INFECTION CONTROL IN NICU
DR RHISHIKESH THAKREDM ( Neonatology )
MD, DNB, DCH, FCPS, MB
+NEO CLINIC+27, Samarth Nagar, Aurangabad
Risk factors for infections
• Birth weight• Inadequate space• Under - staffing• Duration of hospitalization• Duration of antibiotics• Invasive procedures• Mechanical ventilation
COMMON SOURCES
• Hands• Stethoscopes• Thermometer• Suction bottles / catheters• Ambu bag / Laryngoscopes• Linen• Drugs / Fluids
PREVENTIVE MEASURES
�Hand Washing�Disinfectants�Antiseptics�Gloves / Gowns
�Housekeeping�Fumigation�Surveillance�Antimicrobials
BASIC CONCEPTS
• CLEANING :Physical removal.
• STERILIZATION :Destruction of all forms of microbial life.
• DISINFECTION :Intermediate measures between physical cleaning and sterilization.
HAND WASHING
• Types : 1. Mechanical : Use of soap & water.2. Chemical : Use of antimicrobial.
• Micro-organisms on skin :1. Resident : Coagulase –ve staph,
Acinetobacter, Corynebacterium2. Transient : Gram negative coliforms and
Staphylococcus aureus.
: PURPOSE OF HAND WASHING :
• Remove all dirt and debris.• Reduce cross contamination.• Interrupt fecal oral route of infection.• Reduce risk of hands acting as vectors.• Break link in chain of infections.• Increase image of cleanliness of health
providers
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• Remove jewelry, watch etc on hands. Roll up the sleeves.
• Rinse under running water.• Lather with soap using friction both the hands.
(Minimum 10 – 20 sec). • Frequently missed areas are nails, nail bed,
under surface of nails, thumbs, web spaces, back of fingers and hands.
• Turn off the water soap by foot or elbow.• Dry hands thoroughly.
HANDWASHING BASICS
� DO’S� Keep basins, dryers,
soap at convenient sites.
� Educate and demonstrate hand wash
� Keep vigilance� Use sink for hand wash
only and not for any other purpose
� DONT’So Do not use nail polish or
artificial nails o Do not use washed
hands for turning off the water source.
o Do not substitute hand washing by gloves.
Soaps for hand washing
Types : Liquid, Bar, Tissue impregnated
Precautions :• Disposable container.• Thorough cleansing.• No adding to the partially filled. • Keep bar soap on racks.
SOAP OR ANTISEPTICHAND WASH ?
Antimicrobial handwashing :• In high risk patients : ICU, NICU, Casualty.• Before any invasive procedure.• In immunocompromised patients.• In barrier nursing leaving an isolation room. • Before contact with patients having invasive
devices.
NoYes� Hexachlorophene
NoYes� Sodium hypochlorite
No Yes� > 50 % Alcohol
YesYes� Chlorhexidine gluconate (4%)
YesYes� Ipodophor iodine
NoYes� Plain Soap
RESIDUALEFFECT
IMMEDIATEEFFECT
AGENT
Alcohol based handwash
• ADVANTAGE– Rapid reduction in
microbial counts.– Easy to use.– Time saving.– Better compliance.– Eliminates use of
water and drying.– Does not need
sink, dryers.
• DISADVANTAGE- Skin irritation.- Sensitive to dilution
with water.- Costly.
HAND DRYING
• Wiping to personal wears / towel• Hand dryers• Autoclaved napkins• Autoclaved papers
Improving Handwashing
• Policing each other• Educating the need for hand washing .• Demonstrating the technique• Convenient placement of infrastructure
like sinks, dryers etc • Senior staff should serve as role models.
