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
International

HIGH LEVEL DISINFECTION

• Boiling for 20 minutes, completely covered

with water
• Chemical: bleach 1:50 dilution for 20
minutes… corrosive to stainless steel
 Infection
International

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

DISINFECTING WORK AREAS

• Clean dirty areas with detergent

• Disinfect area with bleach 1:100
dilution
• Wear gloves
• Exam tables should be disinfected
daily
 Infection
International

Infection
 Infection
International

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

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

Incidence and scope:

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

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

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
 Infection
International

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
International

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
 Infection
International

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
 Infection
International

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
 Infection
International

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)
 Infection
International

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) 60-
100 mg q8h +clindamycin 900 mg q8h
 Infection
International

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
International

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)
 Infection
International

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
 Infection
International

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
International

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

Special case:
Postpartum or postabortal septic shock

definition: any toxic patient who has

hemodynamic or acid base changes with fever
38.5ºC (after abortion, vaginal or operative
delivery)
 Infection
International

Etiology of postpartum/postabortal shock

- usually gram-negative bacteria (eg. E. Coli) and

occasionally gram positive (staphylococci,
anaerobic streptococci, clostridium)
 Infection
International

Pathophysiology of postpartum postabortal

shock

- not fully understood

- endotoxins from cell wall of bacteria initiate
vascular damage and vasodilatation
- hypotension / hypoperfusion
 Infection
International

Conclusions

- major problem
- proper diagnosis
- early and aggressive treatment
- prevention
 Infection
International

MALARIA IN PREGNANCY
 Infection
International

Objectives
• Describe epidemiology of malaria
• Describe maternal and fetal
complication
• Principle of management and
preventive strategies
 Infection
International

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)

 Infection
International
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:12-
50%
 Infection
International

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
 Infection
International

Maternal complication
In Endemic areas In non-Endemic
• malaria related areas
anaemia • Greater risk of
• Febrile illness severe disease
• Placental • Higher risk of
sequestration death
• Anaemia,
hypoglycemia,
pulmonary
oedema, renal
failure
 Infection
International

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
 Infection
International

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

Fetal complications
In endemic areas In non-endemic areas
• Low birth weight • Abortions
• Intra-uterine growth • preterm delivery
retardation • Congenital malaria
• Low birth weight
 Infection
International

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
International
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
 Infection
International

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
 Infection
International

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
 Infection
International

Use of Insecticide treated nets

YEAR LOCATION MALARIA GRAVIDITY PREVALENCE
TRANSMISSION OF ANAEMIA

1993 Thai/Myanm 0.8 All 56 to 27%

ar Border
1996 Gambia 1-10 Primegravid 17 to 3%

1998 Kenya 10 Primegravid 20 to 15

 Infection
International

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.
 Infection
International

PREVENTION OF MATERNAL
TO CHILD TRANSMISSION OF
HIV
 Infection
International

Objectives
• Describe relationship of HIV on
pregnancy

• Factors affecting vertical transmission

• Strategies to prevent maternal to child

transmission
 Infection
International

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)
 Infection
International

HIV AND PREGNANCY

• Effect of pregnancy on HIV progression

• Effect of HIV on pregnancy outcome

 Infection
International

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

 Infection
International

Effect of HIV on pregnancy

course and outcome
Abortions Possible increase risk

Perinatal deaths Developed: No association

Developing:Increased
IUGR Increased risk

Low birth weight Increased risk

Preterm delivery Increased risk

Fetal malformation No evidence of increased

risk
 Infection
International
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%
 Infection
International

Factors affecting transmission

• Viral • Preterm deliveries
factors:(Load,strain • Duration of membrane
variation)* rupture.*
• Maternal: CD4 count • Invasive procedure in
• STD infections* Labour( Instrumental
• Substance abuse vaginal
• Sexual behavior* deliveries,episiotomies*
• Placental disruption • Mode of delivery
• Fetal/neonatal factors
• Breast feeding *
 Infection
International

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
 Infection
International

Comprehensive ANC
minimum package for PMTCT
• Provision of quality ANC
• Health education
• Micro nutrient supplementation
• Prevention and treatment of infections
• Anti- retroviral drugs
 Infection
International

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
International

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
 Infection
International

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
 Infection
International
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
 Infection
International
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
 Infection
International

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
 Infection
International

Oral Anti retroviral treatment

Antepartum Intrapartum Post partum neonatal
For mother

1.AZT 300mgs AZT 300mgs p.o AZT 300mgs p.o 4mgs/kg p.o B.D
p.o B.D after 35 3hourly till B.D for 7 days for 7 days
weeksgestation delivery

2. None NVP 200 mgs p.p none 2mgs/kg p.o 48-

at onset of labour 72 hours
 Infection
International

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)
 Infection
International

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.