Preventing infection transmission in NICU-key principles to guide

policies

DrJKumuthaChennai

Health Care Associated Infection (HCAI)

bullLow birth weight most important risk factor directly linked to nosocomial infection

bullSurveillance report from CDC from 2006 to 2008

In babies lt 750g - incidence of CLABSI and umbilical catheter infection was 49 and 57 respectively

bull In birth weights gt 2500g -incidence of CLABSI and umbilical catheter infection was 12 and 10 respectively

HCAI is one that was neither present nor incubating at the time hospital admission

Vulnerability

bull NICU babies with less diverse gut microbial flora- pathogenic bacteria colonization - epithelial translocation - sepsis

bullSkin GI tract and nasopharynx

bullNICHD - Western scenario Gram positive bacteria espStaphylococci common

bullDeveloping countries- Klebsiella AcinetobacterEcoli Pseudomonas common More MDR

bullDeNIS Trial -13530 neonates High incidence of MDR was seen in Acinetobacter(82) Klebsiella (54) E Coli (32) MRSA(38) MRSE(61)

bullViral agents- Influenza Parainfluenza Rhinovirus

Strategies followed

bull Nursery design

bull Policy on visitors

bull Staffing education amp accountability

bull Hand hygiene

bull Cautious insertion of intravenous catheters

bull Bundle approach towards CLABSI and VAP

bull Antibiotic stewardship

bull Biomedical waste management

bull House keeping

Strategies followed -are these evidence

based

bull Interventions incorporated into standards of care may or may not be always evidence based

bull Most extrapolated from adult studies

bull Very few studies in NICUs on these policies

bull NICU should maintain the belief that HCAI are preventable and unacceptable

bull Understanding of infection control strategies- first step in preventing infection

NICU design

Adequate space

A sink within 20 feet of every bed

An isolation bay supporting at least 2 septic babies

Hand washing area a separate area for gowns and disposable outside NICU

A good design is of no use with bad policies and good policies can still make a bad design work

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Health Care Associated Infection (HCAI)

bullLow birth weight most important risk factor directly linked to nosocomial infection

bullSurveillance report from CDC from 2006 to 2008

In babies lt 750g - incidence of CLABSI and umbilical catheter infection was 49 and 57 respectively

bull In birth weights gt 2500g -incidence of CLABSI and umbilical catheter infection was 12 and 10 respectively

HCAI is one that was neither present nor incubating at the time hospital admission

Vulnerability

bull NICU babies with less diverse gut microbial flora- pathogenic bacteria colonization - epithelial translocation - sepsis

bullSkin GI tract and nasopharynx

bullNICHD - Western scenario Gram positive bacteria espStaphylococci common

bullDeveloping countries- Klebsiella AcinetobacterEcoli Pseudomonas common More MDR

bullDeNIS Trial -13530 neonates High incidence of MDR was seen in Acinetobacter(82) Klebsiella (54) E Coli (32) MRSA(38) MRSE(61)

bullViral agents- Influenza Parainfluenza Rhinovirus

Strategies followed

bull Nursery design

bull Policy on visitors

bull Staffing education amp accountability

bull Hand hygiene

bull Cautious insertion of intravenous catheters

bull Bundle approach towards CLABSI and VAP

bull Antibiotic stewardship

bull Biomedical waste management

bull House keeping

Strategies followed -are these evidence

based

bull Interventions incorporated into standards of care may or may not be always evidence based

bull Most extrapolated from adult studies

bull Very few studies in NICUs on these policies

bull NICU should maintain the belief that HCAI are preventable and unacceptable

bull Understanding of infection control strategies- first step in preventing infection

NICU design

Adequate space

A sink within 20 feet of every bed

An isolation bay supporting at least 2 septic babies

Hand washing area a separate area for gowns and disposable outside NICU

A good design is of no use with bad policies and good policies can still make a bad design work

