ROYAL HOSPITAL FOR WOMEN

Sydney
Newborn Care Centre
Neonatal Intensive Care Unit
 6,200 births/year on Campus
 46 cots 18 NICU
 Tertiary Neonatal & Neonatal
Surgery Referral Centre for NSW

1. Infection Prevention & Control in an Australian NICU

2. Multi-Drug Resistant Organisms in NICU & Biofilms

Margie Evans MPH, B Health Sc, RM, RN

Infection Control Clinical Nurse Consultant (CNC)
Royal Hospital for Women Sydney Australia 1991-2024
Dr John Smyth FRACP Neonatologist RHW Sydney
H O S P I TA L I S E D N E O N AT E S A R E V U L N E R A B L E TO
H E A LT H C A R E - A S S O C I AT E D I N F E C T I O N S ( H A I ’ S )

o Very Low Birthweight & Preterm Neonates - at high risk of developing HAI’s
o Neonatal Mortality from Sepsis in Low & Middle Income Countries is up to 30%
Reasons include:
o Underdeveloped immune system & skin barrier – are predisposed to getting
infections in their blood (sepsis)
o Environmental factors
- frequent use of invasive medical devices
- risk of transmission of micro-organisms from healthcare workers & caregivers
- contamination of hospital equipment & surfaces (cots, incubators, oximeters, breast
pumps, sinks & drains)
- use of ‘contaminated’ mobile phones
NOW we have the added burden of Antibiotic Resistance with
Gram Negative Bacteria & MRSA in Hospitals but also in the Community
How Newborns get
Bacteria transmitted to
Hands & Phones
them which places them contaminated Sinks, Drains
at increased risk of Contaminated
Surfaces &
Healthcare-Associated drains
Infections (HAI’s)
o Immature Immune
system & skin barrier
o Invasive devices

Hands & Phones

Colonised/Contaminated

Nyantakyi et al. Clin Microbio Inf 2024

 WE NEED TO ACT TO PREVENT TRANSMISSION TO
T H ESE VU L N ER A B L E N EO N AT ES

RHW Infection Prevention & Control Practice in NICU: (5 Elements)

1. Enhanced Hand Hygiene (H.H.) & Aseptic Technique
o Hand Hygiene (with regular audits aiming for >90% compliance) - especially Moment 2
- Feedback of H.H. Audit results to our NICU every 3 months
o Increased availability of Alcohol Hand-Rub dispensers – 3 next to incubators in ICU
and 1 dispenser on every cot
NB: H.H. is the intervention with the potential greatest impact (on mathematical modelling)1
Contaminated hands of Health Care Workers &/or Care Givers plays a major role in cross-
transmitting pathogens to patients resulting in healthcare-associated infections (HCAI’s)
o Gloves are NEVER a substitute for HH Strict Hand Hygiene Practice
o Bare below the Elbow (with regular audits 3 monthly >90%) by everyone is the first,
o Strict Aseptic Non-Touch Technique (ANTT) for peripheral IV insertion the simplest & the most
(regular audit >85%) impressive thing we can do
to save the lives of these
little babies
WE NEED TO ACT TO PREVENT TRANSMISSION TO
T H ESE VU L N ER A B L E N EO N AT ES

RHW Infection Prevention & Control in NICU (cont):

2. Care Bundles for Central Lines:
(i) Central Line Insertion Bundle (written guideline + active training)
(ii) Central Line Maintenance Bundle (written guideline + active training)
(iii) Peripheral Line insertion bundle (active training of junior medical staff)

o Cleaning skin < 28 wks - use aqueous Chlorhexidine 0.5% (allow to air dry)
o Cleaning skin ≥ 28 wks - Alcohol & Chlorhexidine (allow to air dry)
 RHW Elements of CVL Care Bundles for Insertion & Maintenance
Past Practice Present Practice
• Education & Training • Education & Training
• Hand Hygiene • Enhanced Hand Hygiene
• Sterile barrier • Strict Sterility during PIVC & Central Line Insertion (Sterile
• Skin Asepsis – Alcowipes barrier Skin Asepsis - Strict Aseptic technique - observed)
only at entry site - Doctors / Nurse Practitioners accredited for line insertion
• “Clean” technique with training - choose insertion site prior to scrubbing up
• New improved transparent sterile dressing for CVL 6

