatal Carriers Change bed linen daily after each day’s chlorhexidine application. Follow this procedure for 7 days. Repeat screening of baby 72 hours after stopping skin decontamination. Bactroban resistance and worry of nasal obstruction & apnoea – NO nasal treatment

HAND WASHING

What does the Evidence show? Problem  Tertiary hospital, Argentina Low hand washing compliance High nosocomial infection rate Intervention Education, training & performance feedback Results Compliance improved from 23.1% to 64.5% Infection rate improvement of 41.3% Am J Infect Control, 2005; 33: 392-397

CDC Handwashing Guidelines, 2002 Visibly soiled Before & after patient contact Before & after gloves Invasive procedures Surgical invasive procedure – nail brush Alcohol-based hand sprays No artificial nails or polish MMWR, 2002; 51: 1-56

Dissemination & Impact on Infection Rates Guidelines published in 2002 Implementation & compliance 44.2% DID NOT follow guideline recommendations Compliance - 24% & 89% (mean 56.6%) Implementation needs to be driven within the ward & management Am J Infect Control, 2007; 35: 666-675

Implementation CDC guidelines Infection Site Pre – Guidelines Rate:1000 Post – Guidelines P value Central Line Assoc Blood Stream Infection 5.54 4.76 <.001 Ventilator Assoc Pneumonia 6.16 4.79

Sepsis rates dropped by 30% during time of Rotavirus outbreak TBH Infection Rates Sepsis rates dropped by 30% during time of Rotavirus outbreak

Summary Infection not uncommon in neonatal nurseries Overcrowding increase risk Staff shortages increase risk

Summary Infecting organisms “hardy” Difficult to eradicate May be “dormant” Carriers may be asymptomatic often unaware

How do we “Better Our Best & Beat the Odds”? Awareness Prevention

Better Our Best & Beat the Odds Hand washing > 15sec Hand spray – before & after 70% alcohol 0.5% chlorhexidine Glycerine Proper disposal of waste Proper cleaning of equipment

Better Our Best & Beat the Odds Education Mothers Medical staff (Doctors, nurses, other) Cleaning staff Administrative staff (superintendents/CEO)

Better Our Best & Beat the Odds Limit / monitor use of antibiotics Peripheral line for antibiotics Limit access of central lines – STERILE Limit use of topical antibiotics

Better Our Best & Beat the Odds Protocols Involve other colleagues O&G UIPC Microbiology & virology

Better Our Best & Beat the Odds Involve management Help with staff Help with disposables Help with ward closures

Their Future is in Our Hands  Thanks to: Sr Aucamp Dr Post TBH IPC team TBH neonatal team