PREVENCION DE IAAS EN UCIN: ALPAR Y Alimentación enteral

Dra Daniela Fuentes H

Pediatra infectóloga Hospital Carlos Van Buren

Universidad Valparaíso

IAAS EN NUTRICION ENTERAL

Les voy a contar una historia de la vida real…

• Día lunes am visita UCIP• 3 pacientes con diarrea durante fin

de semana: virus y clostridiumnegativo “las leches otra vez” SEDILE

• Abril 2018 UPC neo• Inusual aumento de NEC precoces

últimas semanas• ¿las leches?

• ¿Quiénes de ustedes han visitado alguna vez SEDILE en sus

hospitales?

URGENTE VISITA A SEDILE

EXPECTATIVA REALIDAD

¿Y el Lactario dónde está??

Diagnóstico

• Infraestructura• Inexistencia lactario• Superficies deterioradas• Sin flujo unidireccional

• Limpieza• Mezclas de detergente/Cloro, agua

caliente/Cloro• Hisopos eternos!

• Quiebres en técnica limpia preparación leches• Mal uso EPP• HM deficiente• Teteras caseras con sarro

• Autoclave no estaba funcionando…

• Ausencia controles microbiológicos producto terminado

IMPLEMENTO O AREA

MEDIDA

RESULTADO IMPLEMENTO O AREA

MEDIDA

RESULTADO

Mesón preparación

Pediatría

164 Tapa caja tapas estériles 349

Mesón Preparación Adultos 67 Manos TPM (1) 3991

Mamadera sector

etiquetado

30 Manos TPM (1) post HM 306

Mesón etiquetado 121 Manos TPM (2) 896

Caja leches 7º piso 8893 Manos TPM (2) post HM 57

Caja leche maternidad 242 Puerta acceso sector

preparación

113

Manilla carro 91 Manos AS (1) lavado

material

652

Teclado computador sector

preparación

77 Manos AS (1) lavado

material post HM

375

balanza 87 Manos AS (2) lavado

material

847

Mesón preparación adultos 55 Manos AS (2) lavado

material post HM

133

¿Pueden las fórmulas enterales estar implicadas en la ocurrencia de IAAS en especial NEC en una

UPC neonatal?

¿Cuáles son los estándares de calidad que debe tener SEDILE y UCIN?

Calidad microbiologica de una formula enteral (FE)

La nutrición enteral puede asociarse a infecciones relacionadas con contaminación de fórmulas

Cuantía de la contaminación microbiana, microorganismo y estado inmunitario del huésped

Recuentos de mesofilas (Me) < 104 ufc/ml se asocia a colonizacion GI y recuentos > 105 ufc/ml a infeccion Clínica variable: colonización asintomática GI,

gastroenteritis, sepsis, shock séptico, meningitis

Contaminación desde materias primas hasta su administraciónRev Chil Infect 2004; 21 (4): 312-316

TODOS debemos participar

Rev Chil Nutr Vol. 43, No1, 2016

REGLAMENTO SANITARIO DE ALIMENTOS

- No hay normas para identificar C.sakazakii en

fórmulas prematuros, inicio o continuación

Reflejo calidad sanitaria

Tolerancia 0

OMS: problema identificado

• Existen 2 tipos de fórmulas• Líquidas: listas para usar (RTH), son estériles y debieran preferirse

• Polvo (FP): requieren reconstitución y NO son estériles

Cronobacter sakazakii y Salmonella spp

(Clara evidencia de causalidad)

Otras: Enterobacter spp, Klebsiella spp,

Citrobacter, E. coli y Acinetobacter

Infecciones asociadas Brotes descritos en varios países

Causas probables, pero no demostradas epidemiológicamente

Journal of Hospital Infection 86 (2014) 169e177

Cronobacter spp

• Enterobacteria BGN anaerobio facultativo ubicuo• Aislado en múltiples alimentos• Ambiente: agua, bolsas aspiradoras,

hisopos de limpieza, deposiciones animales e insectos

• Patógeno oportunista emergente que afecta RN e inmunosuprimidos• “Infant formula patoghen”

• Resistente al stress osmótico, sequedad, ph acido y pasteurización, termotolerante• Hasta por 2,5 años en fórmulas

• 11 especies, de las cuales 3 causan enfermedad en neonatos• C. sakazakii, C. turicensis and

C.malonaticus

• Aislado de muestras clínicas: • LCR, sangre, TGI y respiratorio,

médula ósea, heridas piel, orina y leche materna extraída

• Requiere combinación de métodos diagnósticos para su identificación

Virulence 6:5, 433--440; July 2015 BMC Microbiology 2009, 9:225

Cronobacter sakazakii

• Enfermedad de incidencia baja, pero alta mortalidad 40-80% • 1/100.000 lactantes• 9,4/100.000 RNMBP

• RNPT Y BPN• Flora alterada y > permeabilidad

• Patogénesis• Enterotoxina potente termoestable• Adherencia, invasión y disrupción

• Biofilm en latex, silicona, policarbonato y acero inoxidable

Journal of Hospital Infection 86 (2014) 169e177 Virulence 6:5, 433--440; July 2015

Manifestaciones clínicasCronobacter sakazakii

• Clínica: meningitis, bacteriemia con sepsis, NEC, ITS-CVC• > 90% asociadas a FE polvo

• Brotes UPC neonatales

• Friedemann et al: letalidad 150 casos durante 8 años• Meningitis, 41.9%

• Bacteriemia 10%

• NEC 19.0%

Eur J Clin Microbiol Infect Dis 2009; 28:1297-1304

Virulence 6:5, 433--440; July 2015

Más allá de las fórmulas en polvo…

• Todas meningitis con morbimortalidad asociada

• Estudio clonalidad concluye que fuente sería LM extraída, bomba de extracción y ambiente domiciliario.

• CDC: normas de higiene extractor de leche• Importancia educar a padres en

relación a higiene y limpieza • Fundamental en RNPT• Esterilizar una vez al día

Cronobacter sakazakii I nfect ion from Expressed Breast Milk, Australia

Rowena McMullan, Vidthiya Menon,

Alicia G. Beukers, Slade O. Jensen,

Sebastiaan J. van Hal, Rebecca Davis

Author affil

i

at ions: Ro yal Pr ince Alfred Hospital Women and

Babies, Sydney, New South Wales, Australia (R. McMullan);

Royal Prince Alfred Hospital, Sydney (V. Menon, A.G. Beukers,

S. van Hal, R. Davis); Western Sydney University, Sydney

(S.O. Jensen)

DOI: https://doi.org/10.3201/eid2402.171411

Cronobacter sakazakii neonatal infections are often epi-

demiologically linked to the consumption of contaminated

powdered infant formula. We describe a case resulting from

consumption of contaminated expressed breast milk, as

confir

m

e d by whole-genome sequencing. This case high-

lights potential risks associated with storage and acquisition

of expressed breast milk.