• Surveillance of CVL site on each Nursing shift – Line site &

Line dressing - VIP Score (assess IV site)
• ‘Scrub the Hub’ - 48 hr hang-time for infusion fluids - Avoid
breaking the line otherwise (STRICT) unless is no other IV
access
• Early removal in Central Lines when babies on 120ml/kg
enteral feeds + Earlier enteral feeding of breastmilk and
pasteurised breastmilk (use of lactation consultant)
 has resulted in fewer Line days
Central Line Care (cont)
Once Central Line is in-situ
o Cannula hub & extension set require protection
from contamination
‘ HH & ANTT must be performed.’

Application of “Scrub the Hub” Guideline

o Clean surface area & threads of hub
o Use friction when scrubbing with antiseptic
solution for 30 seconds
o Leave solution to air-dry for 30 seconds
o Repeat before accessing hub
o Waiting for 30 sec is difficult to do – ? sing a song
BIOFILM & BACTERIA ON EXTERNAL SURFACE OF
NEEDLELESS CONNECTOR

B E E L I N D R E A – C N C - K W E E
N C C / R H W T R A I N I N G
F A C I L I T A T O R
8

S P R 2 0 2 2 ; W I N T E R 2 0 2 3
1 2 / 0 7 / 2 0 1 9 ; R E V S P R 2 0 2 1 ;
Ryder et al. Microscopic Evaluation of Microbial Colonization on Needleless Connectors. 2009. APIC Poster Presentation
Medical Staff scrubbing
the procedure trolley for
a central line insertion
procedure
Central Line Care Bundle (cont):
Changing TPN/Fluid Infusion of IV
Central Line:
o Two Nurses doing it
o Nurses checking fluids
o Hat and mask must be worn
o Sterile Field
o Procedure person is scrubbed & sterile
gloves, mask and hat on
o Use of ‘Scrub the Hub’ technique (waiting
30 sec)

Assistant:
o stands on opposite side of the trolley
o must wear mask and hat
 RHW Infection Prevention & Control in NICU (cont):

3. Active Surveillance of Positive Cultures/Isolates & MRO

screening:
o Hospital CNC IPC is actively involved & meets monthly with Medical
team to review all positive blood culture isolates  monthly report of
Infection rates
BSI’s & CLABSI’s with benchmarking against other units in NSW & ANZ
o Feedback to NICU IPC Committee & Plan of Action for any issues
arising
o Monthly meeting of Unit NICU IP&C committee (At RHW: 1 consultant, 1
Registrar, 5 Neonatal nurses & Clinical Nurse Educator)
o Twice weekly ward rounds & Liaison with Paediatric Infectious Disease
Team from Sydney Children's Hospital
RHW Infection Prevention & Control in NICU (cont):
3. MRO Screening:
o Screen (nose & rectal swab/stool) all transfers-in
from other health facilities
o Screen (nose & rectal swab) any transfers-out from
our unit to other facilities – screen prior to transfer
o Regular Whole Unit screening for MRO’s (1-3
monthly) - Review of Positive cultures / Outbreaks
(colonisation) with the log of their specific location
in the Unit during their admission
o Cohorting of infants colonised with MRO’s – use of
floor lines to increase staff/parent awareness

For an Infant colonised or infected with an MRO

- to increase staff awareness
- PPE is used for any direct patient contact
Bed-Mapping:
Electronic Patient Log of
their location in the Unit
during their admission
- to assist with any
possible Outbreak tracing
RHW Infection Prevention & Control in NICU (cont):

4. Environmental (Audit of cleaning)

1) Frequently touched surfaces
2) Daily cleaning
3) Sinks
4) Project cleaning
 RHW Infection Prevention & Control in NICU (cont):

