Analysis of Klebsiella Outbreak in Neonatal Nursery at Mahatma Ghandi Hospital. Final report

Transcription

1 Analysis of Klebsiella Outbreak in Neonatal Nursery at Mahatma Ghandi Hospital Preamble Final report On Monday 20 th June 2005 a fax arrived at my office from the office of Dr Zungu, appointing me as member of the inquiry committee on this matter together with my colleague, Prof. Y.M.Coovadia and Prof. M. Adhikari. As Prof. Coovadia and my expertise are in the same field we decided that I would take this further. The instruction for the inquiry was to investigate the cause of the outbreak of klebsiella infections in Mahatma Ghandi Memorial Hospital s neonatal nursery. As these outbreaks are mainly a microbiology/infection control issue, I started the inquiry with my microbiology team on the morning of The findings are as follows. General Between and the date of this report ( ), 26 babies had positive blood cultures with Klebsiella pneumoniae and one with a Klebsiella oxytoca. All these babies were born and nursed at Mahatma Ghandi Hospital. Of these 26, 20 were admitted to the high care neonatal nursery (Ward 4). When it was realised that there might be an outbreak, newborns that needed low as well as high care nursery were admitted to the unused Adult High Care ward. Of the 6 that were admitted to that ward, 4 became infected as well. Of the 26 babies infected with K.pneumoniae, 21 (81%) died, 2 recovered and were discharged and 3 are still admitted but doing well at the time of writing the report. The baby with the K.oxytoca infection died as well. The difference in numbers with Interim Report III is result of a double count of one baby. The figures presented above are accurate and final unless one or more of the currently still admitted babies takes a turn for the worse. However, this is not expected. The table summarises the characteristics of the infected babies, excluding the baby infected with K.oxytoca as this is definitely not part of the outbreak. As the susceptibility patterns of these isolates are not fully identical, it is still unclear whether we are dealing with one outbreak or with two or more clusters of infections at the same time. Genotyping of the available isolates can provide that information. Funding for the set up of a genotyping facility at IALCH is awaited. However, finalisation of this report can be done without this information.

2 Characteristics of babies infected with Klebsiella pneumoniae (n=26) Mean (range) gestational age at birth (weeks) 33.4 (30-40) No.(%) mothers known HIV infected 6 (22) No.(%) delivered by CS 8 (31) No.(%) with risk factors for neonatal infection 27 (100) Mean weight at birth (g) 1845 no. (%) with low birth weight (< 2500g) 11 (42%) no. (%) with very low birth weight (< 1500g) 7 (27) no. (%) with extremely low birthweight 2 (8) No.(%) of deaths 21 (81) Mean (range) age at death (days) 6.5 (1-13) No. (%) babies at high risk of death without infection 12 (46) On the first day of the investigation, , a number of points for attention were identified as reported in Interim Report I. 1. All isolates of patients as well as environmental cultures need to be further analysed at the Department of Medical Microbiology, Nelson R Mandela School of Medicine. The susceptibility patterns were re-identified but genotyping still needs to performed. 2. The obstetric histories of the mothers and the medical histories of the babies were analysed to identify a possible source of the infection. This has been done in collaboration with Dr. K. Chinniah, paediatrician. 3. Design of the nursery ward need to be revised with respect to infection prevention. A number of flaws were identified that have an inhibitory effect on adherence to infection prevention practices. These are specified in Annexure 1 in which also recommendations are made for changes to be put in place before the nursery ward is reopened. 4. Staff was observed during daily activities with regard behavioural aspects of infection prevention. Several flaws were identified. This was to be expected as an earlier attempt to find the source showed the presence of Klebsiella pneumoniae on the hands of 10 % of staff. 5. Interviews revealed that the nursery is usually overcrowded with babies and shortstaffed even if there was no overcrowding. This works against adherence to infection control principles. Bed occupancy figures and numbers of babies per staff member are shown in Annexure 2. This confirms a continuous overcrowding as well as a too low number of staff to provide appropriate high care. 6. During periods of overcrowding, incubators and cribs are often shared as well as monitoring equipment. There are 8 incubators, 3 servocribs, 3 incubators and 6 cardiac monitors to serve the average number of 37.5 babies each day. On the second day of the investigation, it became clear from the clinical histories that a large number of babies grew Klebsiella pneumoniae from the blood while on intravenous treatment with antimicrobial agents (ciprofloxacin and amikacin) to which the

