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

Infection
International

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

Infection
International

Definition:
any patient with fever of 38.5C 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) 60100 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 38.5C (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

Oral Anti retroviral treatment

Intrapartum Post partum For mother
AZT 300mgs p.o B.D for 7 days

Antepartum

neonatal

1.AZT 300mgs p.o B.D after 35 weeksgestation

AZT 300mgs p.o 3hourly till delivery

4mgs/kg p.o B.D for 7 days

2.

None

NVP 200 mgs p.p at onset of labour

none

2mgs/kg p.o 4872 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.