INTRODUCTION
Perinatal
infections especially neonatal bacterial infections are the commonest cause of
neonatal mortality in india. Infections
can occur during intranatal period or
during delivery or during the neonatal period. The neonates are more
susceptible to infections because they lack in natural immunity and take some
time for development of acquired immunity
TERMINOLOGY
Neonatal sepsis:- Neonatal sepsis is a
severe bacterial infection occurring in a newborn. Infants are
particularly susceptible to infection due to their immature immune system and lack of immunity.
Pyoderma:- it is the superficial skin infection
usually caused by staphylococcus aureus.
Oral thrush:- it is the fungal infection of the oral
cavity and tongue by candida albicans in
the late first week and second week of age.
Opthalmia neonatorum:- inflammation of conjuctiva
during first three weeks of life is termed as opthalmia neonatorum.
SOURCES OF INFECTIONS
Infections
can occur during antenatal, intranatal, postnatal period due to various
conditions.
Antenatal
period
·
Intrauterine
infections can occur due to various microorganisms and described with an
acronym of STORCH where in S for
syphilis, T for toxoplasmosis, o for others (eg:- gonococcal infections,
tuberculosis, malaria, varicella,hepatitis B, HIV)R for rubella, C for
cytomegalovirus and H for herpes simplex hominis.
·
Ascending
infections with contaminated liquor amnii and amnionitis related to infected
birth passage and premature rupture of membrane may also lead to intrauterine
infection to the fetus.
Intranatal
period
·
Aspiration of
infected liquor inprolinged labour following early rupture of membrane which
may lead to neonatal aspiration pneumonia.
·
Infection may
occur due to repeated vaginal examination by delivery assistant especially when
membvrane is ruptured.
·
Infected birth
passage may infect the eyes and mouth of the neonates leading to ophthalmia
neontarum and oral thrush.
·
Improper aseptic
technique during care of umbilical cord may cause umbilcal sepsis.
Postnatal
period
The following are important causes of neonatal
infections in postnatal period:
·
Transmission of
infection from human contact or care gives especially from infected hands of
mother, family members and health care providers (doctors, nurses, other staff)
·
Cross-infection
from other baby who is infected and no barrier nursing is practised and
universal precautions are not followed.
·
Infected articles
for baby care and contaminated clothing.
·
Invasive
procedures without aseptic technique.
·
Infected
environment around the neonates at hospital/ health center or home.
The organisms can cause neonatal infections, are:
- E. coli
- Herpes
- Rubella
- Syphilis
- Listeriosis
- Candidiasis
- Chickenpox
- Toxoplasmosis
- Coxsackie virus
- Cytomegalovirus
- Rotavirus, Enteroviruse
·
Group B Streptococcus
(GBS)
·
coagulase-negative
Staphylococcus
·
Epidermidis
·
S. Aureus
·
Streptococcus mutans.
·
Enterococcus faecalis
·
Streptococcus pneumoniae
·
Streptococcus pyogenes.
·
Neisseria
meningitides
·
Pseudomonas aeruginosa
·
Haemophilus influenzae
·
Lactobacillus species
- Clostridium perfringens
Factors responsible for neonatal
infections
The
predisposing factors responsible for neonatl infections are:-
-
Low birth weight
infants
-
Contaminated
intrauterine environment like prolonged rupture of membrane, unhygienic and multiple vaginal examination,
meconium-stained liquor, etc.
-
Infected birth
passage and infection at birth in delivery room or neonatalcare units.
-
Birth asphyxia
and resuscitations.
-
Congenital
anomalies.
-
Venous neonatal
procedures with inadequate asepsis during IV infusion, parenteral medications,
endotracheal intubation, assisted ventilation, exchange blood tranfusion etc
-
Sex of the body –
male babies are more prone to neonatal infections than female in two times. The
exact explanation is not known.
-
Artifitial
feeding other than human breast milk.
BASIC
PHYSIOLOGY OF NEONATAL INFECTIONS:
Throughout pregnancy and until the
membranes rupture, the foetus is relatively protected from the
microbial flora of the mother by the chorioamniotic membranes, the
placenta, and poorly understood antibacterial factors in amniotic
fluid.
However, there are many ways that
infectious agents can reach the foetus or newborn to cause
infection.
