Neonatology Practice MMA Faridi, Priyanka Gupta
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Infection Control in Neonatal Intensive Care Unitchapter 1

Prevention of infection is better than cure
Commonly identified sources for nosocomially aquired infections are lapses in house-keeping and poor hand hygiene, contaminated equipment (like stethoscope, thermometers and humidifiers) and reservoirs (like sinks). The infection conrol and preventive steps which should always be taken care of in a neonatal intensive care unit (NICU) are listed here.
 
INFRASTRUCTURE RELATED MEASURES
  • Provide at least 4–6 feet space in between the two babies. Overcrowding should be avoided. Doubling should be strictly denied.
  • Air conditioner should provide at least 6–12 air exchanges per hour. The air delivered should be filtered with minimum 90% efficiency.
  • There should be at least one hand-washing sink for each four beds. The sink should be wide and deep enough to minimize splashing. Its tap should be elbow-operated/foot operated (hands-free).
  • Besides electricity, ensure 24 hours supply of water in the NICU, so as to never have any compromise with hand washing and hand hygiene, and proper house-keeping.
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POLICY RELATED MEASURES
  • There should be sufficient number of personnel for newborn care, so that there are less chances of cross infection.
  • Restrict visitors in the baby care area.
  • Anyone including any medical personnel with fever, respiratory infection, diarrhea, pyoderma, draining wounds, active herpes simplex, herpes zoster or other viral exanthems should not be allowed to enter into baby care area.
  • Remove shoes and socks or wear shoe-cover over them. It is better to use separate slippers for NICU.
  • Gown, face mask and head cover should be worn for any invasive procedure. It is a good practice to wear gown and face mask all the time by anyone entering or working in the NICU. This reminds everyone that NICU is a special area for infection control and helps in restricting entry of other hospital staff also who have been found to break the infection-control measures more often than not.
  • Single room isolation is recommended for babies with infections like varicella and tuberculosis.
  • NICU infection control surveillance should be in place as a routine. Culture swabs should be sent periodically (at least once a month, may be earlier also as required) from various equipment and environment of NICU. This becomes mandatory during the outbreaks.
  • Culture/sensitivity register should be maintained. It should record all blood, CSF, urine and other body fluids culture/ antibiotic sensitivity patterns that helps in deciding the first and second line antibiotic policy for the NICU. This also helps in early identification of any outbreak.
 
DISINFECTANTS AND GERMICIDES
The choice of disinfectants varies among hospitals. Every personnel should be aware of their usage and there should be 3no compromise over the disinfection or sterilization procedures. Manufacturer's guidelines should be strictly followed while their preparation and the required contact time should also be adhered to. Disinfectants and germicides used in our units are:
Name
Uses
Soap/detergent
Wash-basins/sinks, fans, windows of airconditioner, refrigerator, buckets, dustbins, slippers, swab containers, injection trays, oxygen hoods
Spirit (ethyl alcohol or 70% isopropyl alcohol)
Preparation of skin, laryngoscope blades, stethoscope, measuring tape, thermometer
Sterilium (2-propanolol, 1-propanolol, ethyl-hexadecyle dimethyl ammonium ethyl sulfate)
Disinfection of hands, laryngoscope blades, stethoscope, measuring tape, thermometer
Cidex (2%/2.25% glutaraldehyde)
This is made by adding 225 mL cidex with 1000 mL water. Once made, the solution remains active for 14 days. Contact time for disinfection and sterilization is 20 minutes and 4–6 hours respectively.
Face mask, resuscitation bag, reservoir, ventilator circuits, suction bottles, humidification chambers, weighing machine, laryngoscope blades, surfaces of incubators and warmers
Ecoshield (11% hydrogen peroxide with 0.01% silver nitrate)
20% solution (200 mL ecoshield in 800 mL water) is used for fumigation in NICU.
5% solution (50 mL ecoshield in 950 mL water) is used for wet mopping of floors, walls, and surfaces of incubators and warmers.
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Formalin (40%)
Used for fumigation of NICU.
It is not a good surface disinfectant.
Betadine (7.5% povidone iodine)
Skin preparation (it should be left over the skin for at least 15 seconds before wiping off)
Bleach solution (1% sodium hypochlorite)
Change the solution daily Contact time for disinfection is 30 minutes
Sharps/needles, kidney trays
Savlon (cetrimide solution, chlorhexidine gluconate and isopropyl alcohol in concentration of 15%, 7.5% and 7% respectively)
To fill suction bottles
Carbolic acid (3%)
For cleaning surfaces of incubators and warmers, and drains
Phenol (3%)
Wet mopping of floors and walls
Lysol (5%)
Wet mopping of floors and walls
 