5. Antimicrobial Stewardship (AMS):

1) Judicious use of Antibiotics - use the narrowest spectrum possible
RHW - 1st line at birth Benzyl Penicillin & Gentamicin
*Appreciate this is difficult to do when there are high rates of ESBL & CPE
1) Limit length of use when blood cultures are negative & baby is clinically well – limit
to 24-48hrs then stop
2) If need to commence a broad spectrum antibiotic stop as soon as possible – use of
CRP to monitor in first 48hrs & when stopping antibiotics
3) Via AMS on-line request antibiotic when prescribing certain types of antibiotics,
including Meropenem, 4th generation Cephalosporins
An antibiotic stop order is activated if antibiotics are continued beyond 72 hr,
without any justification or evidence from culture and sensitivity results
 RHW Central Line Associated Blood Stream Infections 2002-2016
o with all these measures we have seen a 60% reduction in our Blood Stream (BSI’s) & Central Line Associated
Blood Stream Infections (CLABSI) - CLABs reduced to 4 per 1000 line days
o maintaining this low rate does take alot of effort and our rates do rise at times – dedicated team
o Appreciate how hard this can be in Low & Middle Income Countries if staffing levels are low and workload is high – to
be most effective need Nursing & Medical Staff to be allocated time (hours) to the task (difficult but v. important)

Central Line Associated Blood Stream Infections

(CLABSI) at RHW NICU 2002-2016
Rate of
Central Line
Use
Rate of
(CLUR)
CLABSI
per 1000 
Line days
_____
5. Pharande P, Lindrea KB, Smyth J,
Evans M, Lui K, Bolisetty S. Trends in
late onset sepsis following an Infection
Control Bundle.
J Paed Child Health 2018: 54:1314
 BACTERIA ARE BECOMING MORE
R E S I S TA N T

• Sole purpose is survival and replication

• The more antibiotics, disinfectants and antiseptics we throw at them the more they
mutate to survive
• Increasing in prevalence are ESBL’s (Extended Spectrum Beta-Lactamase
producing Gram Negative Bacteria) & CPE’s (Carbapenemase-Producing
Enterobacteriaceae)

Study from 3 Neonatal Intensive Care Units in Pune India:

• 4073 infants admitted over 1 year (2017-2018)
• 58% of BSI’s caused by Gram Negative Bacteria (GNB)
• 45% of GNB were resistant to Carbapenems (CPE)
• Non–Low Birth Weight (ie: Term) Neonates with late-onset BSI had greatest excess in
mortality (22% vs 3%, P < .001)
Johnson et al. Clinical Infectious Dis 2020
C A R B A P E N E M - R E S I S TA N T / P R O D U C I N G
ENTEROBACTERALES CRE/CPE
• CRE are commonly CPE & CPE are commonly CRE but neither group is entirely a subset of
each other
• CPE are resistant to carbapenem antibiotics, they produce an enzyme which hydrolyse
carbapenems (as well as other B-lactamases e.g. penicillins & cephalosporins)
• It is possible to share/transfer this genetic trait to other members of the Enterobacteriaceae
(E. coli, Klebsiella pneumoniae)
• CRE are transmitted from person to person, usually by direct contact with contaminated
faeces, skin, or instruments used in hospitals
• Individuals who have received multiple antibiotics in the recent past, especially if they had
been hospitalised
• Patients have been hospitalised overseas

• Although most CPE infections occur and spread in hospitals, there are more reports that
some CRE bacteria are becoming community-acquired
T H E G L O B A L D I S T R I B U T I O N O F VA R I O U S
CARBAPENEMASES IN CPE
 Formation of Biofilms
o Biofilms are embedded in
an extracellular organic
matrix (the polysaccharide
structure they produce)
clinging to each other & a
solid surface
o 99% of bacteria survive by
forming Biofilms
o Biofilms can be found both
in and on wet and dry
o Organisms within Biofilms can withstand nutrient
deprivation, pH changes, Oxygen radicals, Disinfectants &
surfaces even after the
Antibiotics better surfaces had 2 terminal
o MDRO contamination is significant and these organisms cleans with 500ppm free
remain viable for prolong periods of time chlorine solution
o Biofilms are also resistant to phagocytosis
BACTERIA CAN HIDE IN BIOFILMS
• Wet areas
• Sinks - Sinks and drains provide an ideal environment for microorganisms to form
biofilms
• Objects on the sink
• Splash back on HCWs hands
• (Biofilms grows in drains especially if fed from what we empty into drains)
• Neonates proximity to the sink
• Suction tubing
• Humidity cribs