Cronobacter sakazakii neonatal infections can cause

severe systemic infection and meningitis, resulting in

mortality rates as high as 42% (1). C. sakazakii infections

have been epidemiologically linked with contaminated

powdered infant formula (PIF), whereas reports of Crono-

bacter infection in infants exclusively fed breast milk are

rare (1). In 2016, a case of clinical meningitis was report-

ed in an infant who had consumed expressed breast milk

(EBM) contaminated with C. sakazakii (2). The source of

contamination was unknown; however, pulsed-fiel d gel

electrophoresis revealed indistinguishable isolates from a

contaminated breast pump and EBM. We report a similar

case of an infant with onset of C. sakazakii clinical men-

ingitis after consumption of contaminated EBM. We con-

fir

m

e d the source of the infection by using whole-genome

sequencing (WGS).

In 2015, a 30-year-old woman underwent preterm la-

bor at 27 weeks and 5 days and delivered a male infant.

Cultures of infant blood specimens collected soon after

birth were negative for bacteria and fungi. From day 2 of

life, the infant received probiotics (Inflor an; Laboratorio

Farmaceutico, Mede, Italy) and was fed exclusively with

EBM administered through an orogastric feeding tube. On

day 10 of life, the infant’s health suddenly deteriorated,

requiring intubation and ventilation. Blood cultures grew

mucoid yellow colonies that we identified as C. sakazakii

by using matrix-assisted laser desorption/ionization time-

of-fli

g

ht mass spectrometry (Bruker Daltonics, Breman,

Germany). Despite appropriate antimicrobial treatment

with meropenem, the infant had onset of status epilepticus,

pulmonary hemorrhage, and acute renal failure. After dis-

cussion with his parents, care was redirected to palliation,

and the infant died at 11 days of age.

Samples of EBM stored on the neonatal unit at 4°C

were sent for culture. Two milk samples expressed during

the mother’s 7-day inpatient stay were cultured and grew

skin flor a. Three samples expressed during the 6 days after

discharge grew C. sakazakii. After leaving the hospital, the

mother expressed breast milk by using a handheld breast

pump that had not been sterilized before use. EBM was

brought to the unit and stored in the same manner as EBM

expressed while in hospital.

We conducted WGS on isolates of C. sakazakii cultured

from EBM and the infant’s blood (online Technical Ap-

pendix, https://wwwnc.cdc.gov/EID/article/24/2/17-1411-

Techapp1.pdf). The EBM and infant isolates were iden-

tical, with 6 single-nucleotide polymorphisms between

them, confirm i ng that the infant was exposed to the patho-

gen through consumption of EBM (Figure).

C. sakazakii has been shown to colonize equipment

used to prepare and administer milk formula (3). The

risks associated with consumption of PIF and Crono-

bacter infection in infants are well understood. Con-

sequently, much effor t has gone into providing safe

instructions and guidelines for preparation and storage

of PIF to prevent such infections, including appropriate

cleaning and sterilization procedures and storage condi-

tions for this heat-resistant organism. C. sakazakii have

been shown to survive and grow in human breast milk at

temperatures of 10°C, 23°C, and 37°C (4) after introduc-

tion of the organism from an external source. Therefore,

in the case of our neonate patient, the handheld breast

pump probably was colonized with C. sakazakii, lead-

ing to contamination of the EBM (especially because

EBM cultures while in hospital were negative for Crono-

bacter) and subsequent infection.

Per hospital practice at the time of this case, moth-

ers who were inpatients and expressing breast milk were

advised to perform hand hygiene before using or cleaning

the hospital breast milk pump kits. The kits were washed

in hot soapy water, rinsed and dried after use, and steril-

ized every 24 hours. After discharge from the hospital,

mothers were to use their own reusable kits and breast

pumps and were given the same cleaning advice about the

kits. In this case, it appears that although verbal and writ-

ten advice was given initially, no follow-up discussion oc-

curred, and a pump was used without sterilization of the

kit. Subsequently, several changes have been instituted,

including processes to ensure daily discussion with moth-

ers about breastfeeding and breast milk hygiene, espe-

cially given that parents of preterm infants are often in an

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 2, February 2018 393

RESEARCH LETTERS

Cronobacter sakazakii I nfection from Expressed Breast Milk, Australia

Rowena McMullan, Vidthiya Menon,

Alicia G. Beukers, Slade O. Jensen,

Sebastiaan J. van Hal, Rebecca Davis

Author affil

i

at ions: Royal Pr ince Alfred Hospital Women and

Babies, Sydney, New South Wales, Australia (R. McMullan);

Royal Prince Alfred Hospital, Sydney (V. Menon, A.G. Beukers,

S. van Hal, R. Davis); Western Sydney University, Sydney

(S.O. Jensen)

DOI: https://doi.org/10.3201/eid2402.171411

Cronobacter sakazakii neonatal infections are often epi-

demiologically linked to the consumption of contaminated

powdered infant formula. We describe a case resulting from

consumption of contaminated expressed breast milk, as

confir

m

e d by whole-genome sequencing. This case high-

lights potential risks associated with storage and acquisition

of expressed breast milk.

Cronobacter sakazakii neonatal infections can cause

severe systemic infection and meningitis, resulting in

mortality rates as high as 42% (1). C. sakazakii infections

have been epidemiologically linked with contaminated

powdered infant formula (PIF), whereas reports of Crono-

bacter infection in infants exclusively fed breast milk are

rare (1). In 2016, a case of clinical meningitis was report-

ed in an infant who had consumed expressed breast milk

(EBM) contaminated with C. sakazakii (2). The source of

contamination was unknown; however, pulsed-fiel d gel

electrophoresis revealed indistinguishable isolates from a

contaminated breast pump and EBM. We report a similar

case of an infant with onset of C. sakazakii clinical men-

ingitis after consumption of contaminated EBM. We con-

fir

m

e d the source of the infection by using whole-genome

sequencing (WGS).

In 2015, a 30-year-old woman underwent preterm la-

bor at 27 weeks and 5 days and delivered a male infant.

Cultures of infant blood specimens collected soon after

birth were negative for bacteria and fungi. From day 2 of

life, the infant received probiotics (Inflor an; Laboratorio

Farmaceutico, Mede, Italy) and was fed exclusively with

EBM administered through an orogastric feeding tube. On

day 10 of life, the infant’s health suddenly deteriorated,

requiring intubation and ventilation. Blood cultures grew

mucoid yellow colonies that we identified as C. sakazakii

by using matrix-assisted laser desorption/ionization time-

of-fli

g

ht mass spectrometry (Bruker Daltonics, Breman,

Germany). Despite appropriate antimicrobial treatment

with meropenem, the infant had onset of status epilepticus,

pulmonary hemorrhage, and acute renal failure. After dis-

cussion with his parents, care was redirected to palliation,

and the infant died at 11 days of age.

Samples of EBM stored on the neonatal unit at 4°C

were sent for culture. Two milk samples expressed during

the mother’s 7-day inpatient stay were cultured and grew

skin flor a. Three samples expressed during the 6 days after

discharge grew C. sakazakii. After leaving the hospital, the

mother expressed breast milk by using a handheld breast

pump that had not been sterilized before use. EBM was

brought to the unit and stored in the same manner as EBM

expressed while in hospital.