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Vulnerability

bull NICU babies with less diverse gut microbial flora- pathogenic bacteria colonization - epithelial translocation - sepsis

bullSkin GI tract and nasopharynx

bullNICHD - Western scenario Gram positive bacteria espStaphylococci common

bullDeveloping countries- Klebsiella AcinetobacterEcoli Pseudomonas common More MDR

bullDeNIS Trial -13530 neonates High incidence of MDR was seen in Acinetobacter(82) Klebsiella (54) E Coli (32) MRSA(38) MRSE(61)

bullViral agents- Influenza Parainfluenza Rhinovirus

Strategies followed

bull Nursery design

bull Policy on visitors

bull Staffing education amp accountability

bull Hand hygiene

bull Cautious insertion of intravenous catheters

bull Bundle approach towards CLABSI and VAP

bull Antibiotic stewardship

bull Biomedical waste management

bull House keeping

Strategies followed -are these evidence

based

bull Interventions incorporated into standards of care may or may not be always evidence based

bull Most extrapolated from adult studies

bull Very few studies in NICUs on these policies

bull NICU should maintain the belief that HCAI are preventable and unacceptable

bull Understanding of infection control strategies- first step in preventing infection

NICU design

Adequate space

A sink within 20 feet of every bed

An isolation bay supporting at least 2 septic babies

Hand washing area a separate area for gowns and disposable outside NICU

A good design is of no use with bad policies and good policies can still make a bad design work

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies followed

bull Nursery design

bull Policy on visitors

bull Staffing education amp accountability

bull Hand hygiene

bull Cautious insertion of intravenous catheters

bull Bundle approach towards CLABSI and VAP

bull Antibiotic stewardship

bull Biomedical waste management

bull House keeping

Strategies followed -are these evidence

based

bull Interventions incorporated into standards of care may or may not be always evidence based

bull Most extrapolated from adult studies

bull Very few studies in NICUs on these policies

bull NICU should maintain the belief that HCAI are preventable and unacceptable

bull Understanding of infection control strategies- first step in preventing infection

NICU design

Adequate space

A sink within 20 feet of every bed

An isolation bay supporting at least 2 septic babies

Hand washing area a separate area for gowns and disposable outside NICU

A good design is of no use with bad policies and good policies can still make a bad design work

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies followed -are these evidence

based

bull Interventions incorporated into standards of care may or may not be always evidence based

bull Most extrapolated from adult studies

bull Very few studies in NICUs on these policies

bull NICU should maintain the belief that HCAI are preventable and unacceptable

bull Understanding of infection control strategies- first step in preventing infection

NICU design

Adequate space

A sink within 20 feet of every bed

An isolation bay supporting at least 2 septic babies

Hand washing area a separate area for gowns and disposable outside NICU

A good design is of no use with bad policies and good policies can still make a bad design work

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

NICU design

Adequate space

A sink within 20 feet of every bed

An isolation bay supporting at least 2 septic babies

Hand washing area a separate area for gowns and disposable outside NICU

A good design is of no use with bad policies and good policies can still make a bad design work

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Floor space and Ventilation

bull 150 sq feet for care + 100 for supportive

bull Clearance of 8 feet between beds

bull Air temperature of 25-26deg C

bull Relative humidity of 30-60

bull Six air changes per hour

bull Ventilation- Filtered air (HEPA filter- 03 micron)

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Not only at entry but also each care bay

Within 6 meters of each bed

Not closer than 3 meters from bed

Sinks 24 inches wide x 16 inches front to back x 10 inches deep to avoid splashing

Elbow operated taps only

Handwashing areas

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

CeilingWall and Floor surfaces

bull Minimal No crevices

bull Easily cleanable

bull Floor should be durable with reflectance lt40

bull Avoid wooden flooring furniture

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Human resources in NICU

Head of the unit-1

Senior doctors-4

Junior doctors registrars-4

Nurses 1 per 2 beds

Supervisory Education Administrative cadre

Infection control nurse

Lactation counsellor

Biomedical engineer

Under staffing

Equitable distribution

Back up for absence amp

emergencies

Overcrowding

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Hand Hygiene

bull Prevents direct and indirect

transmission

bull Removes resident and transient

microbes

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Hand Hygiene

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Hand Hygiene

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Level of Evidence

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Hand wash amp rub technique

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Breast milk feeding

bull Narayanan et al 1984 in 226 high risk neonates - The infection rate in the group given pasteurised human milk and formula (33) was significantly higher than the rates in the groups given raw human milk (10middot5) pasteurised human milk (14middot3) and raw human milk and formula (16)

bull Hylander et al human milk feeding reduced incidence of sepsis meningitis compared to human milk feeds ( OR 043 95CI 023 to 081)

