23.

ASEPSIS ROUTINES

23.1 DEFINITIONS

The single most important intervention to reduce sepsis in a newborn unit is hand hygiene. Hand
hygiene is defined as any method that removes or destroys microorganisms on hands. The following
definitions are relevant to hand hygiene:

• Hand hygiene: A general term that applies to hand washing, antiseptic hand wash, antiseptic
hand rub, or surgical hand antisepsis.
• Hand washing: Washing hands with plain (i.e., non-antimicrobial) soap and Water,
• Plain soap: Refers to detergents that do contain antimicrobial agent or contain low
concentrations oOf antimicrobial agents that are effective Solely as preservatives. They may bar
or liquid soap. Antibacterial effects lies in their capacity to dislodge bacteria from skin under
running water.
• Antimicrobial soap: Soap (i.e., detergent) containing an antiseptic agent.
• Antiseptic hand wash: Washing hands with water and soap or detergents containing an
antiseptic agent.
• Alcohol-based hand rub: An alcohol-containing preparation deigned for application to the hands
for reducing the number oOf viable microorganism on the hands (usually contain 60-80%
ethanol oOr isopropanol or n-propanol or combination). Hand rubs are usually supplemented
with emollients to protect skin. These should be available at point of care use within an arm’s
length.
• Antiseptic agent: Antimicrobial substances that are applied to the Skin to reduce the number of
microbial flora. E.g. alcohols, chlorhexidine, chlorine. hexachlorophene, iodine, chloroxylenol,
quaternary ammonium and triclosan.
• Antiseptic hand rub: Applying an antiseptic hand-rub product to all surfaces Of the hands to
reduce the Of microorganisms present.
• Decontaminate hands: To reduce bacterial counts hands by performing antiseptic hand rub or
antiseptic hand washes.
• Visibly soiled hands: Hands showing visible dirt or visibly contaminated with proteinaceous
material. blood, or Other other fluids (e.g., fecal material or urine),

23.2 5 moments of hand hygiene (figure 1)

1. Before touching a patient: This includes before touching a patient and before entering patient
zone. This prevents cross transmission between patient zone and transmission of microbes by health
care worker. This should be done after last contact with an object outside the patient zone and
before first contact within the patient zone. E.g., after touching doorknob.

2.Before clean/aseptic procedures and manipulating invasive devices: such as inserting peripheral
IV canula, surgical wounds dressing change, touching areas with breaks in skin and mucous
membrane, endotracheal suctioning, giving an injection or taking sample form central venous line.
This ensures no entry of microbes into patient through these sites of lowered immune defense.

3.After body fluid exposure: This includes contact with mucous membranes, nonintact skin, wound
dressing, and body fluids. This protects health care worker. This must be performed even in absence
of visible soiling or even when gloves are used.
4. After touching a patient: and before touching anything outside the patient zone. This protects
health care worker and prevents cross contamination.

5. After touching patient surrounding: Even without touching patient, hand hygiene has to be
performed after touching patient surrounding include linen, bedside furniture, monitor, IV stand,
infusion pump, since these may be contaminated with patients’ flora.

23.3 Technique of hand hygiene: There are two methods of performing hand hygiene: using alcohol
based hand rubs or hand washing using soap and water.

Alcohol based hand rubs have been shown to definitely Superiorsuperior to soap and water hand
washing in reducing bacterial colony counts of the hands. Hence. application of alcohol-based hand
rubs must be preferred over hand washing.

In following settings, hand washing is recommended than using alcohol-based hand rub

• At entry/reentry into any newborn care area

 If hands are visibly soiled (see definition in section 23.1)
 Before & after eating and after using the toilet.

In all other situations, alcohol-based hand rub is superior to hand washing. All hand washing must be
followed by drying and by application of an alcohol hand rub.

23.4 Technique of applying alcohol-based hand rubs

Apply product to palm of one hand (one press of 500 mL Sterilium® pours ~ 1.5 mL of sterilium) into
cupped hand and rub hands together, covering all surfaces of hands and fingers.
 1. Rub your hands palm to palm.
2. Rub fingers of one hand to dorsum of other hand and interlace the fingers, to reach dorsal
interdigital area of hand.
3. Repeat procedure on palmar side of hands, to reach palmar interdigital area.
4. Rub back of your fingers across palm of other hand, to cleanse dorsal aspect of distal
phalanges.
5. Clasp base of thumb in palm of other hand and rotate you thumb and vice versa, to cleanse
base of thumb.
6. Rotate tips of fingers on the palm of other hands to decontaminate tips of fingers and
subungual region.

