Prevention &

Control of Infection
on NICU
Dr Catherine Smith
SpR Neonatology
July 2007
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 Hospital acquired infection is a
significant cause of morbidity and
mortality on the neonatal unit.
We all have a large role to play in
reducing hospital acquired infection.
This training package covers important
ways in which YOU can do this.
Remember, infections kill babies.
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 Infection Control Training Menu
• Introduction

• Hand-washing & using alcohol rub

• Blood cultures
• Aseptic technique & sterile draping for line insertion
• Dressing & on-going care of long lines
• Accessing central lines & arterial lines
• Other interventions
Use the coloured
• Guidance for parents & visitors
buttons to
• Competencies navigate around
• References the package
• Acknowledgements
 Introduction
Sepsis is defined as an episode of clinical deterioration. Bacteraemia is sepsis
associated with a positive blood culture. On the neonatal intensive care unit
infections can be described as congenital or perinatal, presenting at less than 48
hours of age and usually related to maternal illness and/or Group B streptococcus
colonisation of the birth canal, or ‘late onset’ presenting after 48 hours of age. The
latter is deemed to be a hospital acquired infection when the organism was not
cultured at admission.

Hospital acquired sepsis is a serious problem for infants in neonatal intensive care
units. Infections are associated with increased morbidity and mortality and a
prolonged hospital stay1.

Infants born more prematurely and with lower birth weights are at greater risk due to
immature immune responses such as low immunoglobulin concentrations, reduced
phagocytosis, poor skin and gut barrier function2.

Studies have demonstrated that a range of simple interventions, such as improving

hand hygiene and adhering to antibiotic policy, can reduce the rates of hospital
acquired sepsis. For example, one group reduced hospital acquired infection rates
from 24.6% to 16.4%3.

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 Hand-washing & Alcohol Rub
Organisms that cause hospital acquired infection are most commonly transmitted by
the hands of hospital staff4.

The average hand may be colonised by up to 10 million bacteria. These consist of

resident microflora and transient organisms picked up during normal activities and
patient contact.
Hand hygiene is the SINGLE most important measure which can prevent hospital
acquired infection and careful hand hygiene should be practiced by all medical staff,
parents and visitors having contact with babies.
Hand-washing mechanically removes organisms from the hands. Anti-microbial soaps
and alcohol rubs kill micro-organisms. Improving compliance with hand hygiene
strategies on the neonatal unit have been shown in one study to reduce hospital
acquired sepsis rates from 11.3 to 6.2 per 1000 hospital days4.

Jewellery, watches & other accessories

Handwashing & alcohol rub

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Jewellery, watches & other accessories
• Jewellery, watches and other accessories are
places for bacteria to lodge and are difficult to
decontaminate.

• Long and artificial nails have been associated

with pseudomonas infection 5.

• Nail varnish should not be worn on the

Neonatal Unit as this decreases hand hygiene.

• Any cuts or sores on hands should be covered

with waterproof plasters. Emollients should be
used regularly to prevent drying and cracking
of the epidermis as a result of frequent
washing and use of alcohol rub.

WATCHES, BRACELETS, AND RINGS WITH

STONES SHOULD NOT BE WORN ON NICU.

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 How to wash your hands6
• At the start of every shift -
• WASH YOUR HANDS THOROUGHLY - even if you are not gong
to handle babies immediately
– ‘Surgical’ hand-washing routine
• Remove all watches, bracelets and rings with stones
• Wet hands and forearms under tepid water and apply soap/antimicrobial agent
• Wash hands and forearms for at least 2 minutes following the 6-stage washing process
(see below)
• Rinse thoroughly and dry with paper towel and apply alcohol rub as described later

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How to wash your hands
• During the shift

– Visibly soiled hands must be washed with soap and

water
• Wet hands under tepid water before applying soap/anti-microbial agent
• Hands should be rubbed together vigorously for at least 15 seconds, paying
attention to finger tips, nails, thumbs, and finger spaces – use the same
method as for ‘surgical hand-washing’
• Rinse thoroughly and dry with paper towels

– Hands must be decontaminated before and after

every episode of patient contact, regardless of whether
gloves have been used
• If hands are not visibly soiled alcohol rub can be used for decontamination

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 Alcohol Rub
The use of alcohol rub is recommended by the Centre for Disease Control and Prevention 7. However, it’s important to remember that alcohol rub does not kill spores.
The following technique should be used for the application of alcohol rub.