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

bullSchanler et al 2005 studied 243 lt30 week neonates receiving donor milk (DM) preterm formula(PF) and MOM Compared with groups DM and PF group

bullMOM had fewer episodes of LOS andor NEC and total infection-related events and a shorter duration of hospital stay

bullO Fidel-Romon et al 1995-2001 studied 385 VLBW infants Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants

Breast milk

feeding

Effective

intervention for

prevention of

transmission

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

RCT -EPI

Exclusively human milk diet

(donor human milk and human

milk based human milk fortifier)

Vs bovine milk-based preterm

formula

Lower incidence of NEC (21

versus 3 p = 008) and surgical

NEC (17 Vs 0 p = 004)

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Early enteral feeding

Nine trials - 754 very preterm or VLBW infants

Early trophic feeding (milk volumes up to 24 mlkgday introduced before 96 hours) versus a comparable period of enteral fasting in very

preterm or very low birth weight infants

Meta-analysis did not detect a statistically significant effect on the incidence of NEC

(risk ratio 107 95 confidence interval 067 to 170)

bull Supports microbial flora

bull Improved feeding tolerance better weight gain improved bone mineralization reduced systemic sepsis and shorter hospital stay

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Cochrane Review ndash2014Rapid advancement

bull 9 RCTs - 949 infants

bull Preterm infants with BW 1000 and 1500 g

bull Fewer in extremely preterm ELBW or GR

bull Daily increments of 15 to 24 mLkg Vs

30 to 40 mLkg

bull Slow feeds advancement delayed the

establishment of full enteral nutrition by 1 to

5 days and increased the risk of invasive

infection

bullFast increment did not increase the risk of NEC (pooled RR 097 (95 CI 054 174) orbull Mortality (pooled RR 141 (95 CI 081 274)bull Fast daily increment group regained birth weight and reached full feeds faster (LOE 1b and 2b)

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Blood stream infection prevention

Line insertion

bull Choose a good site that limits contamination

bull Meticulous hand wash gown sterile gloves cap and mask

bull Swab with 70alcohol ndash 10 povidone iodine (PI) - 70 alcohol

bull Chlorhexidine gluconate (CHG) associated with reduced infection rate

bull Neonate - concern of dermatitis

bull Garland JS et al a pilot study on 48 neonate comparing CHG and PI No significant difference in dermatitis in both groups and no difference in catheter tip colonization and blood stream infection

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Blood stream infection prevention

bullInfection results from microbe entry via skin at insertion site due to catheter hub colonization and repeated manipulation

bullMinimize blood sampling by batching

bullPrepping hubs with antiseptic

bullHub design with antiseptic chamber

bullNeedless system

bullLimiting catheter lumens and avoiding 3 way stopcocks

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Blood stream infection prevention

bull Duration of central lines

bull To be removed as early as possible when not in need

bull Maximum duration of 21 days after which colonization rate increases

bull Removal during positive blood culture

bull Vancomycin prophylaxis

bull Reduced CLABSI rate

bull Concern on vancomycin resistance and exposure

bull Not recommended

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

CLABSI bundle

bullHand hygiene

bullMaximal barrier protection

bullSkin disinfection as per unit protocol

bullSterile field for procedure

bullTransparent dressing and change when contaminated with blood

bullDo not break line continuity for antibiotics

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

VAP Bundle

bullHand hygiene

bullAseptic precaution

bullNo routine use of saline

bullHead elevation 30 degrees

bullOptimum humidification

bullMEN - expressed breast milk - MOM

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Framing antimicrobial policy

bull Choice of antibiotic driven by unit culture patterns and antibiogram

bull Avoid regimens which increase strain resistance

bull Reduce over usage of meropenam amp vancomycin

bull Stop antibiotics at 48 hours if cultures are negative

bull Judicious Antifungal prophylaxis for ELBWs

bull Hand book e book

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Housekeeping

bullClean floors in each shift

bullWalls everyday

bullNo dry dusting only wet cleaning

bullChange IV sets daily

bullNo stock solutions

bullEquipment daily Terminal cleaning

bullTraining

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Rules keep changing ndash Updating essential