We conducted WGS on isolates of C. sakazakii cultured

from EBM and the infant’s blood (online Technical Ap-

pendix, https://wwwnc.cdc.gov/EID/article/24/2/17-1411-

Techapp1.pdf). The EBM and infant isolates were iden-

tical, with 6 single-nucleotide polymorphisms between

them, confirm i ng that the infant was exposed to the patho-

gen through consumption of EBM (Figure).

C. sakazakii has been shown to colonize equipment

used to prepare and administer milk formula (3). The

risks associated with consumption of PIF and Crono-

bacter infection in infants are well understood. Con-

sequently, much effor t has gone into providing safe

instructions and guidelines for preparation and storage

of PIF to prevent such infections, including appropriate

cleaning and sterilization procedures and storage condi-

tions for this heat-resistant organism. C. sakazakii have

been shown to survive and grow in human breast milk at

temperatures of 10°C, 23°C, and 37°C (4) after introduc-

tion of the organism from an external source. Therefore,

in the case of our neonate patient, the handheld breast

pump probably was colonized with C. sakazakii, lead-

ing to contamination of the EBM (especially because

EBM cultures while in hospital were negative for Crono-

bacter) and subsequent infection.

Per hospital practice at the time of this case, moth-

ers who were inpatients and expressing breast milk were

advised to perform hand hygiene before using or cleaning

the hospital breast milk pump kits. The kits were washed

in hot soapy water, rinsed and dried after use, and steril-

ized every 24 hours. After discharge from the hospital,

mothers were to use their own reusable kits and breast

pumps and were given the same cleaning advice about the

kits. In this case, it appears that although verbal and writ-

ten advice was given initially, no follow-up discussion oc-

curred, and a pump was used without sterilization of the

kit. Subsequently, several changes have been instituted,

including processes to ensure daily discussion with moth-

ers about breastfeeding and breast milk hygiene, espe-

cially given that parents of preterm infants are often in an

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 2, February 2018 393

RESEARCH LETTERS

Cronobacter sakazakii I nfection from Expressed Breast Milk, Australia

Rowena McMullan, Vidthiya Menon,

Alicia G. Beukers, Slade O. Jensen,

Sebastiaan J. van Hal, Rebecca Davis

Author affil

i

at ions: Royal Pr ince Alfred Hospital Women and

Babies, Sydney, New South Wales, Australia (R. McMullan);

Royal Prince Alfred Hospital, Sydney (V. Menon, A.G. Beukers,

S. van Hal, R. Davis); Western Sydney University, Sydney

(S.O. Jensen)

DOI: https://doi.org/10.3201/eid2402.171411

Cronobacter sakazakii neonatal infections are often epi-

demiologically linked to the consumption of contaminated

powdered infant formula. We describe a case resulting from

consumption of contaminated expressed breast milk, as

confir

m

e d by whole-genome sequencing. This case high-

lights potential risks associated with storage and acquisition

of expressed breast milk.

Cronobacter sakazakii neonatal infections can cause

severe systemic infection and meningitis, resulting in

mortality rates as high as 42% (1). C. sakazakii infections

have been epidemiologically linked with contaminated

powdered infant formula (PIF), whereas reports of Crono-

bacter infection in infants exclusively fed breast milk are

rare (1). In 2016, a case of clinical meningitis was report-

ed in an infant who had consumed expressed breast milk

(EBM) contaminated with C. sakazakii (2). The source of

contamination was unknown; however, pulsed-fiel d gel

electrophoresis revealed indistinguishable isolates from a

contaminated breast pump and EBM. We report a similar

case of an infant with onset of C. sakazakii clinical men-

ingitis after consumption of contaminated EBM. We con-

fir

m

e d the source of the infection by using whole-genome

sequencing (WGS).

In 2015, a 30-year-old woman underwent preterm la-

bor at 27 weeks and 5 days and delivered a male infant.

Cultures of infant blood specimens collected soon after

birth were negative for bacteria and fungi. From day 2 of

life, the infant received probiotics (Inflor an; Laboratorio

Farmaceutico, Mede, Italy) and was fed exclusively with

EBM administered through an orogastric feeding tube. On

day 10 of life, the infant’s health suddenly deteriorated,

requiring intubation and ventilation. Blood cultures grew

mucoid yellow colonies that we identified as C. sakazakii

by using matrix-assisted laser desorption/ionization time-

of-fli

g

ht mass spectrometry (Bruker Daltonics, Breman,

Germany). Despite appropriate antimicrobial treatment

with meropenem, the infant had onset of status epilepticus,

pulmonary hemorrhage, and acute renal failure. After dis-

cussion with his parents, care was redirected to palliation,

and the infant died at 11 days of age.

Samples of EBM stored on the neonatal unit at 4°C

were sent for culture. Two milk samples expressed during

the mother’s 7-day inpatient stay were cultured and grew

skin flor a. Three samples expressed during the 6 days after

discharge grew C. sakazakii. After leaving the hospital, the

mother expressed breast milk by using a handheld breast

pump that had not been sterilized before use. EBM was

brought to the unit and stored in the same manner as EBM

expressed while in hospital.

We conducted WGS on isolates of C. sakazakii cultured

from EBM and the infant’s blood (online Technical Ap-

pendix, https://wwwnc.cdc.gov/EID/article/24/2/17-1411-

Techapp1.pdf). The EBM and infant isolates were iden-

tical, with 6 single-nucleotide polymorphisms between

them, confirm i ng that the infant was exposed to the patho-

gen through consumption of EBM (Figure).

C. sakazakii has been shown to colonize equipment

used to prepare and administer milk formula (3). The

risks associated with consumption of PIF and Crono-

bacter infection in infants are well understood. Con-

sequently, much effor t has gone into providing safe

instructions and guidelines for preparation and storage

of PIF to prevent such infections, including appropriate

cleaning and sterilization procedures and storage condi-

tions for this heat-resistant organism. C. sakazakii have

been shown to survive and grow in human breast milk at

temperatures of 10°C, 23°C, and 37°C (4) after introduc-

tion of the organism from an external source. Therefore,

in the case of our neonate patient, the handheld breast

pump probably was colonized with C. sakazakii, lead-

ing to contamination of the EBM (especially because

EBM cultures while in hospital were negative for Crono-

bacter) and subsequent infection.

Per hospital practice at the time of this case, moth-

ers who were inpatients and expressing breast milk were

advised to perform hand hygiene before using or cleaning

the hospital breast milk pump kits. The kits were washed

in hot soapy water, rinsed and dried after use, and steril-

ized every 24 hours. After discharge from the hospital,

mothers were to use their own reusable kits and breast

pumps and were given the same cleaning advice about the

kits. In this case, it appears that although verbal and writ-

ten advice was given initially, no follow-up discussion oc-

curred, and a pump was used without sterilization of the

kit. Subsequently, several changes have been instituted,

including processes to ensure daily discussion with moth-

ers about breastfeeding and breast milk hygiene, espe-

cially given that parents of preterm infants are often in an

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 24, No. 2, February 2018 393

RESEARCH LETTERS

¿FE contaminadas como causa de NEC?

