Infection

International

ROUTINE INFECTION PREVENTION

Infection
International

ROUTINE INFECTION PREVENTION

Hand washing
Universal precautions Safe handling of sharps

Infection
International

STERILISATION
Instruments must be cleaned first Sterilize with steam autoclave or hot-air oven Preferable over disinfection for critical instruments

Infection
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HIGH LEVEL DISINFECTION

Boiling for 20 minutes, completely covered with water Chemical: bleach 1:50 dilution for 20 minutes corrosive to stainless steel

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ANTISEPTICS
Patient skin prep
Wound cleanser Hand washing/surgical scrub Examples isopropyl alcohol chlorhexidine gluconate iodine/iodophor

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DISINFECTING WORK AREAS

Clean dirty areas with detergent Disinfect area with bleach 1:100 dilution Wear gloves

Exam tables should be disinfected daily

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Infection

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Objectives
definition predisposing factors pathophysiology clinical features sites of postpartum infection treatment prevention

Infection
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Definition:
any patient with fever of 38.5C 48-72 hours following a vaginal or forceps delivery with uterine tenderness

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Incidence and scope:

- major cause of maternal death in emerging countries - less frequent with vaginal births - complications include: shock, pelvic abscesses and pelvic thrombosis

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Pathophysiology
- normal flora of genital tract contains potential pathogens - amniotic fluid and increase in white blood cells during labour

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Predisposing factors
- trauma and tissue necrosis following deliver creates a culture medium for ascending - cesarean section is most important predisposing - prolonged labour and ruptured membranes - poverty and poor hygiene/nutrition

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Bacteria
- polymicrobial - most common: Escherichia coli, Kelbsiella, Proteus and Bacteroides fragilis - less common: Clostridium, Staphylococcus aurea and Pseudomona - exogenous source: Group A beta-hemolytic streptococci

Infection
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Clinical Features
- usually 2-3 days post partum - low grade temperature, lower abdominal pain and uterine tenderness - also: malaise, anorexia, foul lochia - if severe: high temperature and generalized peritonitis

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Clinical Features
- Group A beta-hemolytic stretpococci may be fulminant with peritonitis and septicemia

- if cultured, hospital personnel must be screened to try and identify the source

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Diagnosis
- sites of infection to consider in post partum patient (culture if able): endomyometritis urinary tract episiotomy site abdominal incision breast thrombophlebitis: legs, pelvis appendicitis other: upper respiratory infection

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Management - Prevention
- correct aseptic technique - antibiotic use in women with cesarean section or prolonged rupture of membranes (1g ampicillin IV given prophylactically in cesarean section reduces infection)

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Management -- Treatment
mild case: single broad spectrum antibiotic (eg. ampicillin 1 g IV q6h Or orally) if cesarean section: flagyl 500 mg q8h + cefoxitin 2g q6h OR aminoglysocide (gentamycin or tobramycin) 60100 mg q8h +clindamycin 900 mg q8h

Infection
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Management - Treatment
if intravenous antibiotics used, continue for 48 hours after fever has stopped.
if fever continues and aminoglycoside-clindamycin combination was used, add penicillin (5M units q6h) to cover enterococci

oral antibiotics should be used for 5 days

Infection
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Other issues
- the more antibiotics used, > the higher the chance of necrotizing colitis - antibiotics do appear in breast milk but in most cases are not clinically significant (avoid tetracyclines)

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Specific issues:
episiotomy infection: treat with antibiotics, baths (clean water!), heat - remove sutures if fluctuation or pus - rarely needs debridement necrotizing fascitis: rare, rapid progression of local inflammation followed by gangrene -patient is toxic: high dose antibiotics but MUST surgically DEBRIDE

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Other issues
- Septic pelvic thrombophlebitis--usually anaerobic sepsis - usually patient is already on antibiotics but continues to have high spiking fevers - diagnosis of exclusion - treatment is intravenous heparin - > condition should respond to heparin

Infection
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Other issues
- Mastitis--penicillin G or penicillinase-resistant (methicillin or cloxacillin) for 7-10 days continue breast feeding! if breast abcess--drain