Procedures disturbing the
integrity of the uterine contents, such as amniocentesis, cervical
cerclage, transcervical chorionic villus sampling, or percutaneous
blood sampling can permit entry of skin or vaginal organisms,
causing amnionitis and secondary fetal infection.
Certain bacteria, particularly Treponema pallidum and Listeria monocytogenes, can reach the
fetus through the maternal bloodstream despite placental protective
mechanisms, causing transplacental infection. This process is
uncommon, but it leads to either congenital infection not unlike
infections caused by certain viruses or Toxoplasma or to stillbirth resulting from
overwhelming infection.
Initial colonization of the
neonate usually takes place after rupture of the maternal membranes.
In most cases, the infant is colonized with the microflora of the
birth canal during delivery. However, particularly if the rupture of
membranes lasts longer than 24 h, vaginal bacteria may ascend and in
some cases produce inflammation of the fetal membranes, umbilical
cord, and placenta.
Fetal infection can result from
aspiration of infected amniotic fluid, leading to stillbirth,
premature delivery, or neonatal sepsis. The organisms most commonly
isolated from infected amniotic fluid are anaerobic bacteria, group
B streptococci, Escherichia coli,
and genital mycoplasmas.
Infection of the mother at the
time of birth, particularly genital infection, is the principal pathway
of maternal transmission and can play an important role in the development of
infection in the neonate.
Transplacental haematogenous infection during
or shortly before delivery (including the period of separation of
the placenta) is possible, although it seems more likely that the
infant is infected during passage through the birth canal. Finally,
bacteria can be introduced after birth from the environment
surrounding the baby, either in the nursery or at home.
Many pre- and intra partum
obstetric complications are associated with an increased risk of
infection in newborn infants. Among these are premature onset of
labour, prolonged rupture of the fetal membranes, uterine inertia
with high forceps extraction, and maternal pyrexia.
Sophisticated equipment for
respiratory and nutritional support combined with invasive
techniques provide life support to the ill infant. Arterial and
venous umbilical catheters, central venous catheters, peripheral
arterial and venous canulas, urinary indwelling catheters, hyper
alimentation infusions, and assisted ventilation provide enormous
opportunities for relatively non virulent pathogens to establish
infection and to invade the host.
Sometimes, however, depending on
the age of the patient, the virulence and number of bacteria in the
blood, the nutritional and immunologic status of the host, and the
timing and nature of therapeutic intervention, a systemic
inflammatory response is established that can progress independently
of the original infection.
COMMON INFECTIONS IN NEONATES
The
neonatal infections are superficial and localised or systemic. The common sites
of superficial infections are eyes, skin, umbilicus, and oral cavity. The
systemic infections include septicemia, meningitis, pneumonia, necrotizing enterocolitis
,tetanus neonatrum, systemic candidiasis, pyelonephritis etc. Intrauerine infections may be manifested at birth or delayed for few days to several
weeks. Viral infection in utero may lead to fetal death, congenital
malformations or severe systemic manifestations of the disease.
OPHTHALMIA NEONATRUM
Inflammation
of conjuctiva during first 3 weeks of life is termed as ophthalmia neonatorum.
Sticky eyes without purulent are common during first 2 to 3 days after birth.
Þ
Unilateral
conjuctivitis after 5 days of life is often due to chlamidia trachomatis.
Þ
Purulent
conjuctivitis with profuse discharge is usually due to gonococcus which may affect one or both eyes within 48
hours.
Þ
Other
microorganism include streptococcus, staphylococcus, pneumococcus, e.coli, herpes simplex virus etc.
Þ
Chemical
conjuctivitis may occur due to irritation of silver nitrate, soap, local
antibiotic drops.
Mode
of infections
- Infected hands of care givers
- Infected birth canal
- Cross infection from other infected infants.
- Directly from other sites of infection like
skin and umbilicus.
Clinical
features
May
vary with mode of infection and causative organism
Neonate
may present with sticky eyes with or without
discharge ranging from watery or purulent or mucopurulent in one or both
eyes. The eyelids may be markedly swollen and stuck together with redness of
eyes.
Management
-
Management is
done with specific antibiotic therapy (as eye drops or in parenteral route),
after identification of causative organism.