Make sure your hands are completely dry before handling babies.

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 Using Alcohol Rub
• During the shift - use alcohol rub regularly
• When entering or leaving the Neonatal Unit
(you ask parents to do this so why shouldn’t you?)

• When entering or leaving the nursery, and between bays Treat the
nursery as a clean area, do not rest items (e.g. clinical notes) on
incubators or cots that are not clean

• Before you handle a child or enter a cot or incubator

DO NOT just reach in to adjust something in the incubator
DO NOT clean your hands then fiddle with your hair or other part of your
body! You wouldn’t if you were in theatre.

• Clean hands with alcohol rub after you have finished handling a
baby or their surroundings

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 Blood Cultures
A positive blood culture is important for diagnosis of hospital acquired
infections and guides subsequent treatment. Obtaining a sample properly
is important to reduce incorrect results.
Hand-washing, gloves and adequate cleaning of the skin prevent
contamination causing false-positive results and prolonged antibiotic use.
Ensuring an adequate volume of blood is obtained reduces the likelihood of
false-negative results8.
Samples MUST reach the lab within 18 hours (including processing) so the
exponential growth phase of organisms is not missed and a false-negative
result produced.

Procedure

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 Procedure
• Use an aseptic technique
• Wash your hands & use alcohol rub as described
• Wear sterile gloves
• Clean the skin over and around your chosen site with an alcohol wipe
for 30 seconds and allow to dry9
• Use a cannula and collect blood from the hub using a sterile needle
and syringe
• Collect at least 0.5ml of blood, 1ml in bigger babies8
• Place the blood into 1 neonatal blood culture bottle
• Fill out the details thoroughly on the request card
• Ensure sample reaches the laboratory as soon as possible
– Call for a porter (24 hours a day)
• Document in the notes

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 Aseptic Technique & Draping for
Line Insertion
Central venous catheters increase the risk of hospital acquired sepsis, often with
coagulase negative staphylococci10. Placement of umbilical lines (UAC/UVC) and
percutaneous long lines on the neonatal unit is common, especially in the smallest and
most preterm infants most at risk from acquired infections.
Line colonisation can occur at insertion. This can be reduced by using maximal
precautions and aseptic technique11. The risk of colonisation increases with the duration
of the line.
Please refer to Guidelines G1, G3 and G5 for information regarding technique of line
insertion.

Procedure for draping for line insertion - step-

by step instructions
Procedure for draping for line insertion - video
When to remove central lines
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Aseptic technique for line insertion - step-by-step
1) You will need a second member of staff to assist you for the procedure
2) Assess baby, measure for line insertion
3) Wash hands, using the surgical scrub technique
4) Gown and double glove
5) Ask your assistant to aseptically open the required equipment onto a trolley
cleaned with alcohol wipes. The sterile surface should fully cover the top of the trolley
6) Place flushed line, dressings and instruments in a sterile towel and wrap If you need to use a cold
7) When all equipment is ready, ask them to open incubator doors and clean the port light, either:
holes with alcohol wipes a)Place ‘wee-light’ cleaned
8) Ask the nurse to position baby and to lift limb/cord and keep it raised with alcohol wipe inside a
9) Place a sterile drape under limb/around cord sterile glove
10) Take hold of the cord clamp/limb extremity using sterile gauze b)Cut a small hole in top
11) Clean the skin (and cord) using chlorhexidine soaked swabs for 30 seconds and layer of sterile dressing,
let dry hold a sterile glove over the
12) For umbilical lines apply cord tie. Use sterile blade to remove clamp (watch for hole with cuff poking
bleeding) through. Ask your
13)Using a clean piece of gauze hold a clean part of cord/limb and clean the extremity assistant to pass the clean
for 30 seconds and allow to dry for 30 seconds cold light into the glove and
14) Place second sterile drape around cord/limb - this should fit more closely around tape the cuff to the tubing.
the body part and should also cover the bed surface of the incubator Push cold light to tip of
15) Clean the skin (and cord) again for 30 seconds and allow to dry glove for use.
16) Place third sterile drape around cord/limb - this should fit closely around the body
part and should cover the bed surface of the incubator and line the bottom of the
incubator port holes.
17) Clean the skin (and cord) again for 30 seconds and leave to dry
18) Place instruments wrapped in sterile towel into incubator and open in a stable
corner
19) Apply tourniquet loosely to limb
20) Remove top pair of gloves
21) Begin procedure