Infection
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Special case:
Postpartum or postabortal septic shock
definition: any toxic patient who has hemodynamic or acid base changes with fever 38.5C (after abortion, vaginal or operative delivery)

Infection
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Etiology of postpartum/postabortal shock

- usually gram-negative bacteria (eg. E. Coli) and occasionally gram positive (staphylococci, anaerobic streptococci, clostridium)

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Pathophysiology of postpartum postabortal shock

- not fully understood - endotoxins from cell wall of bacteria initiate vascular damage and vasodilatation - hypotension / hypoperfusion

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Conclusions
- major problem - proper diagnosis - early and aggressive treatment - prevention

Infection
International

MALARIA IN PREGNANCY

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Objectives

Describe epidemiology of malaria Describe maternal and fetal complication Principle of management and preventive strategies

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Global Effect

Affects 300-500 million people yearly Causes 1 to 2.7 million deaths 90% of deaths occur in Sub -Saharan Africa (approximately 3000 deaths each day)

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Size of problem in Africa (WHO 1999)

Population: 564 Annual births: 24.7 Exposed to malaria: 93% ANC coverage: 63% Low birth weight: 16% Malaria attributable fraction to LBW:1250%

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Effect of malaria on pregnancy

Related to Level of transmission and immunity of individual exposed

In areas of high transmission ,endemic or stable malaria area. In areas of low transmission or non endemic or unstable areas

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Maternal complication
In non-Endemic areas Greater risk of severe disease Higher risk of death Anaemia, hypoglycemia, pulmonary oedema, renal failure

In Endemic areas malaria related anaemia Febrile illness Placental sequestration

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Anaemia

Multi factorial:affects 50-60% pregnant women in Sub-Saharan region Haemolysis Increased immune clearance of infected and non infected RBCs Malarial hyperactive splenomegaly Nutritional & hookworm infestation Increased risk in pregnancy to Post -partum Hemorrhage & Heart failure

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Severe malaria

Cerebral malaria: Unrousable coma with asexual peripheral parsitaemia or placental infection. Hypoglycemia Pulmonary edema (ARDS) Acute renal failure

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Fetal complications
In non-endemic areas Abortions preterm delivery Congenital malaria Low birth weight

In endemic areas Low birth weight Intra-uterine growth retardation

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Management and Preventive Strategies

Early diagnosis and effective treatment Use of chemo-prophylaxis or intermittent treatment presumptive treatment. Use of insecticide treated bed nets Regular Antenatal care and health education about malaria

Infection
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Early Diagnosis and Treatment

Use of National treatment guideline for treatment. In uncomplicated malaria: Chloroquine, SP,Mefloquine,Quinine (combination therapy) In Severe malaria: Parenteral Quinine, Artemesinin derivatives and supportive therapy

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Studies on IPT

Results: A decrease in febrile illness A decrease in peripheral &placental parasitemia A increase in maternal hemoglobin level A lower proportion of Low birth weights

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Chemoprophylaxis and Intermittent Presumptive Treatment

In endemic areas ,use of intermittent presumptive treatment (IPT): Target population at Risk Dosage: SP given in two doses; 1st dose: 16-24 weeks 2rd dose 28 to 36 weeks. Alternative: Chloroquine Full dose than 2 tablets weekly dose till delivery or proguanil

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Use of Insecticide treated nets

YEAR LOCATION MALARIA TRANSMISSION GRAVIDITY PREVALENCE OF ANAEMIA

1993 1996 1998

Thai/Myanm 0.8 ar Border Gambia Kenya 1-10 10

All Primegravid Primegravid

56 to 27% 17 to 3% 20 to 15

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Conclusions

Improve implementation of existing strategies and health delivery system with emphasis on integration in existing services Improve on Health education to community on dangers of malaria and early ,regular ANC attendance.