-
Baby kept
isolated to prevent cross- infection
-
Sulfacetamide or
framycetion or chloramphenicol drops or erythromycin ointment can be used.
-
For gonococcal
infection penicillin therapy (local or
parenteral) should be inititated promptly.
-
If organism are
resistant to penicillin, then cefotaxime
or ceftriaxone are used.
-
Cleaning of
infected eyes with sterile cotton swabs soaked in saline should be done after
handwashing.
-
Instillation of
eye drops should be done with proper aseptic precautions.
Preventive
management
·
Include treatment
of maternal infection, aseptic technique
during delivery, special care and attention inface nd breech presentation,
isolation of infected babies and general of cleanliness.
Prognosis
In
neglected cases orbital cellulitis and dacrocystitis with obstruction of
nasolacrimal duct may develop.
In
gonococcal infection corneal infection may lead to corneal opacity.
In
rare cases blindness may occur if no treatment done
UMBILICAL SEPSIS
The
incidence of omphalitis is reduced tue to aseptic technique and clean practices
at birth.
The
source of infection may be unhygeinic environment at the time of delivery,
umbilical catherization, exchange transfusion, contaminated cord cutting
instrument, infected hands of care giver or infected clothing.
The
causative organism are mainly staphylococcus, E.coli, or any pyogenic organism.
Clostridium tetani can also infect umbilical cord and cause tetanus neonatorum.
The incidence of tetanus neonatorum is also reduced due to administration of
tetanus toxoid to antenatal mothers. But
it is found in rural areas in home delivery.
Clinical
features of umbilical sepsis are mainly
swollen and moist periumbilical tissue with redness, foul smelling and
serous or seropurulent discharge, delayed falling off umbilical cord and fever . jaundice and features of
septicemia may appear in complicated cases. The clinical manifestation of
tetanus found in clostridium tetani.
Management
of this condition is done with dressing of the infected cord with triple dye or
spirit and antibiotic powder or lotion.
Umbilical cord should left uncovered rather than application of dressing. Systemic antibiotics is given in complicated
cases. The infected baby should be kept in isolation. Special management
required in tetanus neonatorum. Culture and sensitivity test of umbilical swab
may be needed in some cases who are not responding to routine treatment.
Umbilical
sepsis can be complicated with thrombophlebitis of umbilical vein, umbilical
granuloma, hepatitis, liver abscess, peritonitis and portal hypertension.
Prognosis depends upon nature of infection, initiation of management and
nursing care. Prevention of umbilical cord infection is more easy and important
in neonates.
ORAL THRUSH
It
is fungal infection of the oral cavity and tongue by Candida albicans in the
late first week or second week of age. Infection occurs from infected birth
canal, infected feeding bottles ans teats or contaminated feeding
articles, mother’s hands and breast
nipples. It may develop due to prolong antibiotic therapy.
The
neonate usually presents with milky-ahite elevated patches on buccal mucosa,
lips, tongue and gums, which cannot be easily wiped off with gauze and oozes
blood on attempt to scrap the patches. Swalowing difiiculties may be present due to posterior
oropharyngeal white patches. Sucking reflex may be normal. Infection may cause
monolial diarrhea, perineal monoliasis and lung infections.
Oral
thrush is managed by oral application 0.5 percent aqueous solution of gentian violet
after each feed. Nystatin and ketoconazole or cotrimazole lotion are used 4
times per day fro 5-7 days. Parenteral antibiotics can be administered in
disseminated candidiasis. This conditon can be prevented by treating maternal
fungal infection and using clean utensils and maintainence of general cleanliness and hygeinic measures.
PYODERMA
It
is the superficial infection usually caused by staphylococcus aureus. The skin
eruptions and pastules are commonly seen on scalp, neck groin and axillae.
These are commonly found in summer months. This infection occurs from
contaminated hands of the personnel responsible for care of the neonate. Unhygeinic environment ,
spread from other infected baby and contaminated baby clothings can also result
in this infections.
The
infection may spread to cause abscess, osteomyelitis, parotitis and septicemia.
The life-threatening staphylococcal infection may result in pemphigus
neonatorum, that is manifested as marked erythema, bullous lesions and
exfoliation which give an appearance of scalded skin syndrome.