Wait until hands are dry. Do not touch the baby with wet hands.

Entire procedure should take around 20-30 seconds.

23.5.2 4 HAND WASHING PROTOCOL

23.241 .5.1 Perform hand washing for 2 min40-60s:

At entry/reentry into any newborn care area

If hands are visibly soiled (see definition in section 23.1)

Before performing any invasive procedure (Inserting vascular lines, bladder catheterization etc). A 2
min hand wash with soap is required even if one would wearing sterile gloves for the procedure.

After touching soiled items, body fluids or excretions, mucous membranes, non-intact Skin. and
wound dressings, even if hands are not visibly soiled.

If moving from a contaminated site to a clean Site Of the same patient during patient care.

After touching any baby with culture-proven sepsis. This includes fomites attached to or in the
vicinity of the baby- e.g. tubes, lines. baby linen, cot, incubator, radiant warmer, devices attached to
baby, files. charts of baby, items dedicated to baby- e.g. measuring stethoscope, BP cuff etc.

After removing gloves,

Before & after eating and after using the toilet.

• At entry/reentry into any newborn care area

 If hands are visibly soiled (see definition in section 23.1)
 Before & after eating and after using the toilet.
• Exposure to spore forming organisms.
• In all other situations, alcohol based hand rub is superior to hand washing. All hand washing
must be followed by drying and by application of an alcohol hand

23.25.2 Pre-requisites for hand washing

Ideally, hands must be washed with liquid soap from and with running lukewarm water from an
elbow operated tap. Avoid using hot water, because it destroys the superficial layers of the
epidermis and promotes colonization.
Once the liquid Soap finishes, the must emptied, cleaned thoroughlythoroughly, and filled afresh. Do
not simply "top up" the liquid soap. Without periodic cleaning. the dispenser may develop a biofilm
with bacteria.

If liquid is unavailable, one may use a bar soap. It must be ensured that the bar soap either hangs So
that the Water drips off, Or it is kept in a rack with holes at the bottom for drainage. It is the
responsibility of the sister-in-charge to get the rack thoroughly scrubbed und cleaned in each shift. It
is dangerous to use a bar soap that is lying in a stagnant of water.

If the tap is not elbow operated, it must be closed using a sterile paper towel that is used for hand
drying. Do not touch the tap directly.

23.23 5.3 How to perform hand washing:

All personnel who handle newborns must keep their nails short.

First roll up the sleeves till above the elbow. Remove wrist watchwristwatch, rings, bangles etcetc.
(this must be adhered to irrespective of marital or religious status or the prevailing fashion).

Wet from finger tips to the elbows under running water, apply Soap on the wet areas and rub to
create lather.

Then follow the 6 Steps of hand washing (same as that of application of hand rub) washing taking
care that it occupies 2 min.Look at a clock Two min is longer than you think!

(1) Palm to opposite palm, fingers

(2) Palm to back of opposite hand, fingers interlocking

(3) Knuckles rubbed against opposite palm

(4) Hand encircling opposite thumb

(S) Fingertips to centrecenter oOf palm

(6) Hand encircling opposite wrist

• Wash hands and forearm under running water, keeping them upright under the tap.

• Slay in this position for a few seconds until excess water drips off

23.25.4 Drying

Wet hands transfer pathogens much readily than dry hands.

• Always dry hands immediately after washing using air dryer or sterile paper towels and discard the
sheets in the waste bin. Mop hands towels for 10 s and it with another set of paper towels.

• Never use a common towel meant for multiple users.

23.3 ALCOHOI -BASED HAND RUB

23.3.1 Use alcohol hand rubs:

• After drying hands following hand washing

• Before and after every routine patient contact.

Remember; Alcohol based hand rubs have been shown to definitely Superior to soap and water
hand washing in reducing bacterial colony counts of the hands. Hence. Application of alcohol-
based hand rubs must be preferred over hand washing for routine contact.

It is important to remember : Alcohol based antiseptics are not effective on hands that are visibly
dirty or contaminated with organic materials. Hands that are visibly dirty or contaminated with
organic material must washed with and water, even if hand antiseptics are to be as an adjunct
measure.