• Plastic devices Neonates often require

• Central lines, arterial lines and peripheral lines, , endotracheal tubes, humidity devices, Ventilator tubing

• Scratches and groves

• Torn mattress covers
• Scratched cribs etc

Good Environmental cleaning can’t completely eradicate Biofilms however it

does show a reduction in number isolates with fewer infections
Strategies to reduce NICU Blood-Stream Infections (HCAI’s):
Summary:
1. Good Hand Hygiene practice with regular audits:
 HH Compliance is so important **  need > 50-70% HH compliance for it to have
an effect & ideally > 90%1
2. Use of Central Line Care Bundles – both Insertion & Maintenance bundles
- Strict Aseptic practice for IV lines & Drug administration (ANTT)
3. Active Surveillance of Positive isolates & regular MRO Screening of
transfers & whole unit
4. Regular Environmental cleaning of patients immediate environment
5. Antimicrobial Stewardship - where possible
- Appreciate there is an is an urgent need for large pragmatic randomised
controlled trials to address Optimal empiric first- and second-line antibiotic
treatment strategies in LMIC hospital settings with a significant AMR burden
- but can at least stop more antibiotics sooner
Reducing the Risk of NICU Blood-Stream Infections:

Summary (cont):
Other measures:
o Reduce Overcrowding: unacceptably small distances between cots &
infrequent decontamination of cots may lead to ↑ infection rates
o Kangaroo Care & Early feeding and advancement of breastmilk feeds to
reduce the need for invasive IV lines & reduce length of time with lines to
reduce infection risk & reduce use of parenteral nutrition (TPN)
o Empowerment of Nursing Staff – to run Infection Prevention & Control
o Ownership of the Problem by the whole Unit with belief in the importance of
good Infection Control & celebration of improvements & progress – Unit
champions for Infection Control
Hand Hygiene Compliance & Health Care Associated
Infections (HCAI’s) globally:
• Improvement in Hand Hygiene Compliance is the most effective
measure to reduce transmission of pathogenic microorganisms in
health settings & to lower the incidence of HAI’s in health-care settings 1
• Availability of hand hygiene supplies (especially alcohol hand rub on
each cot/bed to enable HH at point of care) is very important 1
• Need Hand Hygiene Leadership with champions & role models with
training
• Health care workers need to feedback to other workers if Hand
Hygiene is being missed and auditors of HH are needed to monitor HH
Compliance rates
• Prevention of HAI’s can reduce length of hospital stay and save costs
REFERENCES
1. De Kraker et al. Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-
Assessment Framework global survey 2019 . Lancet Infectious Disease 2022 https://doi.org/10.1016/ S1473-
3099(21)00618-6
2. WHO. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: World
Health Organization, Patient Safety; 2009. https://www.who.int/gpsc/5may/Guide_to_Implementation.pdf
https://www.who.int/teams/integrated-health-services/infection-prevention-control/hand-hygiene
1. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospitalwide programme to improve compliance with hand
hygiene. Infection Control Programme. Lancet 2000; 356: 1307–12.
2. Saliba et al. Limiting the Spread of Multidrug-Resistant Bacteria in Low-to-Middle-Income Countries: One Size Does
Not Fit All. Pathogens 2023
3. Pharande P, Lindrea KB, Smyth J, Evans M, Lui K, Bolisetty S. Trends in late onset sepsis following implementation of
an Infection Control Bundle. J Paed Child Health 2018: 54:1314
4. NSW Health: Control Guideline for ‘Carbapenemase-producing Enterobacterales (CPE) infection or colonisation’ 2019
5. Davis C ‘CRE Infection (Carbapenem-Resistant Enterobacteriaceae)’ MedicineNet
6. Baltogianni M, Giapros & Kosmeri C ‘ Antibiotics Resistance & Biofilms in NICU & Methods to Combat it;’ Published
online 2023 Feb 8. doi: 10.3390/antibiotics 12020352