Babies transferred from other hospitals

• Screen on arrival. Include babies who attend other hospitals for invasive day case procedures (e.g. PDA ligation)
  MRSA:
  • swab nose and perineum plus umbilicus if still moist, and swab any skin lesion (e.g. indwelling vascular line) 
  • urine if long-term urinary catheter present
• MGNB:
  • obtain rectal swab or swab from stool sample; swab must contain visible faecal material to ensure a reliable screening result
  • urine if long-term urinary catheter present
• Barrier nurse until all swabs confirmed negative at 48 hr

Routine screening on unit

• MGNB: monthly
• MRSA: monthly
• Frequency of screening may be increased on advice of lead infection prevention doctor/ infection prevention team if unexplained acquisition of MRSA and/or MGNB occurred on ward

Infection control alerts

• Infection control alert to be triggered for 2 yr after last positive result, irrespective of any negative follow-up screens 
• Babies colonised with CPE and other carbapenemase-producing GNB require an infection control alert to be displayed for 5 yr after the last positive result, irrespective of any negative follow-up screens
• Babies identified by infection prevention team as a close contact of a baby with CPE will require a patient infection control alert up to 5 yr; can be removed when 3 follow-up screens for MGNB, submitted since the creation of the alert, reported as ‘MGNB not isolated’

If new case MRSA reported in patient, offer screening for MRSA

Mother

• Screen mother with nasal, perineal, wound and skin lesion swabs, if any of the following:
  • delivery by caesarean section 
  • mother had recent admission to hospital before delivery
  • mother has chronic health problem (e.g. diabetes mellitus, asthma)
  • mother has other risk factor, high BMI or is a healthcare worker with patient contact
  • mother or household member has a history of skin/soft tissue infection abscess or recurrent skin infections in the last 12 months 
• If none of these risk factors present, screening contacts is not necessary unless advised by consultant microbiologist

Contacts on NICU (patients only):

• Those who have been in close proximity of the index case (i.e. in the same room) 
• Potentially all babies on the ward following a risk assessment and discussion with consultant of the week, co-ordinator, infection prevention team and consultant microbiologist 
• Healthy babies about to be discharged home do not require screening unless advised by consultant microbiologist

Decolonisation of MRSA carriers

• Discharge term healthy babies without decolonisation treatment
• Smaller babies with indwelling lines or CPAP probes are more at risk of infection and should be treated
• Decolonisation may fail due to presence of indwelling lines/foreign body material; repeat once all indwelling lines/foreign bodies removed
  • mupirocin (Bactroban Nasal®) ointment applied to inner surface of each nostril 3 times daily for 5 days; if MRSA reported as high level resistant to mupirocin discuss with consultant microbiologist
  • wash daily with antimicrobial wash, e.g. chlorhexidine or octenidine, for 5 days
• Repeat screening swabs 48 hr after all antibiotic treatment has finished and if baby not about to be discharged
• Successful eradication can be assumed if 3 consecutive swabs taken at 3–7 day intervals are negative. Do not attempt to decolonise more than twice during any 1 admission

MGNB

• Do not attempt decolonisation. Do not treat asymptomatic rectal carriage. Colonisation is in the gut. Drugs are ineffective – may severely damage gut flora and encourage development of resistant organisms
• MGNB: gut carriage not permanent, however may last for several months to years
  • barrier nurse until discharge

MRSA

• ≥2 babies with same strain of MRSA constitutes an outbreak
  • considered ‘the same’ if they have been sent by microbiology to a reference laboratory for typing and have been reported by reference laboratory as ‘indistinguishable’

Action on advice of infection prevention team

• Screen all babies in NNU (swabs as above)
• Optimise infection control measures: see local infection control policy
• If further cases of the same strain occur: 
  • arrange incident meeting to discuss further measures, e.g. swabs from all clinical staff on unit 
• If contact screening of clinical staff for MRSA recommended by lead infection prevention doctor/consultant microbiologist, to be co-ordinated by infection prevention team in collaboration with occupational health (OH)
  • results sent to OH and infection prevention team 
  • contact screening for MRSA of healthcare workers must follow local infection prevention guidance

MGNB

• ≥2 babies with same type of MGNB/CPE constitutes an outbreak 
  • considered ‘the same’ if sent by microbiology to reference laboratory for typing, and reported as ‘indistinguishable’ 
• For CPE ≥2 babies with the same carbapenemase gene (OXA-48, KPC, VIM, NDM-1 etc.) irrespective of organism if associated in time and space constitutes an outbreak

Action

• Screen all babies in NNU on advice of infection prevention team
• Optimise infection control measures: see local infection control policy
• If further cases of same strain occur arrange incident meeting to discuss further measures e.g. environmental screening etc.

CPE

• Screen all contacts (should be alerted on local hospital system)
• 3 rectal swabs/swab from stool sample, ≥24 hr apart
  • if baby on antibiotics: take ≥1 swab >48 hr after stopping antibiotics 
  • if all 3 swabs negative: clear of CPE contact status 
  • if any swab positive, following required:
    • strict isolation 
    • long sleeved gowns 
    • gloves 
    • barrier nursing 
    • barrier cleans 
• Barrier nurse all colonised babies until discharge
• Ensure strict infection prevention measures in place for all babies identified as CPE contacts/with close contact alert 
• If CPE reported during current hospital admission: 
  • strict infection prevention measures to remain in place (irrespective of any negative follow-up screens) 
  • follow-up screens not required 
  • if baby discharged whilst being investigated as contact, follow-up rectal swabs in the community are not required
  • if readmitted whilst having a close contact alert, commence/continue follow-up MGNB screening and repeat on different days until 3 follow-up screens have been reported as ‘MGNB not isolated’
  • close contact alert will remain on hospital system for 5 yr, unless 3 follow-up screens reported as ‘MGNB not isolated’