The term "patient contact" is not restricted to contact with a patient It includes (but is not limited
to) the following.

• Performing any kind Of non-invasive procedure

• Recording any patient parameter

• Touching baby's clothes/linen

• Handling baby’s incubator/warmer/devices attached to baby

• Handling baby's probes /BP cuff

Handling baby IV tubings/syringes

• Handling baby's milk tubings/ syringes

23.3.2 Technique of applying alcohol-based hand rubs

• Apply product to palm of one hand (one press of 500 mL Sterilium® pours ~ 1.5 mL of sterilium)
and rub hands together, covering all surfaces of hands and fingers.

Wait until hands are dry. Do not touch the baby with wet hands.23.6 Skin irritation associated
with hand hygiene.

Itching, cracking, bleeding and in rare cases allergic dermatitis can occur.

Damaged skin more susceptible for colonization and may reduce efficacy of hand hygiene.

23.6.1 Steps to prevent skin irritation.

• Use skin care products liberally during work shifts.

• Avoid use of hot water when washing hands.
• Refrain from using gloves unless specifically indicated.
• Use alcohol-based hand rubs.

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23.4 7 ASEPSIS ROUTINES FOR INDIVIDUAL BABIES

• Maintain adequate supply of disposables. If the patient's family has financial difficulties, it is
preferable to invest in than buying expensive items like IVIGs surfactant etc.
• Use triple swab technique that involves skin break.
• Change dressings as soon as they get soiled.
• Ventilator tubings used for single baby need not be routinely changed. Change once they are
visibly contaminated.
• Remove all lines (IV or arterial, centralcentral, or peripheral) as soon as they are not required.
• Change all the tubings for parenteral fluids OD in the morning shift and immediately if they are
visibly contaminated.
• Autoclaved linen should be used for placing, wrappingwrapping, or cleaning the baby.
• All linen should be changed once daily and immediately if they are visibly soiled.
• Parents be instructed about hand hygiene measures as soon as they enter NICUNICU, and they
must be supervised a few times. In a study conducted in Gujarat where video surveillance of
hand hygiene practice in 26 bedded NICU was conducted, 1 in 7 hand hygiene was unacceptable

and most were during night hours or by parents.

• Supporting staff from other departments (including doctors,radiographersdoctors,
radiographers, ECG technicians, etc) must be instructed about hand
• hygiene measures as soon as they enter the NICU and they must he supervised. Do not assume
that they remember the hand hygiene protocols from their previous visits.
• All babies receiving intensive care must have their individual resuscitation tray, resuscitation
equipment, measuring tape, spirit swab bowl, thermometer, saturation probe, BP cuff and
Sterilium bottle. Sharing Of these items is prohibited.
• • Babies in non-intensive areas should be sponged daily with individual autoclaved cotton using
a personal bowl. Babies must not be bathed.

23.47.1 Policy for vascular catheters

• Use vascular catheters made of polyyurethane. , silicone elastomer Or or Teflon; and not
polyvinyl chloride or polyethylene.,
• • For peripheral cannulas, hand hygiene by use of an alcohol-based hand rub or hand
washing with an anti-bacterial soap followed by the use of a pair of fresh. clean (not
necessarily sterile) gloves is recommended. The insertion site must not be touched after
disinfection. A small sterile drape for placing the articles is sufficient.
• •Sterile gloves are necessary while inserting arterial catheters. The tip of the glove covering
the index finger may be cut off to allow better palpation.
• •The insertion site must be disinfected by applying chlorhexidine with alcohol solutionspirit

by povidone-iodine. Povidone-iodine must be allowed to

remain for at least 2 min or longer if it has air dried by that time.
• For CVC'S and PICCs, maximal Sterile barrier precautions are surgical scrub, cap. mask, sterile
gown, sterile gloves and a large sterile drape. All subsequent handlings of the CVC or PICC
that involve breaking the line must be performed with the attention to maximal sterile
barrier precautions as the initial insertion.
• A transparent, semi-permeable polyurethane dressing is preferable to standard gauze and
tape dressing as it permits secure fixation, visibilityvisibility, and protection from wetness.
Gauze may be preferable in case of oozing of blood.
• Brachial, axillary and scalp and jugular veins are preferred for PICCs as thrombosis rates are
less. The use of femoral lines is prohibited.
• In-line filters must not be used, The only possible indication is pre- existing phlebitis or use of
a drug highly likely to cause phlebitis, in which case it used after discussing with the
consultant.
• Never in-line filters along with lipids. blood. dextran and mannitol.