NEC

Inmadurez intestinal

Inmadurez inmunitaria

Permeablemacromoléculas

Exagerada respuesta

inflamatoria

Alimentación enteral

Colonización microbiana inadecuada

FE y LM excelente medio cultivo

Ausencia buenas prácticas…

Condición intrínseca e inmodificable RNPT

Leches contaminadas y NEC

• AP: Respuesta inflamatoria exagerada a estímulo bacteriano

Etiología infecciosa

• NO son estériles

• Contaminación es frecuente

• LM: extractor, mamadera, adición fortificante

• LA: materia prima, manos personal, ambiente

Fórmulas lácteas y LM

• Muytjens et al: Enterobacterias en 141 FP de 35 países

• E. agglomerans (25%), E.cloacae (21%), E. sakazakii (14%)

Evidencia contaminación MO

patógenos

Malaysian J Pathol 2016; 38(3) : 223 – 227 Pediatrics. 2016; 137: e20153123.

J. Clin. Microbiol. 1998, 26:743–6.

JOURNAL OF CLINICAL MICROBIOLOGY, Jan. 2001, p. 293–297

6 pacientes con cultivos positivos

10 alimentados con mismo lote

Cultivos (+) en FE y lotes cerrados

Tipificacionmolecular: TODOS los aislados FE fueron iguales,4 pacientes coincidieron

Fuerte asociación ¿causalidad? entre FP contaminadas con E.sakazakii y NEC

Y qué pasa con las Sondas de alimentación enteral ¿Foco infeccioso?

• Asociación Americana de Nutrición Enteral y Parenteral (ASPEN) recomienda que sean desechables y cambio c/24 hrs

• Reflejo vagal, trauma, dolor

• BIOFILM• Tº adecuada

• Nutrientes adecuados (FE o LM)

• Tiempo necesario

• SNG son un reservorio bacteriano

Biofilm-based Healthcare-associated Infections: Volume I, 113 © Springer International Publishing Switzerland2015

Orientación técnica MINSAL para SEDILE 2010Pequeño cuestionario

¿Cada cuántos días cambian SNG?Exequiel GC cada 2 días

Tizné cada 3 díasSotero cada 5 díasSan Borja sin plazoVan Buren sin plazo

CCDM sin plazo

• Objetivo: evaluar colonización SNG por patógenos oportunistas

• Metodología: • 129 SNG de 2 UCIN • Convencional y molecular

• Resultados• 76% biofilm o líquidos residuales

presencia Enterobacterias• LM, LMF, FE polvo (80%), RTH, mezclas• Enterobacter spp, Klebsiella spp,

Serratia marcescens• C. sakazakii, E. coli, Pseudomonas spp,

Cándida albicans

BMC Infectious Diseases 2009, 9:146

Enterobacteriaceae counts from biofilm material iso-

lated from nasogastric enteral feeding tubes of neonates on various feeding regimes

Bacilos Gram negativos

A mayor tiempo SNG aumenta recuento bacteriano en especial BGN

Microscopia electrónica interior SNG con

flora y fauna

RN alimentado con LM y FA

• Cronobacter tiene la capacidad de hacer Biofilm en SNG tras 24hrs instalación • Desprenderse (lavado) y migrar hacia

intestino protegido por acidez gástrica

• SNG diferentes materiales fueron colonizadas precozmente con altas cargas

• Crecimiento y adherencia de microorganismos patógenos en SNG constituyen un riesgo de infecciones en pacientes neonatológicos

Bacteria entre matrixfórmula láctea

E. Hurrell et al. / International Journal of Food Microbiology 136 (2009) 227–231

Reservorio precoz MO multirresistentes

Journal of Pediatric Surgery, Vol 37, No 7 (July), 2002:

Pediatric Research accepted article preview online 11 April 2016

Reducing Necrotizing Enterocolitis in VLBW Infants Using Quality Improvement Methods

• Alto% alimentación LM (90%), aumento incidencia NEC (4% a 10%)

• OBJETIVO: impacto de la incorporación mejoras en la calidad de la alimentación en RNMBP (QI: quality improvement) por equipos multidisciplinarios (neonatólogos, nutricionistas)

• Q1 tras revisión literatura desarrollaron un protocolo de alimentación• 5m después se agrega nueva intervención

• Disminuir duración SNG a 7 días dado evidencia de colonización y subsecuente riesgo NEC • Cambio bajada en cada alimentación• Educación padres en relación a manipulación e higiene al extraerse LM

• 3 grupos: basal (219), Q1 fase 1 (62) y fase 2 (170)

J Perinatol. 2014 November ; 34(11): 850–857

Resultados

• No hubo cambio en NEC > 2 o quirúrgicas tras implementar fase 1 Q1

• Fuerte descenso tras cambios manejo SNG• OR 0.46, 95%CI 0.31-0.68,

p<.001 • Enfoque multidisciplinario en la

forma de alimentar en UCIN

J Perinatol. 2014 November ; 34(11): 850–857

Medidas de prevención IAAS asociadas a alimentación enteral

• OMS guías acerca de la seguridad en preparación, manipulación y almacenamiento de las fórmulas en polvo para prevenir la contaminación por patógenos (no así de extracción LM)

• Incidencia NEC disminuye en UCIN con estrategias para el control de infecciones y el adecuado manejo de las fórmulas lácteas• Incidencia variable según grado contaminación LM y LA

Malaysian J Pathol 2016; 38(3) : 223 – 227 39.PLoS One. 2011; 6: e17776.

J Perinatol. 2014; 34: 850-7.

¿Dónde consultar?

Organización M undial de la Salud

en colaboración con la

Organización de las Naciones

Unidas para la Agricultura y la

Alimentación

Preparación, almacenamiento

y manipulación en condiciones

higiénicas de preparaciones en

polvo para lactantes

DI RECTRI CES

2011

2007

Código Sanitario, Reglamento Sanitario de los Alimentos , Norma Chilena Oficial 2004 sobre Sistemas de Analisis de Peligros y de Puntos Criticos y de Control o Hazard Analysis Critical Control Points, Codigo de Practicas para la Fabricacion de Mezclas Alimenticias (OPS/ OMS), y recomendaciones nutricionales e internacionales entre otros.

• Mejoría limpieza ambiental e HM

• Cohorte neonatos y enfermeras

• Cambio lotes de fórmulas en polvo• Control microbiológico de fórmulas

N Engl J Med 1977; 297:984-986 Am J Infect Control 2010;38:144-8

Estándares de calidad para SEDILEOMS/Minsal/Reglamento sanitario alimentos

• TODO el material empleado para alimentar a lactantes y preparar FE debe estar limpio y y esterilizado

• Buenas Practicas de Fabricacion(BPF) en toda la cadena de elaboración y monitorización hasta el momento de su administración• Sistema de garantía de inocuidad

obligatorio (HACCP)• Si cumple con normas de

bioseguridad y BPF la contaminación se reduce de 53% a 2%.

• Planta física: flujo unidireccional, equipos que reúnan condiciones sanitarias

• Recurso humano capacitado

• Autoclave para esterilización final

• Proceso producción debe ser controlado• Contra muestra por 72hrs• Cultivos microbiológicos rutina

Área producción fórmulas

Uso técnica limpia con elementos de protección

- Gorro, delantal, mascarilla- Se agrega antiparra y guantes si LM

LA Esterilización

LM Pasteurización

Protocolos escritos de TODOS los procesos

Regulación por OMS

PREPARACIÓN

TRANSPORTE

ADMINISTRACIÓN

UCIN

• Agua > 70º

• Reducir tiempo entre preparación y distribución, NO > 2hrs Tº ambiente (4hrs ASPEN)

• Etiquetar: nombre FE, fecha/hora/Tº preparación, nombre manipulador

• Si no se administra refrigerar a < 5°C y máx 24 hrs.