Treatment
of these lesions include puncturing cleaning with hexachlorophene, antiseptic
skin care and application of triple dye
over the punctured lesions. Pus should be sent for culture and sensitivity
test. In case of spread of infection, erythromycin 50 mg/kg per day orally in 3
divided doses should be administered. In complicated cases, parenteral
administration of antibiotic should be done. The baby should be kept in
isolation.
This
condition can be prevented by avoidance of dip baby bath in hospital delivery
and during hospital stay, isolation of infected baby, maintenance of general
cleanliness ( include clean clothing) and the treatment of source of
infection.prognosis is good if treated promptly with good nursing care.
NEONATAL SEPSIS
1. Neonatal sepsis is a severe bacterial infection occurring in a newborn. Infants are particularly susceptible to infection due to their immature immune system and lack of immunity.
2. Neonatal sepsis is a bacterial infection in the blood.
3. Neonatal sepsis is a clinical syndrome characterised by systemic signs of infection accompanied by bacteraemia in the first month of life. In neonates, maternal, environmental and host factors determine the risk of sepsis on exposure to a pathogen.
CAUSES:
· In most cases it is caused by kleibsiella pneumonia, staphylococcus aureus, E.coli, pseudomonas aeruginosa etc
· Bacteria can gain entry via the placenta, in the birth canal or after delivery. They gain access in the blood stream, they may cause an overwhelming infections
·
The commonest sources
of infection in the community are unhygienic practices during delivery at home
which include delivery in dark dirty rooms, cord cut with any available sharp
instrument and the baby wrapped in old, dirty clothes. Other practices that
increase the risk of infection include harmful applications to the cord,
discarding colostrum and use of prelacteal feeds. Numerous visitors, who could
be carriers of infection, are another source of infection for the babies.
RISK
FACTORS:
The most common risk factors associated with
early onset neonatal sepsis include
Maternal group B Streptococcus (GBS)
colonization (especially if untreated during labour) Premature rupture of membranes (PROM) Preterm rupture of membranes Prolonged rupture of membranes Prematurity Maternal urinary tract infection Low Apgar score (<6 at 1 or 5 min) Maternal fever greater than 38°C Maternal urinary tract infection Poor prenatal care Poor maternal nutrition Low socioeconomic status Recurrent abortion Maternal substance abuse Low birth weight Difficult delivery Birth asphyxia Meconium staining Congenital anomaliesTYPES OF NEONATAL SEPSIS
o
Neonatal sepsis
may be categorized as early or late onset.
·
Eighty-five
percent (85%) of newborns with early-onset infection present within 24 hours.
·
5% present at
24-48 hours.
·
Smaller
percentage of patients present within 48-72 hours.
o
Onset is most
rapid in premature neonates.
Early onset sepsis syndrome :- It is associated with acquisition of
microorganisms from the mother.
o
Transplacental
infection or an ascending infection from the cervix may be caused by organisms
that colonize in the mother's genitourinary tract, with acquisition of the
microbe by passage through a colonized birth canal at delivery.
Late-onset sepsis syndrome:- It occurs at 4-90 days of life and
is acquired from the caregiving environment. Organisms that have been
implicated in causing late-onset sepsis syndrome include coagulase-negative
staphylococci, Staphylococcus aureus
, E coli, Klebsiella, Pseudomonas,
Enterobacter, Candida, GBS,
Serratia, Acinetobacter, and
anaerobes. Trends in late-onset sepsis show an increase in coagulase-negative Streptococcal sepsis; most of these
isolates are susceptible to first-generation cephalosporins. The
infant's skin, respiratory tract, conjunctivae, GI tract, and umbilicus may
become colonized from the environment, leading to the possibility of late-onset
sepsis from invasive microorganisms. Vectors for such colonization may include
vascular or urinary catheters, other indwelling lines, or contact from
caregivers with bacterial colonization.
o Pneumonia is
more common in early onset sepsis, whereas meningitis and bacteremia are
more common in late-onset sepsis.
o
Premature
and ill infants have an increased susceptibility to sepsis and subtle
nonspecific initial presentations; therefore, they require much vigilance so
that sepsis can be effectively identified and treated.
INCIDENCE AND PREVALENCE:
·
The incidence of
culture-proven sepsis is approximately 2 per 1000 live births.