• Use of inline filters is not recommended.

• Anti-microbial impregnated vascular catheters are not recommended as evidence till now
does not support theory that it reduced infection. Currently not available in India.
• Do not apply any antibiotic /antiseptic ointment at the insertion site of peripheral catheters,
CVC's or PICC's and umbilical catheters, They increase emergence Of resistant organisms,
promote fungal colonization and might affect the integrity of the catheter material. Do not
use prophylactic systemic antibiotics antibiotic solutions us they promote antibiotic

resistance.
• Use heparin prophylaxis (dose 0.5 IU/kg/h) in patients with short- term CVC'S to reduce the
risk Of of blockage [typical RR 0.39, 95% CI 0.22 to 0.67; and NNT 9, 95% CI 6 to 20)0.28.95%
CI 0.15,0.53 NNT 5, 95% CI 3,8. Infusion must run at a rate
of 0.5 mL/hr (for neonates < 30 wks GA) and 1 mL/h for neonates >30 wks GA. For umbilical
arterial catheters, uses heparin in a fixed dose of 0.5 to I IU/mL.

• Peripheral venous and arterial catheters need not be changed at fixed intervals. This is unlike
adults, where the change of peripheral venous catheter is recommended every 72 h,
• CVC's and PICCs need not be electively changed. If a change is mandated due to malfunction.
a useful method is to insert a guide wire and change the catheter over the guide Wire.
 However, this must not be done in Of of suspected catheter related blood stream infection
(CRBSI).
• Administration sets through which lipids or blood products have been given must be
changed within 24 h. Studies in adults Show show that it is safe and to change
administration sets of routine fluids every 72 h. However, given the lack Of of data in
neonates and the high rates of sepsis in India. it would be safer to change all administration
sets every 24 h.
There is no convincing evidence that needleless connector systems (Clave, local agent-
Sudarshan Sharma- 9814602436) decrease sepsis or phlebitis in neonates. They may the
reduce risk Of needlestick injuries. In a pilot RCT in PGI, there was a trend towards longer
intervals till the first episode of sepsis in the needleless connector group. Needleless
connectors may be used after discussion with the consultant on a case wise basis.
Needleless connector, such as vygon octopus available in supply should be used. It keeps a
closed system (no risk of blood reflux) and reduces the risk of cannula movement in the vein
and thus the risk of mechanical phlebitis. negates the need to use the cannula injection port
(non disinfect able) whereas connector hub can be easily disinfected with 70% alcohol

swabs.
• Scrub the access port or hub with friction immediately prior to each use with an appropriate
antiseptic (chlorhexidine or 70% alcohol)
• The use of a common stock solution (e.g. Heparin, saline) for multiple patients is prohibited.
The use of a common multi-dose vial of a drug for multiple patients is prohibited; however,
it can be used for a single patient repeatedly. The use of a single-use vial (generally they
contain no preservative or bacteriostatic agent) on multiple occasions is prohibited.
• UAC's must be placed in the high position (See PGIMER video on neonatal procedures and
section N22). Remove and do not replace umbilical arterial or venous catheters in case of
CRBSI, vascular insufficiency, or thrombosis.
• UAC's should not be left in place >5d. Umbilical venous catheters should be removed as soon
as possible when no longer needed but can be used up to 14 d if managed aseptically.
•

23.5 EQUIPMENT DECONTAMINATION AND HOUSEKEEPING ROUTINES: Shown in Table 23.1 and
23.2
Table 23.1 Equipment Decontamination

Item Activity Periodicity

Incubators and open care In use : detergent and water In use : once daily
systems Not being used: 2% cidex Not being used: dismantle
weekly and clean with 2%
cidex
Ventilator body Clean with moist cloth using Once daily
10% bleach solution or 5%
H2O2 solution1
Infusion pump and monitors Clean with moist cloth Once daily
Resuscitation bags and Dismantle, 2% cidex for 30 After each use
accessories minutes
Rubber and plastic tubings 2% cidex for 6 hrs Once daily
Humidity bottles, suction Clear Clean with detergent Once daily
bottles, and O2 hoods
Laryngoscope Clean with spirit After each use
2% cidex for 30 min Once daily
Thermometer Wipe with spirit Before and after each use
Stethoscope, measuring tape Wipe with spirit Before and after each use
Weighing machine Wipe with moist cloth Once daily
Saturation probe Use disposable in intensive
areas
BP cuff Use disposable in intensive
areas
Procedure sets Autoclave After each use
1 10 ml of 5.25% bleach solution, to be dissolved in 90 ml of water. 10 ml of 50% H2O2 solution,
dissolved in 90 ml of water.