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Aseptic technique & draping for line insertion

Click to play
QuickTime™ and a

video
Cinepak decompressor
are needed to see this picture.

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 When to remove lines
Rates of catheter-related sepsis increase with the duration lines are in-situ
and are also associated with the number of times the line is accessed.
Catheter tips should be sent to the lab when infection is suspected.
In general
• Umbilical arterial and venous lines should normally be removed after 7 days. There is some evidence it may be safe to
leave umbilical venous lines in for longer periods 12. This should be a consultant decision.
• Broviac lines can be used indefinitely.
• Percutaneous long lines should ideally be removed after 21 days of use as after this time the incidence of catheter related
sepsis increases dramatically 13. Percutaneous long lines MUST be removed by Day 29.

Infection
• The presence of a central line makes blood stream infections harder to clear. Infection is more likely when there are a
greater number of line lumens. Also, the risk of infection in a femoral line is higher than at other sites.
• Coagulase negative staphylococcal septicaemia may be cleared by giving antibiotics via the central line. However, if
more than 3 positive cultures are obtained when taken daily after the first positive result then the catheter should be
removed.
• Some organisms are notoriously more difficult to clear and in these cases the line should be removed more quickly after
the positive culture is obtained in infants who are clinically unwell. In particular, there is evidence that if central lines are
not removed immediately upon the diagnosis of Candida septicaemia then there is a high rate of morbidity and mortality 14.
• The decision to remove a central line should be made by the neonatal consultant, particularly in infants with difficult
venous access.
• Replacing a central line which has been removed due to infection should be delayed for at least 48 hours. During which
time appropriate antibiotics should be given peripherally. Replacement is dependent upon the clinical condition of the
baby, infection markers and blood culture results.

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 Dressings & Ongoing Care of
Percutaneous Long Lines
Where the long line enters the skin is a potential entry point for micro-
organisms into the infant. This risk is increased if the line can slide in
and out of the skin, as well as if the dressing does not adhere to the skin
adequately. Loss of a line due to poor dressings is frustrating and
results in further punctures to the skin. Therefore, dressing the line
properly and ensuring this is maintained is extremely important.

How to dress a long line

Review and redressing central lines
How to redress central lines

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How to dress a percutaneous long line
When a long line has been inserted it should be secured using steri-strips and a
sterile adhesive dressing eg. IV3000.
The silastic line should be looped and secured prior to securing the hub. It is
important to ensure that no tension is placed on the silastic line during securing.
The steri-strips should be completely covered by the IV3000 dressing. The steri-
strips and IV3000 dressing must not fully encircle the limb. They may, therefore,
need to be cut to size.

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 Review & Replacement of Dressings
Review of lines should take place during the daily review of the infant:-
1) check the site where the line enters the skin for erythema
2) check the site over where the tip of the catheter lies
3) check for the line leaking or any damage to the line
4) ensure the occlusive dressing is secure and is not peeling away at the edges

Remove the line if:-

1) the skin at the entry site is erythematous or oozing
2) there is swelling or extravasation over the line tip

Redress the line if:-

1) the line is leaking or
2) the dressing is no longer adequate

The dressings should be replaced using a very careful 2 person aseptic technique, ensuring the line is not
dislodged. This does NOT mean sticking a new dressing over the top. See the recommended technique on the
following page.
There is no clear evidence to support regular routine dressing changes particularly in the neonatal population
where the loss of the catheter at dressing change outweighs the risk of not redressing 15.