The
mortality rate in neonatal sepsis may be as high as 50% for infants who are not
treated. Infection is a major cause of fatality during the first month of life,
contributing to 13-15% of all neonatal deaths. Neonatal meningitis, a serious
morbidity of neonatal sepsis, occurs in 2-4 cases per 10,000 live births and
significantly contributes to the mortality rate in neonatal sepsis; it is
responsible for 4% of all neonatal deaths.
·
Sex
The incidence of
bacterial sepsis and meningitis, especially for gram-negative enteric bacilli,
is higher in males than in females.
Premature infants
have an increased incidence of sepsis. The incidence of sepsis is significantly
higher in infants with very low birth weight (<1000 g), at 26 per 1000 live
births, than in infants with a birth weight of 1000-2000 g, at 8-9 per 1000
live births. The risk for death or meningitis from sepsis is higher in infants
with low birth weight than in full-term neonates.
CLINICAL FEATURES:
The clinical signs of neonatal sepsis are
nonspecific and are associated with characteristics of the causative organism
and the body's response to the invasion.
Infants with neonatal sepsis or infection may exhibit some of following symptoms:
·
Apnea
·
Shock
·
Diarrhea
·
Seizures
·
Jaundice
·
Vomiting
·
Cyanosis
·
Weak sucking
·
Slowed heart rate
·
Lethargic,
inactive
·
Breathing
difficulty
Early onset
neonatal sepsis may present as perinatal
hypoxia, resuscitation dificulties and congenital pneumonia in the form of
respiratory distress. The late onset neonatal sepsis in a very small baby may
be silent who may be die suddenly without presenting any signs and symptoms.
The
baby “does not look well” may sound vague but is a most useful clue to an experienced doctor or nurse. The baby
will be lethargic, inactive, and pale or unresponsive and refuses to suck. Poor
cry, vacant look, comatosed and not arousable baby with distension of abdomen,
diarrhea, vomitting, less weight gain or loss of weight and poor neonatal
reflex. In sick neonates poor capillary perfusion may present. In critical
neonates circumoral cyanosis, shock, bleeding, excessive jaundice and renal
failure may develop.
LABORATORY FINDINGS :
Ø History collection (antenatal, intra natal,
postnatal)
Ø Complete physical examination of neonate
Ø By clinical symptoms
Ø CSF analysis:
·
The CSF findings
in infectious neonatal meningitis are an Elevated WBC count (predominately
PMNs)
·
Elevated protein
level
·
Decreased CSF
glucose concentration
·
Positive culture
results
Ø Hematologic studies: The platelet count in the
healthy newborn is rarely less than 100,000/µL in the first 10 days of life.
Thrombocytopenia with counts less than 100,000 may occur in neonatal sepsis in
response to the cellular products of the microorganisms.
Ø Cultures of:
o Blood
o Urine
o Cerebrospinal fluid
o Skin lesions
COMPLICATIONS:
· Neonatal meningitis
· Pneumonia
· Respiratory distress
· Conjunctivitis
· Necrotizing Enterocolitis (NEC)
TREATMENT:
v Antibiotics : administration of
antibiotics to control infection.
It is administered considering the
causative organisms. A combination of ampicillin and gentamycin/amikacin is
recommended for the treatment of sepsis and pneumonia. In case of suspected meningitis,
chloramphenicol should be added. Duration of therapy is individualised. In
general antibiotics is given 10-14 days in septicemia and pneumonia, 14 days
for urinary tract infection and 21 days for meningitis.
Other antibiotics which are used
for neonatal sepsis include amoxycillin, cloxacillin, cefriaxone, ceftazidime,
ciprofloxacin, cefotaxime etc.
v Other drug therapy includes
anticonvulsive (diazepam or phenobarbitone) and corticosteroids in severely
sick neonates ith endotoxic shock. Dopamine to treat shock and mannitol to
reduce intracranial pressure.
v Intravenous Fluids : fluids,
glucose, and electrolytes.
If child is having poor perfusion,
then normal saline bolus infused with 10 ml/kg over 5 to 10 minutes. It can be
repeated with same dose 1 to 2 times over next 30 to 45 minutes if perfusion is
continuing as poor.
Dextrose 10% 2ml per kg bolus can
be infused to correct hypoglycemia and continue to 2 days or till the baby can
have oral feeds.