3 organism was susceptible. There are only a limited number of explanations for such a situation: 1. Seeding from a collection of pus in which the antimicrobials do not penetrate and/or are inactivated 2. Translocation of organisms from a heavily colonised gastrointestinal tract into the blood stream. The GIT can only be decontaminated by oral, non-absorbable antimicrobials, not by parenteral administration. 3. Colonisation of the skin in combination with poor blood culture collection technique. It is not always easy to obtain blood cultures aseptically from these small babies. Skin is not decontaminated by systemic antimicrobials. As a result the blood cultures will grow the organism but there is no infection. 4. Contaminated intra-venous preparations. The first option could be excluded on clinical grounds in all babies, but the other three options needed attention. Therefore, the investigation team went back to Mahatma Ghandi Hospital on the 23 rd June (the 3 rd day of investigation) to take specimens from all possible sources as identified based on the reasoning above. Again, this included both the ICU ward and the nursery ward. Skin swabs, stool specimens and rectal swabs were taken from the babies as well as from the incubators. All IV preparations found in the wards were collected for culture as well as samples from bottles of formula feed and a container with expressed breast milk found on site. The results of these cultures were available on the next day, 24 th of June, and are summarised in the tables (Annexure 3). Significant findings 1. All bottles of one of the intravenous preparations, Vamin-Glucose, contained gentamicin resistant, extended spectrum β-lactamase (ESBL) producing Klebsiella pneumoniae. These were also the characteristics of the isolates grown from blood of the infected babies. Medication information could be found for 17 of the babies and all of these showed that they had received intravenous injections with this solution regularly. Unopened bottles did not grow the organism. This indicates that contamination took place in the wards during handling of the bottles and not at the production plant. The glucose in the preparation provides nutrition for the bacteria allowing increase in numbers during use of a unit. 2. Formula feeds found in the wards, contained several species of bacteria. Amongst this was Klebsiella pneumoniae. However, these were gentamicin susceptible and did not produce ESBL. Therefore, these are not associated with the outbreak. 3. Both the IV medication and the formula feed were used for multiple administrations to all babies.

4 Conclusion 1. Although molecular characterisation of the isolates has not as yet taken place, these findings indicate that this is an outbreak of Klebsiella pneumoniae infection due to contamination of one of the intravenous medications. 2. The reasons are a. multiple-use of units of intravenous medication b. inadequate hand washing practices. 3. The underlying cause for multiple-use of medication is attempts to limit costs 4. The underlying causes for inadequate hand wash practices are a. inappropriate hand wash facilities b. relying on chlorohexidine-alcohol solutions at the bed-side (these are often applied in too small quantities and insufficiently rubbed in) c. inappropriate use of gloves d. understaffing Recommendations 1. Reconstruction of the nursery to allow for better infection prevention (annexure 1) 2. Abandoning the practice of multiple use of units of IV preparations and intraocular medication throughout the hospital. Such preparations should be used only once. Multiple-use for one patient should also not be done. 3. Long sleeves on gowns, white coats and uniforms should be forbidden. Long sleeved personal gear is not allowed. Watches, rings etc. should not be worn on hands and wrists. These interfere with proper hand washing. In high care areas, hand washing needs to include the arms up till the elbow. 4. Continuous education and training re. infection prevention practices. This is best done in the format of professional audits. These should be run as a province-wide program, addressing all major areas of infection prevention. 5. To institute an early warning system and a rapid response team to be able to act more speedily in events like this. 6. To create an Infection Control laboratory at IALCH that allows for rapid molecular characterisation of organisms involved in alleged outbreaks. This is linked to advise 4 and Do not replace proper hand washing by chloro-hexidine sprays or gloves. Gloves become contaminated as well. Hands inside gloves create an environment in which bacteria multiply better than on dry hands. 8. SOPs to be put in place for the use of gloves, gowns and aprons 9. The infection control officer should be given more authority so that she can instruct staff to stop malpractice if she observes this. Such an intervention needs