• Enviar listas para servir

• Si frías calentar en unidades clínicas, no > 15 min NO ocupar microondas

• Continua o en bolos NO > 2 hrs Tº ambiente

• Cambiar bajada con cada mamadera

• NO calentar durante administración

FP están intrínsecamente contaminadas

Considerar rol patogénico incluso frente a MO nosocomiales

SNG evidente reservorio bacterias con potencial riesgo

Fundamental Buena prácticas fabricación y estándares de calidad

TODOS

Cambio periódico parece racional

Evaluar a nivel local

Conclusiones IAAS Nutrición

Enteral

IAAS EN NUTRICION PARENTERAL (NP)

Expectativa v/s Realidad

Les voy a contar otra historia de la vida real…

• ITS pacientes varios centros por Candidalusitaniae y Rhodotorula sp

• ISP/Minsal“Casosposibles”: fungemiasdesde 1 Enero

• Enviar HC (+) al ISP como “estudio brote”

Mayo 2017

• 5 Casos ITS por Enterobactercloacae Clínica Alemana con 2 casos fallecidos en UCIN

• Hospitales públicos Exequiel y J Aguirre también presentan casos mismo Enterobacter

• Factor común NPT RedSana

• En proceso judicial…

Febrero 2018 • 11/03 NPT de Therapia(+) a Serratia marcescenslínea producción Nº3 del 03/02

• 4 RN con ITS por misma bacteria (La Florida, FelixBulnes y San Juan de Dios

• Paralización faenas Therapia Santiago

• Investigación sanitaria

Febrero 2019

IAAS en ALPAR

• La aparición de casos en distintos establecimientos de infecciones por un mismo agente es sugerente de la presencia de un brote

multicéntrico de fuente común 2ª a la contaminación de un fármaco o producto administrado a los pacientes

• ¿NPT qué es?• ¿Un Fármaco?

• ¿Alimento?

Terreno Químicofarmacéutico

Qué nos pasó a las instituciones que licitamos con Therapia

PAVOR

ParanoiaBúsqueda de información y alternativas

InseguridadCupos

limitados

Atención clínica

deficiente

Niños en riesgo…

TODO vuelve a la

normalidad

Aprender de la

experiencia

Sálvese quien pueda

ALPAR EN UCIN

RNPT < 28 EG

“Una Emergencia nutricional”

500grs 50grs tejido seco

1/3 metabolismo basal 24hrs

90% agua

10% proteinas,

escaso lípidos

Minerales

Fuente Energía músculos y órganos

World Rev Nutr Diet. Basel, Karger, 2014, vol 110, pp 177–189

Nutrición parenteral

Cuál es el escenario

IAAS UCIN

Alta mortalidad y morbilidad neurológica

3/4 ITS

Mayoría asociadas a PICC

- Paciente alto riesgo

- Nada que hacer

- Invadido

- Extremar cuidados CP y duración mínima

- NPT, fármacos, fluidos

- Minimizar manipulación y acortar duración

NPT es FR de IAAS, ITS y sepsisMortalidad 11%

Cómo se contamina ALPAR

• Higiene ambiente deficiente

• Materias primas o utensilios contaminados: Falla esterilización

• Quiebre técnica aséptica al preparar

• Almacenamiento inadecuado

Farmacia

Elaboración de mezclas

• Asepsia inadecuada

• Falta de cuidados líneas centrales

• NO cumplimiento Precauciones Estándar

Unidades clínicas

Manipulación

- Staphilococcusaureus y coagulasanegativo

- Enterobactercloacae

- Klebsiella oxytoca- Serratia marcescens- Acinetobacter- Pseudomonas spp- Stenotrophomonas

maltophilia- Burkholderia

cepacia- Flavobacterium spp- Candida albicans

Elaboración de NPT

Farmacias hospitalesProveedor externo

Therapia y Redsana

RTH Mezclas

Solución acuosa de glucosa, electrolitos, aminoácidos, lípidos

y otros nutrientes

• No hay normas ministeriales

• GUIAS ASPEN

Cuál es el problema con ALPAR:Riesgo infección con “Mezclas”

• Emulsión lipídica (EL) es un excelente medio para el crecimiento de bacterias y levaduras• Lípidos aumentan riesgo de precipitación, incompatibilidad e infecciones

• Mezclas con dextrosa y aminoácidos también se contaminan• Con todas las medidas riesgo 5,2% contaminación

• Estabilidad NP 3 componentes dura max 20-24hrs colgada

• Administración lenta a Tº ambiente favorece el crecimiento bacteriano

• Ante brote por Enterobacter spp o Citrobacter spp debe descartarse contaminación intrínseca

VOLUME 39 | NUMBER 6 | NOVEMBER/DECEMBER 2016

Clinical Nutrition 37 (2018) 2418e2429

Int. J. Med. Sci. 2013, Vol. 10

http://www.medsci.org

1082

cillus cereus, Serratia marcescens, Staphylococcus aureus, and Candida albicans in PPN solutions. In particular, the effects of the addition of lipid emulsion (LE) and

multivitamins (MV) to the PPN solutions on the mi-crobial growth were investigated.

Figure 1. Effect of lipid emulsion or/and multivitamins on the growth of Bacillus cereus in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared by

mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure ratio

to physiological saline.

Figure 2. Effect of lipid emulsion or/and multivitamins on the growth of Serratia marcescens in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared

by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure

ratio to physiological saline.

Figure 3. Effect of lipid emulsion or/and multivitamins on the growth of Staphylococcus aureus in AF (pH is 6.6 and OPR is approximately 3). LAF was

prepared by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic

pressure ratio to physiological saline.

Int. J. Med. Sci. 2013, Vol. 10

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1082

cillus cereus, Serratia marcescens, Staphylococcus aureus, and Candida albicans in PPN solutions. In particular, the effects of the addition of lipid emulsion (LE) and

multivitamins (MV) to the PPN solutions on the mi-crobial growth were investigated.

Figure 1. Effect of lipid emulsion or/and multivitamins on the growth of Bacillus cereus in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared by

mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure ratio

to physiological saline.

Figure 2. Effect of lipid emulsion or/and multivitamins on the growth of Serratia marcescens in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared

by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure

ratio to physiological saline.

Figure 3. Effect of lipid emulsion or/and multivitamins on the growth of Staphylococcus aureus in AF (pH is 6.6 and OPR is approximately 3). LAF was

prepared by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic

pressure ratio to physiological saline.

Int. J. Med. Sci. 2013, Vol. 10

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1082

cillus cereus, Serratia marcescens, Staphylococcus aureus, and Candida albicans in PPN solutions. In particular, the effects of the addition of lipid emulsion (LE) and

multivitamins (MV) to the PPN solutions on the mi-crobial growth were investigated.

