NICU Outbreaks NICU Outbreaks

Nawaf M. Al-DajaniNawaf M. Al-Dajani

Disclosure Disclosure

Infection Components Infection Components

Host

Organisms Environment

MRSAMRSA

0

10

20

30

40

50

60

70

1980 1985 1990 1995 2000 2005

%

Infection Rates in NICUs Infection Rates in NICUs

Up to 6-38 (25%) per 100 admissions.

8.9 to 62 per 1000 patient days.

Up to 6-38 (25%) per 100 admissions.

8.9 to 62 per 1000 patient days.

No. approved antibioticsNo. approved antibiotics

0

2

4

6

8

10

12

14

16

83-87 88-92 93-97 98-02 2003-2007

Outbreak: An excess over the usual level of a

disease within geographic area in certain period.

• Epidemic curve:

• Base line data:

Outbreak: An excess over the usual level of a

disease within geographic area in certain period.

• Epidemic curve:

• Base line data:

0

0.5

1

1.5

2

2.5

3

3.5

4

DEC JAN FEB MAR

GP

GN

Can

Nosocomial infectionNosocomial infection

• Preventable • Preventable • Inevitable

What to do during outbreak?What to do during outbreak?

A - Prepare for investigation: - Develop knowledge about investigation techniques. - Review similar outbreak. - Team assembly.

B - Confirm outbreak existence: - Case definition. - Case finding. - Early control measures. - Report to public

health.

- Appropriate consultations.

A - Prepare for investigation: - Develop knowledge about investigation techniques. - Review similar outbreak. - Team assembly.

B - Confirm outbreak existence: - Case definition. - Case finding. - Early control measures. - Report to public

health.

- Appropriate consultations.

Outbreak investigation cont…

Outbreak investigation cont…

C - Verify diagnosis of reported cases:

- Agent - Disease nature - Specimens

D - Search for additional cases: E - Characterize cases of disease: - Time - Place - Person - Graph

F - Formulate hypothesis: - Source - Epi curve

C - Verify diagnosis of reported cases:

- Agent - Disease nature - Specimens

D - Search for additional cases: E - Characterize cases of disease: - Time - Place - Person - Graph

F - Formulate hypothesis: - Source - Epi curve

Cont…Cont…

G - Test hypothesis: H - Evaluate control measures

efficacy: I - Review current practice: J- Communicate findings:

G - Test hypothesis: H - Evaluate control measures

efficacy: I - Review current practice: J- Communicate findings:

ExamplesExamples

MRSA outbreak BCCH, Vancouver. 1999, 33 cases were identified in

NICU. Task force team assembled. Effective IC measures implemented. Enhanced surveillance. Isolation and cohorting.

MRSA outbreak BCCH, Vancouver. 1999, 33 cases were identified in

NICU. Task force team assembled. Effective IC measures implemented. Enhanced surveillance. Isolation and cohorting.

0

5

10

15

20

25

30

35

1998 1999 2000 2001 2002 2003 2004 20050

5

10

15

20

25

30

35

1998 1999 2000 2001 2002 2003 2004 2005

Weekly surveillance

Glove & gown d/c’d

Al-Dajani et al, IDSA 2006

D i s t r i b u t i o n O f C o N S C a s e s

0

2

4

6

8

1 0

1 2

1 4

1 6

Jun-01Aug-01 Oct-01 Dec-01 Feb-02

Apr-02 Jun-02Aug-02 Oct-02 Dec-02 Feb-03

Apr-03 Jun-03Aug-03 Oct-03 Dec-03 Feb-04

Apr-04 Jun-04Aug-04 Oct-04 Dec-04 Feb-05

Apr-05 Jun-05

# of Cases

P e r s i s t a n t C o N S C o N S B a c t e r e m i a

Vanco stoppedDaily tubing replacement

KAAUHKAAUH Eight cases of persistent CoNS in 1 wk. Associated with thrombocytopenia. One term baby? Different allocations. High dose of vancomycin +/- rifampin. Worsening clinical condition. One has PICC. What to do??

Eight cases of persistent CoNS in 1 wk. Associated with thrombocytopenia. One term baby? Different allocations. High dose of vancomycin +/- rifampin. Worsening clinical condition. One has PICC. What to do??

?common source?common source

TPN might be ? Culture from TPN sent. Guess what? Three +ve for CoNS. TPN d/c’d for 5 days. Sepsis well controlled. No more new cases.

TPN might be ? Culture from TPN sent. Guess what? Three +ve for CoNS. TPN d/c’d for 5 days. Sepsis well controlled. No more new cases.

ESBL-KPESBL-KP

Klebsiella pneumonia outbreak Macrae et al, J Hosp Infect 2001; 49: 183-92 Outbreak control group. Closed to transfer. Cohort not feasible. Hand hygiene etc… Screening. Antibiotic changed But outbreak continued???

Klebsiella pneumonia outbreak Macrae et al, J Hosp Infect 2001; 49: 183-92 Outbreak control group. Closed to transfer. Cohort not feasible. Hand hygiene etc… Screening. Antibiotic changed But outbreak continued???

NICU closed. Satellite unit opened. Screen all new comers. Outbreak over.

NICU closed. Satellite unit opened. Screen all new comers. Outbreak over.

Cont…Cont… Klebsiella pneumonia sepsis > 50%, 2001, PIDJ,

05. 88/115 had clinical sepsis, MR 51%. 24 pt develop sepsis in < 24hr, K-P 73%, ESBL

58%. Reviewing their IC practice. IVF prepared at bed side. Inadequate hand hygiene & aseptic tech. Cultures from IVF (65%) revealed KP. Standard IC precautions improved sepsis rate &

MR.

Klebsiella pneumonia sepsis > 50%, 2001, PIDJ, 05.

88/115 had clinical sepsis, MR 51%. 24 pt develop sepsis in < 24hr, K-P 73%, ESBL

58%. Reviewing their IC practice. IVF prepared at bed side. Inadequate hand hygiene & aseptic tech. Cultures from IVF (65%) revealed KP. Standard IC precautions improved sepsis rate &

MR.

Take home messagesTake home messages Team work. Epi-curve. Think of the source. Reinforce IC measures. Appropriate allocation. Review antibiogram. Re-evaluate efficacy of IC. Prevention vs therapy

Team work. Epi-curve. Think of the source. Reinforce IC measures. Appropriate allocation. Review antibiogram. Re-evaluate efficacy of IC. Prevention vs therapy