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Surveillance

bullMonitoring infections in unit conducting periodic surveys identifying patterns of flora and cultures

bullRoom air Surfaces water amp Equipment

bullHealth care worker screening- Entry amp Periodic

bullMonitoring and Audits

bullTerminal deep cleaning

bullFumigation no role

bullOutbreak investigation

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Probiotics

bull In babies born at term by vaginal delivery the gut is colonized with probiotic bacteria from the mother such as lactobacilli and bifidobacteria which are crucial to the development of the intestinal mucosal immune system

bull Preterm neonates have abnormal intestinal colonization often with pathogenic bacteria and have low numbers of probiotic bacteria

bull ProPrems study 1099 preterm VLBW infants randomized to receive a probiotic combination of Bifidobacterium infantis Streptococcus thermophilus and Bifidobacterium lactis or placebo No significant difference was found in definite late onset sepsis or all cause mortality but the rate of Stage 2 necrotizing enterocolitis was reduced (2 versus 44)

bull The Probiotics in Preterm Infants Study Collaborative (PiPstrial) in the UK recruited 1315 infants - 650 administered the probiotic Bifidobacteium breve BBG-001 There was no significant difference in the incidence of LOS in the probiotic patients (11) versus the controls (12) and the rates of NEC were also similar

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Probiotics

bullCochrane metanalysis in 2014 16 eligible trials with 5338 patients concluded that probiotic supplementation did not result in statistically significant reduction of LOS in preterm infants

bull A recent metanalysis of 37 randomized controlled trials with 9416 patients showed that probiotics significantly reduced the risk of LOS (139 versus 163 number needed to treat =44)

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Personal protection equipment (PPE) universal gloving

bull PPE to be used whenever a health care worker (HCW) comes in contact with baby infected with a pathogen or etiological agent unknown

bull To prevent potential occupational exposure

bull Sterile glove for invasive procedure non sterile glove for handling patients

bull No evidence for universal gloving policy Studies shown that it reduced hand washing compliance

bull Ng PC et al demonstrating combined hand washing and universal gloving reduced infection 28 fold

bull Hand washing - alcohol rub - gloving- alcohol rub -handling patient- alcohol rub - deglove

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies that lack evidence

bullGowning before NICU entry

bullTan SG et al 1995 1 year prospective study to study nosocomial infection rates during gowning period and no gowning periods No difference in infection rate

bullRoutine gowning is not cost effective Emphasis should be on hand washing

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies that lack evidence

Intravenous immunoglobin

bull Cochrane systematic review- Nineteen studies

bull 5000 preterm andor LBW infants

bull Statistically significant reduction (p = 002) in sepsis RR [085 (95 CI 074 098)] and RD [-003 (95 CI 000 -005)] NNT 33 A statistically significant reduction was found for any serious infection one or more episodes when all studies were combined [RR 082 (95 CI 074 092) RD -004 (95 CI -002 -006) NNT 25 (95 CI 167 50)

bull There were no statistically significant differences for mortality from all causes mortality from infection incidence of NEC BPD and IVH or length of hospital stay

bull Not recommended for routine use

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies that lack evidence

bullVentilator circuit change

Long et al 1996 RCT on 447 patients- 1 vs 3 circuit changes week No change in incidence of VAP

bullRoutine Increased frequency of tracheal suctioning

bullClosed tracheal suctioning

bullCordero et al 2000 175 LBW infants Open Vs closed tracheal suctioning Though there was statically significant difference in rates of colonization no difference in VAP sepsis BPD mortality and length of stay

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies that lack evidence

bullEmmolient use to maintain skin integrity

bullCleminson J 2016 Cochrane meta-analysis of 18 primary publications involving 3089 infants did not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high middle or low income settings

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Mothers amp Family in NICU

bull Family-Centered Care to Complement Care of Sick Newborns -

Randomized controlled trial

bull Tertiary referral nursery (October 2010 to March 2012) 295 neonates

randomized at the time of hospitalization in neonatal intensive care unit

bull Incidence of nosocomial episodes of sepsis was not different between

groups (incidence rate difference 074 95 CI -421 56 P = 076) There

was no significant difference in nosocomial infection rate between the

two groups

Verma A Maria A Pandey RM Hans C Verma A Sherwani F

Strategies to be followed

bull Nursery design - To be coupled

bull Policy on visitors - Questionable

bull Hand hygiene ndash Yes YES

bull Breast milk ndash Yes YES

bull Staffing education amp accountability ndashYes

bull Aseptic insertion of intravenous catheters -YES

bull Bundle approach towards CLABSI and VAP -YES

bull Antibiotic stewardship ndashYES

bull House- keeping -YES

bull Biomedical waste management -YES

THANK YOU

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