Figure 1. Effect of lipid emulsion or/and multivitamins on the growth of Bacillus cereus in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared by

mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure ratio

to physiological saline.

Figure 2. Effect of lipid emulsion or/and multivitamins on the growth of Serratia marcescens in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared

by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure

ratio to physiological saline.

Figure 3. Effect of lipid emulsion or/and multivitamins on the growth of Staphylococcus aureus in AF (pH is 6.6 and OPR is approximately 3). LAF was

prepared by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic

pressure ratio to physiological saline.

Int. J. Med. Sci. 2013, Vol. 10

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1083

Figure 4. Effect of lipid emulsion or/and multivitamins on the growth of Candida albicans in AF (pH is 6.6 and OPR is approximately 3). LAF was prepared

by mixing AF and 20% LE in a ratio of 9:1. AFV or LAFV was prepared by adding 1/20 of daily dose of MV to 100 mL of AF or LAF. OPR, osmotic pressure

ratio to physiological saline.

In the study, a commercial 3% amino acid and

7.5% glucose solution with electrolytes (AF) was used as the base solution, and AF was added with LE, MV, or both. A specified number of each microorganism was added to each 100 mL of test solutions in sterile plastic flasks. The number of colony forming units (CFU)/mL of each microorganism was counted at 0, 24, and 48 hours after the addition of microorganism. All 3 strains of B. cereus increased rapidly in all test solutions, and the addition of LE or MV seemed to accelerate the proliferation. This finding indicates that B. cereus can increase rapidly in PPN solutions with-out LE and MV, and the addition of LE or MV accel-erates the growth. All 3 strains of S. marcescens in-creased rapidly in all test solutions, and the addition of LE seemed to accelerate the proliferation. Thus, it is indicated that S. marcescens also can increase rapidly in PPN solutions without LE and MV and the addition of LE accelerates the growth. All 3 strains of S. aureus did not increase for 48 hours in AF without LE and MV, and 1 clinical isolate did not increase in AF added with LE, MV, or both. However, the other 2 strains increased slightly in AF added with LE, in-creasing rapidly in AF added with MV and in AF added with both LE and MV. These results indicate that S. aureus cannot increase in PPN solutions with-out LE and MV, but some strains may increase rapidly by adding MV. Since 2 of the 3 strains increased rap-idly with no increase in 1 strain, there seems to be a strain difference in auxotrophy of S. aureus. All 3 strains of C. albicans increased slightly in AF without LE and MV, but increased rapidly in AF added with LE, MV, or both, indicating that C. albicans increases slightly in PPN solutions without LE and MV and the addition of LE or MV accelerates the growth. These results show that B. cereus and S. marcescens can grow

rapidly in PPN solutions containing amino acids, glucose and electrolytes, but S. aureus cannot grow similarly.

We have previously shown that adding wa-ter-soluble vitamins does not affect the growth of S.

aureus but water-insoluble vitamins are essential for the growth of S. aureus.23 PPN solutions available in Japan consist of amino acids, glucose and electrolytes but do not contain LE and MV, although the latest PPN products contain only thiamine (B1) for the pre-vention of Wernicke’s encephalopathy or lactic acido-sis. In clinical practice, PPN solutions are sometimes supplemented with water-soluble vitamins such as B1, B2, B6, B12, and C, but rarely supplemented with MV including water-insoluble vitamins. With regard to the pH value of PPN solutions, the physiological pH of Japanese PPN solutions seems to be suitable for bacterial growth,5,6 and B. cereus and S. marcescens can increase rapidly without LE and MV. With regard to BSI, cases with B. cereus and S. marcescens have been reported in PPN patients, while cases with S. aureus, perhaps also with S. epidermidis, have scarcely been reported in PPN patients. This is likely because those cannot increase without LE and water-insoluble vit-amins. On the other hand, commercially available PPN solutions in European countries and some other countries are acidic (pH 5-6)2,24,25 as similar to TPN solutions, and then BSI outbreaks by B. cereus or S.

marcescens have rarely been reported. However, PPN and TPN solutions with physiological pH have re-cently been launched in European countries,26 and these solutions contain LE and are usually supple-mented with MV, which would be suitable for the growth of all the microorganisms employed in the present study.

Taken together, the results of this study suggest

Int. J. Med. Sci. 2013, Vol. 10

Brotes relacionados con NPT en pacientes neonatales

Nutrients 2012, 4 1495

The differences in the risk of PICC-placement in the upper as compared to the lower extremities

was investigated in a large preterm population in the USA [median gestational age and weight:

28 (CI 95%: 25.5–30); 937 (CI 95%: 760–360)] [50]. The incidence densities of the upper and lower

extremities were 7.1/1000 catheter-days and 4.8/1000, respectively. However, administration of

lipid-containing parenteral nutrition was significantly longer (46 days) in neonates with

catheter-related BSI (CRBSI) as compared to neonates without CRBSI (25 days; p < 0.01).

5. Outbreaks Due to Contaminated Parenteral Nutrition

Various outbreaks due to contaminated parenteral nutrition are reported in the literature. Outbreaks

vary in size, time span, and pathogens. Interestingly, most outbreaks are due to contamination by

Gram-negative bacteria (Table 1). The most likely time point for contamination appears to be within

the span of PN-preparation. For yeasts however, days of TPN-administration seems to be more

predictive [51,52]. Two outbreaks among adults due to contaminated TPN-products further illustrate

the potential harm of contaminated preparations: A multistate outbreak of S. marcescens BSIs linked to

contaminated MgSO4 that was distributed nationally by a compounding pharmacy [53]. The outbreak

included 18 confirmed and 7 probable adult cases in California and New Jersey. Another outbreak due

to S. marcescens involved 19 patients in six hospitals in Alabama, US. Nine deaths were related to

contaminated parenteral nutrition preparations from a compounding pharmacy. The identical strain of

S. marcescens was cultured from a tap water faucet in the pharmacy which was used to rinse production

equipment [54]. Other outbreaks have been described (Table 1), most of them confirmed by pulsed-field

gel-electrophoresis [55–59], ribotyping [60], or by an identical antibiotic susceptibility testing [61].

Table 1. Published outbreaks among neonates related to parenteral nutrition.

Author Ref. Pathogens n Deaths Confirmation 1 PN-preparation Most likely way of

contamination

Maltezou [62] Serratia marcescens 57 9 Epidemiology On ward Preparation

Arslan [55] Serratia marcescens 7 0 Culture/PFGE On ward Preparation

Bou [56] Leuconostoc mesenteroides 11

(42)

3 of 42 Epidemiology

Culture/PFGE

Hospital pharmacy Preparation

Campos [57] Enterobacter hormaechei 19 ND Culture/PFGE Manufacturer Preparation

De Vegas [58] Acinetobacter RUH 1139 24 ND Culture/PFGE Hospital pharmacy Handling on ward

Perniola [52] Rhodotorula mucilaginosa 4 0 Epidemiology Not specified Not specified

Habsah [61] Pantoea spp. 8 7 Culture/AB Hospital pharmacy Preparation

Doit [60] Burkholderia cepacia 8 ND Culture/Ribotype manufacturer Contaminated

rubber stoppers

Aragao [51] Pichia anomala 4 0 Epidemiology Hospital pharmacy Handling on ward

Tresoldi [59] Enterobacter cloacae 11 7 Culture/PFGE Hospital pharmacy Preparation

Archibald [63] Enterobacter cloacae &

Pseudomonas aeruginosa

6 2 Epidemiology On ward Preparation

ND: not determined; 1 Confirmation of the pathogen is done either by PFGE (pulsed-field gel-electrophoresis [PFGE]; ribotyping,

identical antibiotic susceptibility testing [AB]), or by an epidemiological association.