IV fluuids can be continued with
one fifith saline in 10% dextrose from third day onward. Pottasium added as KCl
one ml per 100ml of fluid after 2 to 3 days of age provided if the infant is
passing urine normally.
v Oxygen
therapy if neonate have respiratory distress or cyanosis. Bag and mask
ventilation required if child is apneic.
v Management of fever
v Nutrition: feeding baby through NG tube or
encourage mother to give Breast feed. Enteral feed is mostly avoided due to
abdominal distention
v Vit K to prevent bleeding disorders.
v Hydration : administration of fluids and electrolytes as per order to prevention of hypoglycaemia.
v supportive management:
Use of blood transfusion Fresh frozen plasma Exchange transfusion : Granulocyte and fibronectin transfusion Haematopoietic factors etc.
PREVENTION
OF NEONATAL INFECTION:
Prevention of infections is utmost importance if one has to decrease
neonatal mortality.
v Measures that could have a major impact in lowering neonatal
infection includes:
Ø Late pregnancy and newborn screening for neonatal infections and early treatment has played a major role in reducing the number of cases of newborn sepsis.
Ø Administration of prophylactactic
antibiotics before, during and after delivery to mother.
Ø Administration of two doses of
tetanus toxoid to all pregnant women
Ø Proper care of the cord and skin
Ø Early detection and prompt treatment of minor infections
Ø Hygienic practices at birth are also responsible for reducing infections and
deaths both of the baby and mother.
The
introduction of five cleans at delivery which include
·
clean surface
·
clean hands
·
clean blade
·
clean cord tie
·
clean clothes have
contributed to the reduction of neonatal infections.
Ø Clean cord care to reduce cord infection:
·
Reducing harmful
applications to the cord
·
The simplest way of
caring for the cord is to keep it clean,
·
Avoid any form of
application
·
Leaving umbilical cord
open to dry
·
Skin is kept clean by
bathing the baby beyond first 5-7 days
·
Using clean clothes
·
Avoid baby left in soiled and wet clothes and
nappies.
Ø Exclusive breastfeeding in preventing infection:
Breastfeeding protects the baby against
·
Diarrhea
·
Respiratory infections
(otitis media) and other infections.
Breastfed infants have a 14% less likely chance of
dying of diarrhea and 4% less chance of dying of respiratory infection as
compared to top-fed infants.
Exclusive
breastfeeding is the single most effective strategy to lower the risk of deaths
in neonates through childhood. Colostrum is rich in immunoglobulins and cells
and protects the neonate from infection. Babies must be fed colostrum and the
practice of discarding colostrum must be abandoned.
Ø Avoid supplementary feeds, food before 6 months to the
baby.
Ø Neonates particularly preterm neonates have an
immature immune system and therefore are more prone for developing infection.
It is important to provide a safe environment
in the Neonatal Intensive Care Unit (NICU) to prevent neonates from getting
nosocomial infection.
Ø The source of infection could be: personnel, other
neonates, fomites - equipment, environment or invasive procedures.
Personnel working in the NICU can spread infection if
they are carriers or if they do not observe hand-washing practice strictly.
A strict Hand washing policy should be maintained in NICU
·
2-3 minutes hand wash
upto elbows before entering NICU.
·
15-30 seconds hand
wash in between / before handling babies.
·
Drying hand is
extremely important
·
Dry using dryer,
disposable paper or autoclaved napkins
Ø Septic neonates especially those with open wounds or
skin lesions should ideally be isolated so that infection does not
spread from one neonate to the other.
Ø Maintaining air circulation in the NICU (Laminar air flow or air conditioning
minimum 12 air changes per hour if available)
Ø Maintain optimum distance between beds
·
Use of individual
equipment and use of disposables.
·
Follow
strict aseptic measures during care of newborn in NICU.
NURSES ROLE IN PREVENTION OF INFECTION IN
NICU:
Ensuring the safe, effective and ethical infection
prevention measures is an important component of nursing care.The practice of
standards by nurses will help prevention of infection in the health care unit
[ICU]
The practice standards are
1.
Application of evidence based measures:
Nurses understand
and apply evidence based measures to prevent and control transmission of micro
organism that are likely to cause infection.
