Deadly NICU outbreaks put focus on infections
Deaths traced to caregiver oversights
Three deadly outbreaks of infections in neonatal intensive care units this year are serving as a call to arms for ICUs to tighten up on infection control procedures.The outbreaks include:
• The deaths of four infants in a six-week period at Children’s Hospital in Boston, which was traced to a strain of Pseudomonas aeruginosa The NICU was closed for a month.
• The deaths of two infants reported by clinicians at Temple University in Philadelphia due to a Pseudomonasoutbreak in a newborn ICU.
• The infection of three low-birth-weight infants with Candida lusitaniaeat the Medical University of South Carolina in Charleston. One of the infants died.
The cause of the Boston outbreak, which drew headlines nationwide in the popular media, was traced to an antibiotic-susceptible but unusually virulent strain of Pseudomonas That strain was found on the hands of one health care worker and two surfaces in the NICU, but researchers believe the already-fragile condition of the infants was the main cause of the deaths.
"They were all intubated children, and the most likely portal of entry was the respiratory system," says Bela Matyas MD, medical director of the epidemiology program at the Massachusetts State Health Department in Boston. "It’s very likely that all four of them had pre-existing pneumonias prior to the bloodstream infection forming, but the cause of death was bacteremia. "Pseudomonasis not, generally speaking, anywhere near this aggressive an organism," Matyas says.
P. aeruginosacauses about 10% of the 2 million nosocomial infections reported annually, but the rapid progression of the infections in the outbreak was uncommon.
Investigators in the other two cases found procedural flaws that serve as a grim reminder for ICU managers about the need to follow proper precautions.
In the case reported by Temple University Hospital researchers, the
infections were traced to a failure to properly disassemble and disinfect
a blender used to mix baby formula. As a cost-
savings measure, the hospital had switched from buying prepared infant
formula to buying a powdered formula that was mixed on site, the investigation
found.
But tests revealed that the formula blender housing and blades were
contaminated with the strain that caused the outbreak, which was first
reported in New Orleans at the 1997 annual
conference of the Association for Professionals in Infection Control
and Epidemiology (APIC) by Keith St. John MS, CIC, infection control
professional at Temple University Hospital.
The hospital has returned to the practice of buying prepared formula, he says, and any additives to the prepared formula are done under pharmacy supervision using laminar flow hoods and aseptic conditions.
"I just caution everyone, take a look at your facility because we are all trying to save a dollar," he says.
"Hospital policies concerning infant formula preparation and monitoring are often lacking," he says. "I must say the dietary department cleaned up their act. In fact, we have banned the blender. The blender is no more in our institution as a result of this."
In the Medical University of South Carolina case, researchers say transmission could have occurred via the hands of health care workers, contaminated hospital equipment, or a common vehicle to which all three babies were subjected.
Hand cultures were not taken at the time, but investigators concluded that because the organism was never isolated from equipment or environmental furnishings, hand carriage was implicated in the spread of the organism from one infant to another.
As a result of the outbreak, a multidisciplinary task force was formed and the following steps were instituted:
• Educational inservices were conducted.
• Waterless alcohol hand washing stations were added to encourage compliance.
• A practice monitoring sheet was developed so ICU could observe each other as part of learning a standardized approach to infection control in the unit. (See monitoring sheet, p. 17.)
"We put together a basic infection control practices list. Hand washing is one, of course, and there are some related to isolation precautions and the handling of equipment," says Beth Rhoton RN, MS, CIC, infection control practitioner at the facility. "Eventually, we hope to have everybody in the unit trained so that everybody is working with the same basic infection control ideas. It is not to be punitive. Part of the educational process will be how to communicate to somebody that they are not doing something right so that we don’t have hurt feelings." n
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