Case 16 A hospital acquired infection
Charlie, a 7-week-old male infant who was born at 24 weeks gestation, is transferred from the regional level 3 neonatal unit back to the intermediate care neonatal nursery at the hospital of birth. He remains oxygen dependent and on intermittent CPAP, is enterally fed via a nasogastric tube, and is receiving medical therapy for gastro-oesophageal reflux. Charlie had bilateral grade 2 intraventricular haemorrhages, and his parents are anxious about his long-term prognosis. Charlie’s parents are also worried about the transfer back to the local hospital, because they felt that the care they received at the time of delivery was not optimal.
What actions should be routinely taken when a baby is transferred to a neonatal unit from another hospital?
Charlie’s parents are also anxious about the fact that there is a baby with Methicillin Resistant Staphylococcus aureus (MRSA) colonization in a side-room adjacent to their son’s incubator. They have heard about MRSA and are worried that it might spread to Charlie.
What should the parents be told about MRSA?
On the third day after arrival Charlie has a profound apnoeic episode during a feed. Due to a staffing shortage there is only one nurse in the intermediate nursery who is relatively inexperienced but she immediately calls the doctor for help. The ST2 doctor is in the side-room with the MRSA-colonized baby, and runs straight out to assist the nurse without removing his apron and gloves. Charlie is now bradycardic and requires mask ventilation for a minute before starting to recover. Charlie’s parents watch the whole event and are clearly terrified.
What else would you do at this stage?
Unfortunately, 2 weeks later, Charlie has another profound apnoeic episode during feeding and requires intubation and ventilation for presumed aspiration pneumonia. Charlie is transferred back to the regional neonatal intensive care unit, where a scanty growth of MRSA is isolated from the tracheal secretions on one occasion, and antibiotic therapy is adjusted to treat MRSA pneumonia. He has a prolonged period of ventilation, and subsequently has severe chronic lung disease and eventually requires a tracheostomy for subglottic stenosis.
Some months later Charlie’s parents approach a lawyer to sue the hospital claiming that their baby acquired MRSA at the local hospital and that this has contributed to his poor outcome. They state that a doctor attended their baby without changing gloves or washing his hands after treating a patient known to be MRSA positive, and that proper infection control procedures were not followed. Although the nursing notes documented that MRSA swabs were sent when Charlie was admitted to the intermediate nursery, these were never processed because the wrong hospital number was on the swabs, and nobody repeated the swabs.
Expert opinion
Globally, MRSA is an increasingly common cause of hospital acquired infection in infants in NICUs and has been associated with increased mortality, morbidity and cost of hospital care. MRSA is usually not only resistant to methicillin/flucloxacillin but also to macrolides, quinolones and clindamycin, making it more difficult to treat. The treatment of choice is usually vancomycin. There is little clear evidence to guide the optimal approach to screening for MRSA in infants in a neonatal unit, or to guide the optimal management of those infants found to be colonized. However, most units will screen new admissions with swabs taken from several different anatomical locations and will physically isolate any infants found to be MRSA positive in a separate room, with barrier precautions (gloves and aprons) for any contact with the colonized infant or his/her surroundings because MRSA can be shed into the environment. Although meticulous hygiene standards should always be practised in neonatal units, prevention of transmission of MRSA relies on continuous adherence to these standards. MRSA transmission is often increased by overcrowding or understaffing of the unit, which reduces the likelihood of staff performing optimal hand hygiene. In this case there was a clear failure of basic hygiene standards when the doctor rushed to the emergency without removing a contaminated apron and gloves. It is very unlikely that the time taken to remove gloves and an apron, and apply alcohol hand gel (as a minimum standard of hand hygiene), would have adversely affected the resuscitation efforts. This may have been the cause of MRSA transmission to the infant, but because the admission swabs were not processed it is impossible to know if Charlie was already MRSA colonized. Furthermore, MRSA may not have actually been the cause of the subsequent pneumonia, but because MRSA was isolated from a tracheal aspirate sample, it was prudent to treat as a MRSA pneumonia.
Legal comment
In this case, there appears to have been a breach of duty when the doctor did not remove his apron and gloves before treating Charlie. However, it may well be impossible for the parents to prove, on the balance of probabilities, that Charlie’s subsequent problems were caused by the transmission of MRSA at this incident. He was already in a precarious situation with intraventricular haemorrhages and reflux, and may have developed the aspiration pneumonia and chronic lung disease anyway.
Some detailed analysis by neonatal experts will have to be carried out. Each of them will have to come to a view on the probable chain of events. If the case came to Court, a judge would have to decide which expert’s view on the probable cause is the most cogent. Expert evidence may well be that the transmission of MRSA probably contributed to rather than caused chronic lung disease. In that case, to assess the amount of compensation payable, a calculation would have to be made based on the proportion of the baby’s ultimate disability which is attributable to the MRSA.
Overall, this would be difficult and risky litigation for the parents.
