Neonatal infections

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

·         Human immunodeficiency virus

·         Group B Streptococcus (GBS)

·          Escherichia coli

·         coagulase-negative Staphylococcus

·          Haemophilus influenzae

·          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

    Chorioamnionitis.

    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 anomalies

TYPES 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.

·        Mortality/Morbidity

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.

·        Age

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

·         Irritability

·         Skin rashes

·         Nasal flaring

·         Weak sucking

·         Rapid breathing

·         Low blood sugar

·         Slowed heart rate

·         Lethargic, inactive

·         Irregular heartbeat

·         Breathing difficulty

·         Abdominal distension

·         Body temperature fluctuations (hypothermia)

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

Ø X-rays of the chest or abdomen

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

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:Top of Form

Lars Å. Hansonaf1, Marina Korotkovab

Bottom of Form

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.

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