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 Procedure for Redressing Central Lines

1) This task requires 2 people

2) The equipment must be set up aseptically
3) Place a sterile towel under the limb
4) Hold the extremity with sterile gauze
5) Clean limb around and over IV3000 dressing
6) Very gently & carefully remove the IV3000 dressing
7) Remove the steri-strips over the coiled line
8) Clean around and under coil moving outwards for 30 seconds
9) Replace the coil and secure with 2 steri-strips
10) Apply pressure over entry site with sterile gauze
• Extremely carefully remove the 2 steri-strips at skin entry site
• Clean around the entry site moving outwards and allow to dry
13) Replace the steri-strips
14) Apply IV3000 dressing ensuring the steri-strips and line are completely covered
and neither the steri-strips or IV3000 dressing completely encircle the line

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 Accessing central & peripheral lines
Micro-organisms can be introduced into lines when giving medication, attaching
infusions or obtaining arterial samples. Accessing central venous lines should be
kept to a minimum. Vigorous rubbing of access port bungs removes organisms
mechanically whilst alcohol kills organisms.

Peripheral cannula, peripheral & umbilical arterial lines

Use a ‘clean touch’ technique
1) Wash hands and use alcohol rub
2) Use non-sterile gloves
3) Vigorously rub the access port bung with an alcohol wipe and allow to dry for 30 seconds
4) For peripheral cannula - Flush, give iv medication and flush or attach infusion
5) For arterial lines - Obtain sample, see Guideline G1 for more details of how to do this
6) When iv medication given or sampling complete, again vigorously rub the access port bung with a new alcohol wipe

Central venous lines - UVCs, long lines & broviac lines

Use an aseptic ‘no touch’ technique, this will require 2 people
1) Wash hands and use alcohol rub
2) Use sterile gloves
3) A second person should open a sterile towel which covers the surface of a clean trolley and open required equipment onto
this surface using an aseptic technique
4) Place sterile gauze below access port to establish a sterile field
5) Rub the access port bung vigorously with an alcohol wipe and allow to dry for 30 seconds
6) Give medications/attach infusion
7) When medication given, again rub the access port bung vigorously with an alcohol wipe

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 Other Interventions
•Use of antibiotics
–Use of inappropriate antibiotics and prolonged inappropriate use of antibiotics leads to resistance
–Blood cultures should be chased vigilantly and if negative antibiotics stopped as soon as possible
–Please refer to the Antibiotics Teaching Package & Guideline C1 for more information

Other Interventions
•Minimise the number of skin punctures16
–Incompetent skin increases the risk of sepsis
–Use arterial lines if in situ for blood sampling
–Use the appropriate heel sampling device to avoid repeated punctures
–Cluster blood tests and gases to avoid multiple unnecessary punctures

•Enteral feeding
–Feeding with human breast milk has been shown to reduce rates of nosocomial sepsis
–Use of early trophic feeds also reduces rates of nosocomial infection 17

•Use of iv immunoglobulin
–Trials have shown reduced infection rates but no long-term benefits associated with prophylactic iv
immunoglobulin and therefore this is not recommended 18

•NICU design
–The number of sinks/intensive care space, space between incubators, availability of equipment and
NICU air ventilation systems have been related to infection rates 19.

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 Guidance for Parents & Visitors
The reasons for, and importance of preventing infections on the
Neonatal Unit should be explained regularly to parents and visitors.

Hand-washing
Parents and visitors should be shown how to wash their hands and use alcohol rub. When babies are
in incubators only their parents and staff should be allowed contact with them.

Coats & bags

All outdoor coats and bags should be removed when parents and visitors arrive on the Neonatal Unit.
They should be left in the lockers at NCH, and lockers will be arriving soon at QMC.