The nurse meets the
standards by
- Adhering to
appropriate hand hygiene protocols;
- Using a systematic
approach to care based on current infection control principles.
- Knowing her/ his
personal immunization status relevant to the practice setting and taking
appropriate action to ensure client protection.
- Taking all measures
necessary to prevent the transmission of infection from the nurse to client or
other health care providers.
2.
Application of professional judgement:
Nurse exercise
professional judgement relevant to each client situation and infection
prevention and control practices.
The nurse meets the standards by
·
Assessing situation for potential or actual infectious disease transmission.
·
Selecting and using appropriate prevention measures when microorganism
likely to come into contact with the nurse’s skin, mucus membranes or clothing.
·
Modifying her/his practice appropriately when there is risk of
transmitting a disease to clients or other health care providers.
·
Taking appropriate action when a
co worker has a potentially
transmissible disease.
·
Advocating for an environment and equipment that reduce the risk for disease transmission.
·
Advocating for the establishment of and compliance with infection control
policies relevant to the practice setting [example: single use items]
·
Maintaining open communication with the health care team.
·
Communicating safety concerns to the appropriate authority.
·
Advocating for communication system that protect client confidentiality.
3.
Risk reduction:
The nurses reduce the risk to self and others by appropriately handling ,
cleaning and disposing of materials and equipment.
Participate in
education on the use of safer medical devices and work practices relevant to
the practice setting. Adhering to the best
practices or manufacturer’s guideline on the cleaning, disinfecting and
disposal of waste or hazardous material. Using safety
devices.[ disposable items] Following prevention
control measures like
- Following Hand
washing guidelines or protocols
- Use of protective
barriers includes gloves, mask, eyewear, gowns and plastic aprons
- Care of equipments:
involves the appropriate disposal of waste, contaminated laundry and sharps and
cleaning, sterilization and disinfection of equipments, instruments and
devices.
- Nurse should follow
manufacturer facility protocols.
4.
Communication:
Nurse using appropriate and timely communication strategies with clients
and significant others, health care unit.
§ Using appropriate
teaching strategies to communicate health information to clients
§ Identify hazards and
the potential for injury
§ Reporting a breach
in infection control technique and taking action to limit damage.
§ Communicating safety
concerns
§ Advocating for changes
in practice based on an evaluation or evidence.
REVIEW OF LITERATURE
1. ROLE OF INTRAVENOUS IMMUNOGLOBULIN IN NEONATAL
SEPSIS
Sunita Sreedhar, Anagha Jayakar
Sunita Sreedhar, Anagha Jayakar
A prospective case control study (2004) was
conducted over two years to evaluate the impact of intravenous immunoglobulin
(IVIG) on the outcome of neonatal sepsis and to evaluate the role of
prophylactic IVIG in the prevention of neonatal sepsis in Mumbai. The incidence
of sepsis among newborn in the present study was 28.9/1000 live births which was
higher than that reported from developed countries and in other studies from
India. This study did not find any statistically significant decrease in
mortality with the use of IVIG irrespective of the gestational age and birth
weight.
In the present study 92 babies were
cases and 43 were controls. Incidence of neonatal sepsis was 28.9/1000 live
births. Comparing the mortality of 39.1% and 32.5% of cases and controls
respectively, there was no statistically significant difference, based on both
the gestational age and the birth weight. Of the 92 cases, 23 received exchange
transfusion for hyperbilirubinemia but among them there was no statistically
significant decrease in mortality in those patients given only IVIG compared to
others who received IVIG with exchange transfusion. There was no change in risk
of death in those given IVIG compared to the others. Among the 10 patients who
were given IVIG prophylactically, all developed clinical features of sepsis
showing that IVIG in the present study did not prevent sepsis.
2. THE ROLE OF BREASTFEEDING IN PREVENTION OF NEONATAL INFECTION:
The immune system of the human
newborn is of very limited size. It expands rapidly, especially due to the
exposure to the gut microflora. Normally the newborn is colonized with microbes
from the mother's intestinal flora at and after delivery. The many defence
factors of the mother's milk include large amounts of secretory IgA antibodies
produced by lymphocytes which have migrated from the mother's gut to the
mammary glands. Therefore the SIgA antibodies are mainly directed against the
mother's previous and recent gut microflora. Thus breastfeeding modulates
the early exposure of the neonate's intestinal mucosa to microbes and limits
bacterial translocation through the gut mucosa. This may be a major reason
why breastfeeding protects efficiently against neonatal septicaemia, as well as
several other infections. The defence factors of the milk prevent infections
already at the mucosal level. The transplacentally obtained maternal IgG
antibodies protect primarily in tissues and do so at the cost of
cytokine-induced clinical symptoms, tissue engagement and high energy
consumption.