Nutrients 2012, 4, 1490-1503

• Tras “Fin de semana largo”: 8 casos sepsis en 3 días• Todos en NP• HC (+) Pantoea spp mismo fenotipo

• Solución A (dextrosa, calcio vitaminas hidrosolubles), B y C• Cultivo (+) en solución A almacenada

y recién preparada

• Estudio microbiológico dio (-)• Ambiente zona preparación y UCIN,

utensilios, desinfectantes, componentes en solución, manos personal, tórulas rectales RN.

An outbreak of Pant oea spp. in a neonatal intensive

care unit secondary to contaminated parenteral

nut r it ion

H. Habsaha,*, M. Zeehaidaa, H. Van Rostenbergheb, R. Noraidab,

W.I. Wan Pauzib, I. Fat imahb, A.R. Roslizaa, N.Y. Nik Sharimahb,H. Maimunahc

aDepartment of Medical Microbiology and Parasit ology, Kubang Kerian, Kelantan, MalaysiabDepartment of Paediat ric, PPSP, USM, MalaysiacHospital Infect ion Cont rol and Epidemiology Unit , HUSM, Malaysia

Received 13 October 2004; accepted 4 January 2005

Available online 20 April 2005

KEYWORDSOutbreaks; Neonatal

intensive care;

Parenteral nut rit ion;

Pantoea spp.;

Contaminat ion

Summary Contaminated parenteral nut rit ion (PN) is an important source

of infect ion in neonates. Many organisms have been reported to cause

cont aminat ion that results in outbreaks in intensive care unit s. The

object ive of this study was to invest igate an outbreak caused by Pantoea

spp., which contaminat es PN, in a neonatal intensive care unit (NICU). This

was a descript ive study of an outbreak of sepsis in an NICU of a tert iary

teaching hospital in Malaysia. Pantoea spp. infect ion was detected in eight

pat ients over a three-day period from 24 to 27 January 2004 following the

administ rat ion of PN. Seven of the eight pat ients died due to the infect ion.

Extensive environmental samplings for culture were performed. PN solut ion

from the NICU and the pharmacy were also cult ured during the outbreak

period. Pantoea spp. was isolated from blood cult ures of all infected

pat ients, and the unused PN from the pharmacy and the NICU. All the st rains

of Pant oea spp. had a similar ant ibiot ic suscept ibil it y pat t ern and

biochemical react ion. From the results, we concluded that PN was the

source of the outbreak and the contaminat ion may have occurred during its

preparat ion in the pharmacy. A thorough invest igat ion has been carried out

and, where possible, correct ive measures have been taken to avoid similar

outbreaks in the future.

Q 2005 The Hospital Infect ion Society. Published by Elsevier Ltd. All rights

reserved.

Journal of Hospital Infect ion (2005) 61, 213–218

www.elsevierhealth.com/ journals/ j hin

0195-6701/ $ - see front matter Q 2005 The Hospital Infect ion Society. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/ j .j hin.2005. 01.004

* Corresponding author. Tel.: +60 97664607; fax: +60 97652678.

E-mail address: habsah@kb.usm.my

Journal of Hospital Infection (2005) 61, 213–218

87,5% mortalidadTras plan inmediato de intervención multidisciplinaria NO hubo nuevos

casos: detención NP, todo del día, reeducación, reevaluación procesos

• 12/06: 11 RN shock séptico tras haber recibido NP (media 19hrs)• NP preparada 2hrs previas• 7 fallecieron a pesar AB adecuado

• Estudio microbiológico 250 muestras local y referencia fue (-)• Superficies cámara, infusiones EV UCIN-

farmacia, lípidos multidosis (3d), utensilios, autoclave

• Estudio alícuotas NP refrigeradas de respaldo fueron (+) para E. cloacae• (-) día previo y día después

• DG: contaminación durante preparación NP

Am J Infect Control 2000;28:258-61

Mismo perfil PFGE

REVIEW

Invest igat ion of an outbreak of Ent erobact er

cloacae in a neonatal unit and review of the

literature

M. Dalben, G. Varkulj a, M. Basso, V.L.J. Krebs, M.A. Gibelli,I. van der Heij den, F. Rossi, G. Duboc, A.S. Levin, S.F. Costa*

Hospi tal das Cl ınicas, Universit y of S~ao Paulo, Depar tment of Infect ious Diseases,

School of Medicine of Universit y of S~ao Paulo, Brazil

Available online 16 July 2008

KEYWORDSEnterobacter cloacae;

Neonate; Sepsis;

Outbreak

Summary Enterobacter cloacae has emerged as an important pathogen in

neonatal units, with several outbreaks of infect ion being reported. The aim

of this study was to invest igate an outbreak of sepsis due to E. cloacae in

a neonatal unit and to review the literature. A ret rospect ive cohort study

was conducted in which cases were compared with all newborns hospital-

ised for more than 48 h in the neonatal intensive care unit (NICU). Cohort -

ing of inf ect ed pat ient s and work reorganisat ion were implement ed.

Pulsed-field gel elect rophoresis was performed. The ret rospect ive cohort

included the six cases and 13 control pat ient s that had been in the NICU

during April 2006. Univariate analysis showed that the use of dobutamine

was significant ly associat ed with infect ion (P¼0.036) and that enteral

feeding was a protect ive factor (P¼0.02). Mult ivariate analysis did not find

any independent risk factor. Bed occupancy rate in March 2006 was 109.6%,

indicat ing overcrowding. PFGE ident ified indist inguishable pat terns among

isolates from all six newborns. PubMed and OVID was search from 1 January

1983 to 15 January 2008 for papers including the terms ‘E. cloacae’ , ‘ out -

breaks’ , ‘ clust ers’ in combinat ion wi t h ‘ neonat e’ , ‘ newborn’ , and

‘ infant ’ .We found 26 report s of outbreaks due to E. cloacae in neonate

pat ients: sixteen (52%) were bloodst ream infect ion outbreaks, of which

two (12.5%) were related to mult iple-dose medicat ions. The source for

* Corresponding author. Address: LIM 54, Department of Infect ious Diseases, School of Medicine, University of S~ao Paulo, Brazi l.

Tel.: þ 55 11 30617030; fax: þ 55 11 30697066.