Table 23.2 Housekeeping routines

Items Activity Periodicity

Floors Mop with phenyl Thrice daily
Walls Wipe with detergent/carbolic Thrice daily
acid
Fans Wipe with detergent Fortnightly once
Basins Clean with detergent Thrice daily
Linen Manually clean and then After each use
autoclave
Feeding utensils Wash with detergent, boil for Before each use
20 min
Shelves Wipe with phenyl/carbolic Thrice daily
acid
Telephone Wipe with moist cloth Once daily
23.6 ENTRY RESTRICTIONS

• Encourage parents to visit their baby, Mother should be allowed to visit at any time in all areas.
Father can visit the baby nursed in intensive areas during 5 pm to 1 pm. However, timings for fathers
may be relaxed on request.

• There are no visiting hours for other relatives and well-wishers in the NICU or NNN. They may visit
during the permissible visiting hours in the maternity ward, Gynecology ward, or private wards only.

23.7 UNIVERSAL PRECAUTIONS

23.7.1 Universal precautions apply to blood and to other fluids containing visible Universal
precautions also apply to tissues and to the following fluids: CSF, synovial fluid. pleural fluid,
peritoneal fluid. pericardial thud. and amniotic fluid.

235.2 Universal precautions do not apply to feces, nasal secretion, sputum, sweat. tears, urine,
vomitus unless they contain visible blood. The risk Of transmission Of HIV and HBV from these fluids
and materials is extremely low or nonexistent.

23.7.3 What do universal precautions mean?

Always wear sterile gloves for heel stabs, phlebotomy and insertion of vascular Wearing gloves
appears cumbersome for the beginner,butbeginner, but one can soon getsget used to it. A small
window can be cut at the region of the finger tipfingertip of the index finger of the dominant hand,
to aid palpation of veins and arteries.

Wear gloves while handling any kind oOf body fluids. It is a basic right of every doctor to have a pair
oOf sterile gloves provided by the hospital for every procedure that involves contact with bodily
fluids that require universal precautions.

Do not recap used needles by hand.

Do not remove used needles from syringes by hand.

Do not bend, break, or otherwise manipulate used needles by hand.

Destroy needles using the needle destroyer provided in every ward.

Dispose scalpel blades and Other sharp items in puncture-resistant containers for disposal.

23.8 BABIES WITH THE FOLLOWING CONDITIONS REQUIRE ISOLATION

• Diarrhea
• pyoderma
• Discharging wounds
• IUI (see chapter 26)

23.9 STAFF MEMBERS WITH THE FOLLOWING ILLNESSES SHALL NOT CARE FOR BABIES

• Fever

• Diarrhea

Pyoderma

External infected wounds

Conjunctivitis

Ear discharges

Viral exanthems

Those with upper respiratory infections may work wearing a mask at all times.

23.10 BIOMEDICAL WASTE DISPOSAL: Shown in Table 23.3

Color coding Waste

Yellow (solid Human anatomical waste (human tissues, organs, body parts)
infectious) Microbiology and biotechnology waste (wastes from lab cultures, live or
attenuated vaccines, devices used for transfer of cultures)
Solid wastes(items contaminated with blood and body fluids including cotton,
dressings, soiled plaster casts, line beddings, other material contaminate with
blood, blood bags, discarded medicines, masks, gowns )
Red Solid waste (waste generated from disposable items other than the waste
(contaminated sharps such as tubings, catheters, IV sets, Gloves, Saline bottles etc.)
plastic waste)
Black Food waste, vegetable waste, paper waste
(uncontaminated
general waste)
Sharp waste
White puncture Sharp blade, needles,
proof container
Blue puncture Vials, ampoules
proof container
‍
‍

REFERENCES

1. O'Grady- MMWR 51:'

2. Shah PS, Cochrane 2009