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

3. 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

4. 2 Outbreaks of Infection
Rotavirus
MRSA

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
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

8. Rotavirus - diagnosis Diagnosis Antigen test
Strains: not commonly done
Enzyme immunoassay
RT PCR

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 Total Cases – 58 29 May – 30 June 2008
Symptomatic
Positive lab result

11. Rotavirus at TBH

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

13. Rotavirus

14. Legend
Rotavirus positive
Rotavirus contact
Clean

15. 29 May 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

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

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. 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

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

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

23. 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

24. 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

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

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. 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

28. 11 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

29. 20 June 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

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

33. 10 July 2008 A9 Ext A9 ICU G2 G1 J5 Room 5 Room 4 Room 6 R7 R8 Room 9

34. 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%)

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
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

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 If resistance (GRSA or GISA)
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
Procedure
Gloves
Apron
Nappy
Yes
NG feed
Meds
Insert IV
Draw blood
Hold baby
Exam baby
Dressing
Washing

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

52. 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

53. 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

54. HAND WASHING

55. 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:

56. 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

57. 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:

58. 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

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

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

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

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

63. 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

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

65. 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

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

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

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