E-mail address: costasilviaf@ig.com.br

0195-6701/ $ - see front matter ª 2008 The Hospital Infect ion Society. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/ j .j hin.2008.05.003

Journal of Hospital Infect ion (2008) 70, 7e 14

Available online at www.sciencedirect.com

www.elsevierhealth.com/ journals/ j hin

Journal of Hospital Infection (2008) 70,

7e14

FR: hacinamiento y uso de fármacos multidosis

16 reportes de brotes ITS por E.cloacae- 2 por multidosis- NPT- Ambiente- 50% sin identificación origen

Reforzamiento prácticas higieneRestricción nuevas admisionesFármacos de USO UNICO

Condiciones necesarias elaboración NP

• Preparar diariamente• Sala ”limpia” tolerancia O a

elementos fúngicos ambientales• Campana flujo laminar horizontal

(aire filtrado y sin turbulencias)• Técnica aséptica (gorro, delantal,

mascarilla, guantes estériles)• Lavado de manos con Clorhexidina

• NO se esterilizan• Refrigerar a 4º • Contra-muestra y cultivos

microbiológicos de rutina

Método filtración con membrana

Journal of Parenteral and Enteral Nutrition, 24:1, 2000

Manipulación Unidades clínicas

Prevención ITS-CPC/NP en UCINLo primero es evitar colonización

Catéter e infusiones

SICARSMINSAL 2017

33

Tabla 6.11 Agentes etiológicos, en ITS en pacientes con catéter umbilical, año 2017.

Todas las Complejidades Con agente identificado 25 de 26 96,15

Agente etiológico Frecuencia %

Staphylococcus epidermidis 12 48 Staphylococcus aureus 4 16

Staphylococcus warneri 2 8 Otros * 7 28

Total 25 100

Otros * (un caso cada uno): Staphylococcus capitis ss. capitis, Staphylococcus haemolyticus, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa y Serratia marcescens

6.6. Tendencias en infecciones del torrente sanguíneo (ITS) asociadas a catéter venoso central en niños y neonatos. En el periodo 1996-2017 estos 3 síndromes clínicos mostraron distintos comportamientos en sus ten-dencias. En todas se observa reducción, en las ITS asociadas a CVC y NPT es desde 1996-1998, mientras que en las asociadas a catéteres umbilicales fue desde 2002. Previamente, éstas últimas tuvieron un aumento sostenido posiblemente por la incorporación de estos catéteres a la vigilancia. . Al analizar los últimos 6 años, se observa que la tendencia en la tasa de incidencia de ITS asociada a CVC y NPT es a ir en disminución progresiva, estabilizándose entre los años 2015-2017, mientras que la de ITS asociada a catéter umbilical ha presentado una evolución más bien estable y con varia-ciones menores entre los años 2012-2017 (Gráfico 6.4, sombreado rosado). Gráfico 6.2 Tendencias de las infecciones del torrente sanguíneo (ITS)/1.000 días de uso de catéter venoso central (CVC), catéter de nutrición parenteral total (NPT) en pacientes pediátricos y de ca-téter umbilical en pacientes neonatales. Hospitales del Sistema Nacional de Servicios de Salud Chile, 1996-2017

Sombreado rosado = información recabada con el sistema informático SICARS.

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

CVC 9,7 7,4 4,5 6 4,9 4,1 4,67 3,8 3,49 3,36 2,24 1,82 2,57 3,31 2,84 3,95 3,4 2,8 2,34 2,29 2,04 2,56

NPT 9,7 7,4 2,8 4,7 3,87 4,1 2,46 4,2 2,24 3,12 3,13 1,67 1,77 1,86 2,71 2,35 2,64 1,64 1,11 1,25 1,74 1,57

umbilical 3,8 2,7 4,4 5,8 6,2 7,09 5,8 4,75 4,37 4,47 3,99 3,88 3,77 2,18 4,93 2,22 2,39 1,75 2,26 2,43 1,58

0

2

4

6

8

10

12

Tasa

po

r 1.

000

día

s ca

téte

r

Año

Alto % contaminación puertos de entrada e infusiones

Puertos entrada35 aislados BGN- 11 esporádicos- 24 en cluster

Si fiebre 48hrs previas se les tomó HC

ROL DE LA CONTAMINACION TAPONES - Manos personal- Asepsia alcohol deficiente (15 seg)

Infection Control and Hospital Epidemiology, Vol. 25, No. 3 (March 2004)

• Estudio retrospectivo 2002-2006

• 495 PICC insertados y manejados por team enfermeras• Sin diferencias en EG, PN, sexo, edad

inserción PICC, duración NP y hospitalización, sobrevida

• > duración PICC extremidades inferiores y latencia infección tras inserción

• Conclusión: si técnicamente posible preferir EEII en NP prolongadas

DOI: 10.1542/peds.2007-1962; originally published online April 7, 2008; 2008;121;e1152Pediatrics

Houchang D. ModanlouViet Hoang, Jack Sills, Michelle Chandler, Erin Busalani, Robin Clifton-Koeppel and

InsertionNeonates: Complications Rates Related to Upper Versus Lower Extremity Percutaneously Inserted Central Catheter for Total Parenteral Nutrition in

http://pediatrics.aappublications.org/content/121/5/e1152.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Univ Of North Dakota on September 4, 2014pediatrics.aappublications.orgDownloaded from at Univ Of North Dakota on September 4, 2014pediatrics.aappublications.orgDownloaded from

Cuidados CVC

Manejo NPT

Medidas control infecciones

• Inserción máximas barreras de precaución: técnica estéril y mínimos intentos (experto)

• Mantención/Manipulación: extrínseco (piel), intrínseco (puertos de entrada e infusiones)

• Conexión técnica estéril

• CPC uso exclusivo NPT: mínima manipulación y máxima capacitación

• Cambiar conexiones cada 24 hrs

• Prevención IAAS: prioridad autoridades

• Diseño Unidad adecuado

• Staff: carga laboral y personal entrenado en adherencia PE e H

• Desinfección ambiente

• Vigilancia IAAS

Brotes UCIN se asocian a transmisiones horizontales por mala adherencia a higiene de manos

Retomando la historia que les conté…Recomendaciones finales tras armar el puzle

Qué hacer en caso de sospechar una infección asociada al uso de NPT

ISP/ANAMED son los encargados de realizar el estudio de brote

Avisar y declarar inmediatamente al ISP sobre sospecha

de brote

Comunicación con QF/Farmacia

Cultivos de alimentos, ambiente y fármacos NO deben ser procesados en Laboratorios clínicos

NO inicie estudio de muestras no clínicas en su Laboratorio de

Microbiología

Cultivo filtros dan validez

Cultivos NPT deben realizarse en Laboratorios

certificados ya que son “evidencia”

¿Qué solicitar a proveedor NPT? Para retornar a la tranquilidad…

• Regulación nacional no encontré…

• Exigir ciertos términos en licitación• Maximizar seguridad

• Envío de bolsas NPT con conexiones foto-estables incluidas

• Solicitar protocolos preparación NPT• Aire y ambiente

• Controles microbiológicos NP ¿Qué hacer en caso de cultivos (+)• Considerar contra muestra

• Qué hacer en caso de no cumplir con los requerimientos según contrato

ReflexionesRol fiscalizador

ISP/MINSAL

Proveedores

Mejorar estándares de calidad e Inocuidad

productos

Establecimientos de Salud

Clínicos deben salir de sus Unidades y participar

activamente

MUCHAS GRACIASY qué

hacemos con las SNG??