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PREVENTION OF MATERNAL TO CHILD TRANSMISSION OF HIV

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Objectives

Describe relationship of HIV on pregnancy

Factors affecting vertical transmission

Strategies to prevent maternal to child transmission

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Introduction

UNAIDS about 25 million adults& children living with HIV/AIDS in Sub Saharan Africa. 4million new cases yearly 300,000 to 600,000 AIDS related deaths in 1999 in children (0 -14yrs)

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HIV AND PREGNANCY

Effect of pregnancy on HIV progression

Effect of HIV on pregnancy outcome

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Effects of pregnancy on HIV infection

No effect on HIV progression. Slight decline in absolute numbers of CD4 count ( % of CD4 cells remains stable No overall significant in deaths rate

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Effect of HIV on pregnancy course and outcome

Possible increase risk Developed: No association Developing:Increased Increased risk Increased risk Increased risk No evidence of increased risk

Abortions Perinatal deaths IUGR Low birth weight Preterm delivery Fetal malformation

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Maternal to Child Transmission

Accounts to 15 % of all transmission in Uganda Accounts for > 90% of infection in children In Africa rate of MTCT is 20 -40% Overall risk at point estimate for transmission

During pregnancy: 5 -10% In labour: 15 -20% Breast feeding : 10-15%

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Factors affecting transmission

Preterm deliveries Duration of membrane rupture.* Invasive procedure in Labour( Instrumental vaginal deliveries,episiotomies* Mode of delivery Fetal/neonatal factors Breast feeding *

Viral factors:(Load,strain variation)* Maternal: CD4 count STD infections* Substance abuse Sexual behavior* Placental disruption

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Prevention of Maternal to Child Transmission

Comprehensive MCH services ( antenatal,intrapartum,postnatal) VCCT Short course antiretroviral treatment Modified and optimal obstetrical practice Support for safe infant feeding Family planning services & counseling

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Comprehensive ANC minimum package for PMTCT

Provision of quality ANC Health education Micro nutrient supplementation Prevention and treatment of infections Anti- retroviral drugs

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Provision of Quality ANC-1

Early Attendance Refocused ANC with at least 4 to 5 visits Detailed history taking Examination to rule out signs of HIV related illness Baseline Investigation: Hemoglobin,RPR for syphilis,Urine analysis Voluntary confidential counseling and testing.

Infection
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Provision of Quality ANC-2

1st Visit:Detailed history, examination, investigation, folic supplements,deworming and VCCT 2rd Visit:Monitor progress of pregnancy, Counsel on pmtct and breast feeding option, 1st dose of IPT,tetanus toxoid,iron/folic supplementation. 3rd Visit:Monitor progress of pregnancy,blood pressure ,Hb and urine analysis,2rd dose IPT,tetanus toxoid, iron/folic supplementation.Counseling support 4th Visit: As above. Enrolment on the PMTCT program,Give antiretroviral drugs

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Health education

Nutrition,personal hygiene,environmental sanitation Normal Tetanus toxoid schedule STI treatment Benefits of VCCT Condom usage and family planning Male involvement Breast feeding /other feeding options

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ANC-4

1.Micro-nutrient supplements 2.Prevention & treatment of infections Intermittent presumptive treatment: 3 doses of SP identification& treatment of STI 3.Anti retroviral treatment AZT Neverapine

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Care during Labour and Delivery

1. Good Obstetric practice 2. Ante retroviral drugs 3. Modified Obstetric practice

Delay ARM ECV Routine episiotomies Instrumental deliveries Traumatic suction of child Universal precautions.

4. Mode of delivery

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Short course anti-retroviral treatment

Options: AZT after 36 weeks antepartum,intrapartum amd post partum with neonatal treatment for 7 days. (%Reduction 50%) at 8weeks Nevirapine In labour and neonatal treatment for 48 to 72 hours. (% reduction 47%) at 8 weeks

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Oral Anti retroviral treatment

Intrapartum Post partum For mother
AZT 300mgs p.o B.D for 7 days

Antepartum

neonatal

1.AZT 300mgs p.o B.D after 35 weeksgestation

AZT 300mgs p.o 3hourly till delivery

4mgs/kg p.o B.D for 7 days

2.

None

NVP 200 mgs p.p at onset of labour

none

2mgs/kg p.o 4872 hours

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Post natal care

Dual use of Contraception( Barrier& contraception). Ongoing Care Counseling and support Care of the Neonate,(Exclusive breast feeding for 3/12 months or Artificial infant feeding)

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Conclusion

Maternal to child transmission can be reduced by 50%

Effective counseling ,support,treatment of opportunistic infections and anti retroviral treatment can improve quality of life.