3. PREVENTION OF NEONATAL INFECTION IN THE INDIAN COMMUNITY SETTING USING PROBIOTICS
1 June 2007
- EUNICE KENNEDY SHRIVER.
National institute of child health & human
development
Neonatal sepsis continues to be one of the major causes of
morbidity and mortality in the newborn period around the world. India, with one
of the world's largest populations, continues to struggle with extremely high
infant and neonatal mortality rates. Sepsis accounts for 50% of deaths among
community- born (and 20% of mortality among hospital-born) infants. Closely
linked with this is a burgeoning problem with antimicrobial resistance, which
is increasingly restricting the therapeutic options for medical care providers.
To deal with these critical issues, under the auspices of the NICHD Global
Network, we have conducted population-based surveillance of sepsis in babies up
to 60 days of age and have documented that more than 90% of deaths are due to
late onset sepsis. Laboratory and clinical data suggest that administration of
Probiotics (friendly bacterial strains that are part of the normal intestinal
microflora) has a therapeutic and prophylactic role in specific
gastrointestinal conditions, and, possibly, in neonatal conditions including
sepsis. Using a well-defined, commercially available supplement of Lactobacillus
plantarum (FDA registered in the U.S.), we have performed a hospital- based
study at our Indian collaborating centers that has demonstrated safety and
colonizing ability of this strain when administered orally to neonates with a
corresponding reduction in Gram (-) bacterial load (colony count) at month 1
and 2. To the contrary, Gram (+) bacterial load including Lactobacillus was
higher at month 1 and 2 and continued through month 6. Based on in vitro and
animal studies, which suggest that this and similar strains block bacterial
translocation across the intestinal mucosa, we hypothesize that administration
of this strain will facilitate more rapid generation of normal intestinal
microflora, and reduced translocation of bacteria from the intestine with a
corresponding decrease in the rate of late onset neonatal sepsis. To test this
hypothesis, in the current grant, we are proposing to conduct a double blind,
randomized, controlled trial of this preparation in 8442 newborn infants in 223
rural villages known to have high rates of neonatal sepsis. A successful
outcome would provide a simple, locally available, and inexpensive preventive
therapy for dramatically reducing neonatal infections, and in turn, infant
mortality in India and other developing countries.
CONCLUSION
Newborns are susceptible to
infections more so than adults because their immune systems are not fully
equipped to handle illness. So early recognition and prompt treatment of
infection would helps to reduce neonatal morbidity and mortality.
BIBILIOGRAPHY
1.
Marlow Dorothy
R. Text Book of Paediatric Nursing. 6th
ed. Philadelphia: W.B.Saunders Company; 1998.
2.
Wong LD. Nursing
care of infants and children Principals & practice. 6th ed.
Philadelphia: Saunders; 1999.
3.
Ghai OP, Paul VK,
Piyush G. Ghai Essential Paediatrics.7th ed. New Delhi: CBS; 2009.
4.
Parul datta,
Pediatric nursing. Second edition jaypee. India.
5.
Manoj yadav, A
text book of child health nursing. First edition. India. Peevee.2011
6.
Terri kyle ,
Essentials of pediatric nursing, New delhi. Wolters Kluwer Publishers Pvt Ltd.
7.
Wong and Whaleys,
Pediatric nursing. Philadelphia. Lippincott.
8.
O.P. Ghai.
Essentials of Pediatrics. 3rd edition. New delhi. Interprint 1986.
9.
Suraj Gupte,
Short text book of pediatrics. 11th edition. Jaypee. India.
10.
Merilyn J.
Hockenberry, Wong’s essentials of Pediatric nursing. 7th edition.
Elsevier. Missouri.
14.
http://www.journals.elsevierhealth.com/periodicals/ysiny/article/S1084-2756(02)90124-7/abstract.