DECONTAMINATION
• CRITICAL ITEMS :Come in contact with sterile tissues
• SEMI CRITICAL ITEMS :Contact with mucosa but does not breach
• NON CRITICAL ITEMS : In the vicinity of patient
CLEANING IS MUST PRIOR TO DISINFECTION( Washing + Rinsing + Drying )
�
•All reusable equipment•Environmental surfaces•Stethoscopes, Ear specula•BP cuffs, Bed pans, Urinals
•Blood spillsMicrobial spills•Thermometers
•Semicriticalitems.Scopes, •Nebulizer cups•Nasal specula, Breast pump accessories
Phenol, Iodophors,1 : 500 bleach water
Ethanol, PhenolIodophors, 1: 64 bleach water
2% Glutardehyde6% H2O21 : 64 Bleach water
Low levelIntermediate level
High level
200ml/l 14 g/l10% 10% 10%
20 ml/l 1.4 g/l
5% 5 %
4%
Sodium hypochlorite Calcium hypochloritePhenol Formalin 4.8% Chlorxylenol(dettol)
Articles, Wares, Stainless steel, Plastic eg: Bed pan, bowls, etc
200ml/l
14 g/l
10%
20 ml/l
1.4 g/l
5 %
Sodium hypochlorite 5% Calcium hypochlorite Phenol
Floor, Walls, Sinks, Trolley, Furniture, Basins
DIRTYCLEAN AGENTARTICLE
DIRTYCLEANAGENTARTICLE
70%
70%
70%
70%
Alcohol (Ethyl / Isopropyl) Methylated spirit
Ampoule
No chemical disingection.
Syringes / Needles
Wash with detergent solution. Keep in boiling water for 10 mts
Cutlery / Crockery
Glutardehyde, Chlorhexidine + cetrimide (Savlon). (Keep for 10 mtsbefore next use
Thermometer
2.5 % 10%
2.5% 5%
GlutardehydeChlorhexidine + Cetrimide
Instruments, Cheatleforceps, Sharp instruments
Gloves / Gowns
• Does not replace handwashing• Sterile gloves :
�Open wounds�Invasive procedures
• Non sterile gloves : �Handling of secretions / excretions.
• Sterile gowns for invasive procedures.
HOUSE KEEPING ( Daily )
• Thorough cleaning & scrubbing• Wet mopping of floors• Mopping of dust bins / plastic bags• Nursery slippers• Cleaning of sinks• No dry dusting & sweeping• Open care system / Stethoscope / Non critical
appratus / Hood / Mask / Tubing / Utensils
ISOLATION
• Acute gastroenteritis• Draining abscesses• Congenital CMV, Rubella, Chickenpox,
Syphilis, Tetanus• Babies with meningitis / pneumonia do not
need isolation• Cohort babies with documented sepsis
Antimicrobial Prophylaxis
• IVIG• GM – CSF• Colistin / Neomycin• Nystatin / Clotrimozole• Eye drops• Umbilical cord• Anti - fungal
FUMIGATION
• No additional benefit if good house keeping & aseptic routines
• Definitely following an epidemic• 500 ml formaldehyde ( 40 % ) + 250 g
KMNO4 : 30 m3 for 12 hours• Shut off central O2 / Suction / Vent outlets
/ AC vents / Doors / Windows.• ? UV radiation
Drug Preparation
• Change cannula 48 – 72 hrs• Change infusion set every alternate day• Use disposable syringe / needle• Wipe neck of ampoule / inj. water with alcohol• Top of the vial be wiped with alcohol• Do not stock open ampoules• Use new disposable needle each time fluid is
withdrawn
Feeding Precautions
• Wash utensils with soap / water daily.• Preferably autoclave / boiled for 15 mts• Keep the formulas in dry place & intact• Discard unused feeds immediately• Do not reuse same spoon / syringe• Shift to breast milk at the earliest
What can be done ?
• Do not bathe baby in hospital• Restrict handling babies to minimum• Ensure hand washing strictly• Ensure nails are short / no nail polish• Use gauze underneath while collecting blood• Limit traffic in nursery• Involve mother in baby care at earliest• Cohort infected babies together• Ensure cleaning before disinfection• Watch for ants, flies, and cockroaches.
Practical Tips
• Screen for fungus weekly in urine in preterms
• Use freshly prepared disinfectant solutions• Restrict handling the babies to minimum• Determined & conscious efforts for
asepsis• Involve mother in baby care at the earliest• Use breast milk for feeding
CONCLUSIONS
• Hand washing & common sense are the best disinfectants.
• Breast milk is the best antidote.• Mother is the best nurse of the baby.• Masterly inactivity on our part is the key.• Conscious, determined efforts & health
education is our moral responsibility.
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