Contaminated intravenous equipment and poor infection control measures were found to be the source of an outbreak of klebsiella pneumoniae which killed 21 babies in a KwaZulu-Natal hospital.
Several flaws identified
"Several flaws were identified" with infection control methods, according to the report released on Thursday and compiled by medical microbiologist Professor Willem Sturm of the Nelson R Mandela School of Medicine in Durban.
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Initial investigations at the Mahatma Gandhi Memorial Hospital north of Durban found klebsiella pneumoniae on the hands of 10% of staff.
Interviews revealed that the nursery was usually overcrowded, under-equipped and understaffed, which worked against adherence to infection control.
Early in the investigation, a link was found to the babies' intravenous treatment and after other possibilities were ruled out, medication information for 17 of the babies showed that they had received regular intravenous injections.
Contamination took place in the wards
Unopened bottles did not grow the organism, indicating that contamination took place in the wards during handling of the bottles, and not at the production plant.
The formula feeds found in the wards also contained several species of bacteria, amongst them klebsiella pneumoniae.
Although certain laboratory information is still outstanding, findings point to an outbreak of klebsiella pneumoniae infection due to contamination of one of the intravenous medications, the report said.
Intravenous equipment was also found to be the source of a similar outbreak which killed six babies at Bloemfontein's Pelonomi Hospital last year.
Spread linked to inadequate practices
The spread was attributed to multiple-use of units of the medication to save costs, inadequate hand washing practices and inappropriate hand wash facilities.
The basins which existed were found to be far from where the healthcare workers worked and they were also found to use too little hand wash and to not rub it in properly.
Recommendations made in the report
Recommendations include the sealing off of the nursery with strict hygiene controls and abandoning the practice of multiple use of units of intravenous preparations.
"Such preparations should be used only once. Multiple-use for one patient should also not be done."
Long sleeves on gowns, white coats and uniforms, or personal wear should be forbidden, and rings and watches should not be worn on hands and wrists as these interfere with hand washing.
Hand washing up to the elbow should be done in high care areas and part of the interventions would include the installation of taps operated by the elbow.
Continuous education and training on infection prevention practices should be done province-wide and the infection control authority should be allowed to stop malpractice.
Separate disinfection and sluice rooms were also needed for the babies' equipment.
The report did not hold any single individual or particular section of the hospital community responsible for the outbreak.
Minister announces early warning system
Releasing the report, Health Minister Manto Tshabalala-Msimang said that an early warning system and a rapid response team would be developed.
The Medical Research Council would soon begin a study on ways of preventing hospital-acquired infections and a nationwide education and training campaign on infection prevention would be introduced.
"This has been a difficult moment for all of us in the health sector and the affected families," she said.
The investigation also found that one baby had died of a different type of klebsiella - oxytoca - but this was not considered part of the outbreak. – (Sapa)
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