FUMIGATION POLICY
Routine fumigation does not offer any advantage over and above good house-keeping measures. However, fumigation of NICU is done if air sampling cultures are positive or if there is an outbreak. This may be done with either 20% ecoshield (1 Liter 20% solution for each 1000 cubic feet area) or 40% formalin (30 mL 40% formalin added with 90 mL of water for each 1000 cubic feet area). In contrast to formalin, ecoshield is not irritant to the eyes. NICU has to be sealed properly for at least 6 hours after fumigation with formalin and for at least 1 hour with ecoshield.5
 
HOUSE-KEEPING ROUTINES
Method for disinfection
Frequency
Floors
Avoid dry sweeping and dusting. Wet mopping is done with 5% ecoshield, 3% phenol or 5% Lysol
Once in each shift
Walls (lower 1/3 of the height)
5% ecoshield, 3% phenol or 5% Lysol
Once in each shift
Buckets
Soap and water
Daily once in the morning and then as required
Wash-basins/sinks
Clean with detergent and water. Pour 3% carbolic acid in the drain after cleaning
Daily once in the morning and then as required
Dustbins
Washed daily with soap and water
Polythene changed at least once daily and then whenever full
Fans
Soap and water
Once in a week
Window of air conditioner
Soap and water
Once in a week
Refrigerator
Defrosted and cleaned with soap and water
Once in a week
 
DISINFECTION/STERILIZATION OF EQUIPMENT AND INSTRUMENTS
 
Ventilator
Use disposable ventilator tubes which come already sterilized with ethylene oxide at the time of packaging. Change tubing of 6the ventilator circuit in between the two patients and change them electively after each 72 hours of use.
Wash the reusable tube with soap and water and autoclave it before reuse. Alternatively, keep it immersed in 2% cidex for at least 6 hours. After immersion in cidex, rinse it with sterile distilled water and dry with autoclaved linen. Wrap it in autoclaved linen and affix the date and times of cleaning.
Change bacterial filters of ventilator in between the use by two patients.
Autoclave the humidifier chamber in between the use by two patients. Else sterilize the humidifier in cidex as explained above for the ventilator tubes.
Use only sterile distilled water in the humidifier and it should be changed daily.
 
Incubator/Warmers
Surfaces of incubators and warmers should be cleaned daily once and also in between the use by two different babies with 5% ecoshield, 2% cidex or 3% carbolic acid. Thoroughly clean all of the shelves.
 
Phototherapy Units and Pulse Oximeters
Wet mop with plain water daily once.
 
Oxygen Circuit
Sterilize the humidification chamber daily once by dipping in the cidex for 4–6 hours (20 minutes for disinfection). Change sterile distilled water in the humidifier daily.
Use only sterile disposable oxygen tubings (sterilized with ethylene oxide). Change oxygen tubing daily.7
 
Suction Apparatus
Sterilize the chamber daily once by dipping in cidex for 4–6 hours (20 minutes for disinfection). Change savlon solution in the suction bottle daily and keep it filled till the marked line.
Use disposable sterile suction catheters (sterilized with ethylene oxide) and change them maximum by 24 hours.
After each suctioning, rinse the connector with diluted savlon and cover it with autoclaved linen.
 
Oxygen Hood
Wash them with soap and water daily once in the morning shift and also in between the use by two different babies. Dry them with autoclaved linen.
 
Laryngoscope Blades
After use, remove the bulb of blade. Wash the blade with soap and water and immerse in 2% cidex for 4–6 hours. Wash with sterile distilled water after removal from the cidex. Dry it with autoclaved linen and wrap it in an autoclaved linen. Affix the date and time of cleaning it. In case of short time in emergencies, the laryngoscope may be cleaned with spirit or sterilium.
 
Self-inflating Bag and Reservoir
After use, it should be dismantled and washed with detergent/soap and water. Then, it is immersed in 2% cidex solution for 4–6 hours (20 minutes for disinfection). After removal from cidex, rinse with sterile distilled water, dry with autoclaved linen and assemble. Wrap in an autoclaved linen and affix the date and time of cleaning.8
 
Face Mask
Clean with detergent/soap and water. Immerse in 2% cidex for 4–6 hours (20 minutes for disinfection). After that, rinse with distilled water and dry with autoclaved linen. Wrap in an autoclaved linen and affix the date and time of cleaning.
 
Stethoscope, Measuring Tape, BP Cuffs, Probes of Radiant Warmers and Vital Sign Monitors
They are wiped with spirit or sterilium daily once in the morning shift and also in between the use by two different babies.
 
Weighing Machine
Weighing machine should be cleaned daily with 2% cidex. Use separate sterile paper for each baby at the time of taking weight.
 
Thermometer
It should be separate for each baby. Thermometer is wiped from bulb to base with spirit or sterilium daily once in the morning shift. Store in a case containing sterile dry cotton.
 
Procedure Sets and Instruments
Soiled instruments should be washed with water after use, dried, kept in a tray and wrapped with linen. Then, they are autoclaved for sterilization. Date and time of autoclaving should be affixed over the set. They should be autoclaved after each use or else after every 72 hours if not used.
 
