ISSUE: In December 2006, an outbreak of Salmonella tennesse was identified in two NICU babies. On the day of the second report, 3 additional babies developed bloody diarrhea.
PROJECT: On 12/06, a baby in the neonatal intensive care unit (NICU) developed a sudden onset of bloody diarrhea. Parents who were later identified as the likely source were ill and had not reported this to NICU staff. Two days later a second infant developed similar symptoms. The NICU was closed to new admissions, stool cultures were sent on all infants. Cohorting with universal contact precautions began. An epidemiological investigation was started by the Infection Prevention Coordinator. State and local health departments were notified to assist with environmental cultures and recommendations. The Center for Disease Control (CDC) was also consulted. A review of the literature found no reports of similar Salmonella outbreaks in a NICU. Observation in the unit showed lack of adherence to standard infection prevention practices including hand hygiene and environmental cleaning. A high census made access to two of the three sinks in the unit difficult. The third sink was not functioning properly. Hand sanitizers were available throughout the unit.
RESULTS: At the time of the outbreak the NICU census was 13-average census is 7. Of the 13 infants, 9 were culture positive and 4 of them were symptomatic. A fifth baby was symptomatic but never culture positive despite repeated cultures. The other 3 babies were culture negative. Staff were also cultured with 2 of them positive. Infants were cohorted into infected/colonized and uninfected groups. The health department allowed the culture positive staff to be assigned to the infected/colonized group as long as they remained asymptomatic. All staff and visitors were monitored for signs and symptoms of illness. Uncolonized infants were moved to a room outside of the NICU to provide further segregation. Education on hand hygiene, standard and contact precautions, and environmental cleaning were provided to staff and parents. Visitation was restricted to parents only during the outbreak. Weekly cultures of the uninfected infants identified no further transmission. The first set of environmental cultures showed 8 positive sites. Enhanced cleaning procedures were put into place with environmental service & NICU staffs educated. Cultures done 10 after the change in procedure were all negative. The NICU reopened in 1/07.
LESSONS LEARNED: Salmonella demonstrates prolonged transmission capablity on environmental surfaces. Strict adherence to basic infection control practices including hand hygiene, standard precautions, and appropriate cleaning were key to stopping the outbreak. Education included both staff and visitors. A formal competency has been developed for staff. Additionally, an educational program on key infection prevention measures has been developed for the parents of future NICU admissions.
3:15-3:30 pmPublication Number 237
© 2007 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.