NICU Outbreaks
Nawaf M. Al-Dajani
Disclosure
Infection Components
Host
Organisms
Environment
MRSA
70
60
50
40
%
30
20
10
0
1980
1985
1990
1995
2000
2005
Infection Rates in NICUs
Up
to 6-38 (25%) per 100 admissions.
8.9 to 62 per 1000 patient days.
No. approved antibiotics
16
14
12
10
8
6
4
2
0
83-87
88-92
93-97
98-02
20032007
Outbreak:
An excess over the usual level of a
disease within geographic area in
certain period.
•
•
Epidemic curve:
Base line data:
4
3.5
3
2.5
GP
2
GN
1.5
Can
1
0.5
0
DEC
JAN
FEB
MAR
Nosocomial infection
• Inevitable
•
Preventable
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.
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
F - Formulate hypothesis:
- Source
- Epi curve
- Graph
Cont…
G - Test hypothesis:
H - Evaluate control measures
efficacy:
I - Review current practice:
J- Communicate findings:
Examples
MRSA
outbreak BCCH, Vancouver.
1999, 33 cases were identified in
NICU.
Task force team assembled.
Effective IC measures implemented.
Enhanced surveillance.
Isolation and cohorting.
35
30
Weekly surveillance
25
20
Glove & gown d/c’d
15
10
5
0
1998
1999
2000
2001
2002
2003
2004
2005
Al-Dajani et al, IDSA 2006
ug
-
ug
-
ug
-
ug
-
05
pr
-0
5
-0
5
Ju
n-
A
Fe
b
4
-0
4
04
04
ec
-0
D
O
ct
A
Ju
n-
pr
-0
4
14
-0
4
Persistant CoNS
A
Fe
b
3
-0
3
03
ec
-0
D
O
ct
A
03
pr
-0
3
-0
3
Ju
n-
A
Fe
b
2
-0
2
02
02
ec
-0
D
O
ct
A
Ju
n-
pr
-0
2
-0
2
16
A
Fe
b
1
-0
1
01
01
ec
-0
D
O
ct
A
Ju
n-
# of Cases
Distribution Of CoNS Cases
CoNS Bacterem ia
Vanco stopped
Daily tubing replacement
12
10
8
6
4
2
0
KAAUH
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
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-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???
NICU closed.
Satellite unit opened.
Screen all new comers.
Outbreak over.

Cont…
 Klebsiella pneumonia sepsis > 50%, 2001, PIDJ,
 88/115 had clinical sepsis, MR 51%.
 24 pt develop sepsis in < 24hr, K-P 73%, ESBL
05.
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 messages








Team work.
Epi-curve.
Think of the source.
Reinforce IC measures.
Appropriate allocation.
Review antibiogram.
Re-evaluate efficacy of IC.
Prevention vs therapy