Cheatle Forceps
They should be autoclaved daily and kept in a sterile autoclaved bottle containing sterile dry cotton.9
 
Kidney Trays
Kidney trays should be either autoclaved daily or immersed in 1% sodium hypochlorite solution for 30 minutes.
 
Swab Containers and Injection Trays
Wash with soap and water daily once in the morning shift.
 
PRECAUTIONS IN NEWBORN CARE
  • Hand hygiene: Pictorial instructions for hand washing and hand rubbing should be displayed, including the one at the wash-basin area. These should be followed by everyone involved in the baby care including the mother and the family. Parents and other caregivers should also be guided and supervised for proper hand washing technique. Do not keep long or polished nails. Rolling up of sleeves and removal of accessories like watch, bangles and rings is a must for achievement of effective hand hygiene. Follow strict hand washing before and after touching each patient. Equipment attached to the baby should be considered as an extension of baby and thorough hand washing should be done before/after touching them also. Use hand-rub solutions in cases of emergencies when the hands are not visibly soiled. Do not touch anything like pen, case file, etc. after handwashing/handrubbing, till you have completed the desired job. For more details see the chapter on ‘Hand Hygiene’ (page no. 13).
  • Do not keep fomites like case files, X-rays, etc. on the baby's cot.
  • Personal clothing and unscrubbed areas of skin should not touch the baby. Sterile gown and mask should be worn while handling neonates. Gowns for routine care should be half-sleeved and those for invasive procedures should be full-sleeved. Separate gown should be used for each baby. 10Use separate sterile gown for invasive procedures like exchange transfusion.
  • Wear face mask and head cover while handling neonates.
  • Baby should be nursed on autoclaved linens. Blankets of the baby should be dry-cleaned and then autoclaved before use.
  • Use disposable cord clamp or autoclaved cord ties. Keep cord dry and do not apply anything on the cord. If cord is infected, send culture and sensitivity swab from the site and treat urgently.
  • Clean each eye daily with separate sterile gauze piece soaked in sterile normal saline from medial to lateral side.
  • Use sterile cotton sponges and sterile (boiled) warm water to remove blood/meconium from the skin. Mopping of the neck, axillae and groins should be done daily once. Bottom of newborn should be wiped in anterior to posterior direction (avoiding soiling of vulva or inguino-scrotal folds with stools).
  • Use disposable nappies made of autoclaved cotton and gauze.
  • Avoid using formula and top milk as far as possible. Use expressed breast milk for gavage or cup/katori feeding. Breast milk should be expressed in sterile containers with a lid after thorough handwashing. Feeds should be handled with all aseptic precautions. EBM stored in the refrigerator for more than 48 hours should not be used. Feeding utensils of the baby should be boiled for 20 minutes for sterilization.
  • Always use sterile gloves for invasive procedures including blood sampling, insertion of IV cannula, giving medications, etc.
  • Prepare skin properly with betadine and spirit as mentioned in the chapter on ‘Common Procedures on and for Neonate’ (page no. 303).
  • 11Label IV fluid bottles with date and time of opening the seal. Once opened, they should not be used beyond 24 hours.
  • Burette should be changed every 24 hours.
  • Unnecessary manipulation of peripheral, umbilical, arterial and central lines should be avoided. Invasive lines should be removed at the earliest.
  • IV sets and ports should not be left open.
  • Antibiotic vials should be changed every 24 hours.
  • Use separate IV line for administration of antibiotics. Do not open the IV fluid line to administer injections.
  • Avoid repeated pricks for blood sampling. Try to plan all investigations as much together as possible. Always wipe off the blood soiled skin properly because it may serve as a culture media for pathogens.
  • There is no role of usage of prophylactic antibiotics. This may in fact be a harmful practice by increasing the antibiotic resistance in NICU.
  • Routine use of H2 (histamine receptor) blockers like ranitidine may be a harmful practice as the acid environment of stomach is protective against colonization by pathogenic bacteria.
  • Kangaroo mother care given in very low birth weight babies has been shown to decrease the risk of nosocomial infections.
 
WASTE DISPOSAL
All health personnel should be aware of biomedical waste disposal policy at their hospital which may slightly vary from place to place. The different color drums with different color polythenes for different types of waste are to be disposed off in different ways. Dustbins should be covered and foot-operated.
In our units, black drums/bags are used to collect non-infectious waste like papers, empty card boxes, paper bags, 12etc. This waste is routinely dumped off by municipal committee machinery. Yellow drums/bags are meant to collect infected non-plastic waste like blood, body fluids, soiled dressings and placenta. This waste is incinerated. Blue drums/bags collect infected plastic waste like IV sets, blood transfusion sets, ET tubes, urine bags, etc. This waste is autoclaved to make it non-infectious and then shredded before disposal. Puncture proof containers are used for sharps like needles and blades. These containers have 1% sodium hypochlorite solution for disinfection (which has to be changed daily) or else it is autoclaved to make it non-infectious. Afterward this waste is also shredded and disposed off.