5 to be reported to the line manager of such a staff member, but intervention should precede, not follow such a report. 10. Investigation of the source of contamination of feeds needs to be done. Aknowledgements The input of all involved in this investigation is appreciated, in particular the help of Dr. Kogie Chinniah (paediatrician MMMG Hospital), Dr. Prashini Moodley (Department of Medical Microbiology), Sr. Govindsamy (Infection Control Officer MMMG Hospital) and the registrars from the Department of Medical Microbiology For the commission of enquiry Prof. A.Willem Sturm

6 Annexure 1 Flaws in the design of the nursery and recommendations for structural alterations to the ward. 1. The main entrance of the nursery is in close proximity of the obstetric wards. It is recommended to construct a wall with door in the passage to create an air-lock room. In this area should be a hand wash basin and coat hooks. Anyone entering the nursery should take off white coats used in the rest of the hospital and put on a clean gown. Hands should be washed after the white coat is removed and before the gown is put on. Ideally, the air-lock room should have air pressure higher than the corridor but lower than the nursery. 2. There is a door from the nursery into the kangaroo nursing area and this area is wide open to the rest of the obstetric wards. This kangaroo nursing area needs to be walled off from the obstetric wards and an entrance from the corridor should be created. An air-lock room needs to be built between kangaroo nursing area and the nursery. Air pressure in the kangaroo nursing area should be lower than in the nursery. 3. The nursery consists of 4 areas for patient care: 2 isolation areas and 2 larger sections: one for low care and one for high care. Apart from one of the isolation areas, all of these not really separated from each other. All areas should be separated from the nursing station by means of glass partitioning. Are pressure in the high care area should be higher than the nursing station and low care area. Both isolation cubicles should have lower air pressure. 4. There is one small hand wash basin in both the low care and the high care area These are located in a corner creating a vast distance from most cots/incubators. Both the low care and the high care area need to have 4 large hand wash basins, properly distributed. 5. Only one of the isolation cubicles has a hand wash basin. The other one needs one too. 6. One of the 2 basins in the nursing station needs to be replaced with one of larger size. 7. All hand wash basins need to be equipped with foot or elbow operated, wallmounted soap dispensers. All should have wall-mounted paper towel dispensers and apron dispensers. All hand wash basins should have long-handle elbow taps. The current handles are too short and cannot be closed using elbows. 8. Currently one small room is used for disinfection and maintenance of incubators and other equipment and as sluice area. In this area the dead bodies are kept waiting for transport to the mortuary. Separate disinfection and sluice rooms need to be created.

7 Annexure 2 occupancy no. patients per average/day nurse (prof and staff) staff (incl. assistants) January February March April May June

8 Annexure 3 IV preparations 23/06/ /06/2005 ward area no. cultured result no. cultured result VaminGlucose Nusery in use 1 K.pneumoniae 3 K.pneumoniae x3 ICU low care 3 no growth high care in use 2 K.pneumoniae x2 3 K.pneumoniae x3 unused 3 no growth IV saline ICU high care in use 2 no growth hydrocortisone ICU high care in use 1 no growth Patient associated cultures ICU Nursery patient 1 patient 2 patient 3 patient 4 nose neg neg neg neg axilla neg neg neg neg rectum neg neg neg neg stool neg neg neg neg incubator opening neg neg neg neg linen neg neg neg neg Other samples no. result soap 2 no pathogens hibitane solutions 2 no pathogens O2 moisturers 2 no pathogens monitor wire pads 1 no pathogens basins 3 no pathogens taps 3 no pathogens door knobs 2 no pathogens hands of staff 33 K.pneumoniae x3