Toys in incubators
Toys kept in incubators may be reservoirs for hospital acquired infection. One study cultured toys and
grew bacteria in 98% of cases. During the study 42% of babies had positive blood cultures and 63% of
these were the same organism as grown from the toys 20. We advise that toys should not be kept in
humidified incubators.

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 Competencies

Whilst working on NICU your ability

to wash your hands properly and
perform the skills detailed in this
package will be assessed and
reviewed regularly.

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 References
1. Fanaroff AA, Korones SB, Wright LL, et al. Incidence, presenting features, risk factors, and significance of late onset septicaemia in very low
birth weight infants. Paediatr Infect Dis J. 1998 17:593-8.
2. Craft A, Finer N. Nosocomial coagulase negative staphylococcal catheter-related sepsis in preterm infants: definition, diagnosis, prophylaxis
and prevention. J Perinat 2001 21:186-192.
3. Kilbride HW, Wirtschafter DD, Powers RJ et al. Implementation of evidence-based potentially better practices to decrease nosocomial
infections. Paediatrics 2003 111:e519-e533.
4. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact package. Paediatrics
2004 114:e565-e571
5. Moolenaar RL, Crutcher JM, San Joaquin VH, et al. A prolonged outbreak of Pseudomonas aeroginosa in a neonatal intensive care unit: did
staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol. 2000 21:80-85.
6. Queen’s Medical Centre Nottingham. 5.20 Hand hygiene policy.
7. http://www.cdc.gov/oralhealth/infectioncontrol/faq/hand.htm
8. Jawaheer G, Neal TJ, Shaw NJ. Blood culture volume and detection of coagulase negative staphylococcal septicaemia in neonates Arch Dis
Child Fetal Neonatal Ed. 1997 Jan;76(1):F57-8
9. Malathi I, Millar MR, Leeming JP, Hedges A, Marlow N.Skin disenfection in preterm infants. Arch Dis Child 1993 69:312-6
10. Baltimore RS. Neonatal nosocomial infections. Semin Perinatol 1998 22:25-32
11. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol. 1994 15:231-23
12. Butler-O’Hara M, Buzzard C, Reubens L et al. A randomized trial comparing long-term and short-term use of umbilical venous catheters in
premature infants with birth weights of less than 1251 grams. Pediatrics 2006 118:e25-e35
13. Chathas M, Paton J, Fisher D. Percutaneous central venous catheterization. Three years experience in a neonatal intensive care unit.
Am J Dis Childhood 1990144:1246-1250
14. Kellie J, Nazemi E, Buescher S, et al. Central venous catheter removal versus in situ treatment in neonates with Enterobacteriacea
bacteremia. Pediatrics 2003 111:e269-e274
15. O’Grady N, Alexander M, Dellinger E, et al. Guidelines for the prevention of intravascular catheter-related infections. Pediatrics 2002 110:e51
16. Grant P, Chng C, Sanchez P et al. Relationship to skin puncture: attempts for iv placement to primary bacteraemia in a NICU. APIC 24th
Annual Conference; June 1997; New Orleans, LA
17. Flidel-Riman O, Friedman S, Lev E, et al. Early enteral feeding and nosocomial sepsis in very low birthweight infants. Arch Dis Child Fetal
Neonatal Ed 2004 89:F289-F292
18. Clark R, Powers R, White R et al. Prevention and treatment of nosocomial sepsis in the NICU. Journal of Perinatology 2004 24:446-453
19. The UK Neonatal Staffing Study Group. Relationship between probable nosocomial bacteraemia and organisational and structural factors in
UK neonatal intensive care units. Qual Saf Health Care 2005 14:264-269
20. Davies, Mark W., Mehr, Samuel, Garland, Suzanne T. Bacterial Colonization of Toys in Neonatal Intensive Care Cots. Pediatrics 2000 106:
e18

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 Acknowledgements
Professor N Marlow Dr H Budge
Dr S Wardle Dr D Garner
Mrs J Hulatt Mrs Y Hooton
Kathy Fleming

Thank you for completing the Infection

Control Training Package.
Remember YOU can make a difference to
infection rates on the Neonatal Unit.
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