NeoCLEAN: a multimodal strategy to enhance environmental cleaning in a resource-limited neonatal unit

Abstract

Background Contamination of the hospital environment contributes to neonatal bacterial colonization and infection. Cleaning of hospital surfaces and equipment is seldom audited in resource-limited settings. Methods A quasi-experimental study was conducted to assess the impact of a multimodal cleaning intervention for surfaces and equipment in a 30-bed neonatal ward. The intervention included cleaning audits with feedback, cleaning checklists, in-room cleaning wipes and training of staff and mothers in cleaning methods. Cleaning adequacy was evaluated for 100 items (58 surfaces, 42 equipment) using quantitative bacterial surface cultures, adenosine triphosphate bioluminescence assays and fluorescent ultraviolet markers, performed at baseline (P1, October 2019), early intervention (P2, November 2019) and late intervention (P3, February 2020). Results Environmental swabs (55/300; 18.3%) yielded growth of 78 potential neonatal pathogens with Enterococci, S. marcescens, K. pneumoniae, S. aureus and A. baumannii predominating. Highest aerobic colony counts were noted from moist surfaces such as sinks, milk kitchen surfaces, humidifiers and suction tubing. The proportion of surfaces and equipment exhibiting no bacterial growth increased between phases (P1 = 49%, P2 = 66%, P3 = 69%; p = 0.007). The proportion of surfaces and equipment meeting the ATP “cleanliness” threshold (< 200 relative light units) increased over time (P1 = 40%, P2 = 54%, P3 = 65%; p = 0.002), as did the UV marker removal rate (P1 = 23%, P2 = 71%, P3 = 74%; p < 0.001). Conclusion Routine environmental cleaning of this neonatal ward was sub-optimal at baseline but improved significantly following a multimodal cleaning intervention. Involving mothers and nursing staff was key to achieving improved environmental and equipment cleaning in this resource-limited neonatal unit.

Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis

“…An increase in the rate of facility births and neonatal interventions across many LMICs further highlights the importance of infection control and prevention. Dedicated cleaning interventions can improve cleanliness and reduce the burden of contaminated surfaces in low-resource NICUs [ 121 ]. The types of Gram-negative pathogens and associated AMR patterns are likely to evolve over time, and consideration should be given to the development of platforms that provide these data in a useful format and timely fashion.…”

Healthcare-Associated Infection Prevention Interventions for Neonates in Resource-Limited Settings

“…Sink drains, washbasins, and other moist surfaces (e.g., humidifiers and ventilator tubing) are sources of nosocomial outbreaks in neonatal units (70)(71)(72)(73). Potential interventions to prevent colonization with waterborne pathogens include waterless hand hygiene using CHG or alcohol-based hand sanitizer (74), water-free patient care including sink removal from patient care areas (75,76), and acetic acid (vinegar) as a low-cost method to decontaminate sink drains and multiple-use medical equipment (77)(78)(79).…”

“…The use of low-cost tools, such as fluorescent markers or gel dots, to assess cleaning quality and provide regular feedback is relatively easy to implement in many LMIC settings. This strategy, within a multimodal bundle, has been demonstrated to improve cleaning practices (70,81,82). Commonly used neonatal medical and feeding equipment, such as suction catheters (83)(84)(85) and breast pumps (86,87), are also prone to contamination, especially when shared or reused.…”

“…Prevention of horizontal MDRO transmission in neonatal units relies on the implementation of robust IPC practices, including cleaning and disinfection of high-touch surfaces and equipment ( 80 ). While cleaning and disinfection can reduce the burden of pathogens in the neonatal environment ( 70 ), implementing and sustaining adequate environmental cleaning remains a challenge. High-touch surfaces may become contaminated between cleaning times, undermining hand hygiene initiatives by causing hand recontamination in the neonatal care unit.…”

“…Commonly used neonatal medical and feeding equipment, such as suction catheters ( 83 – 85 ) and breast pumps ( 86 , 87 ), are also prone to contamination, especially when shared or reused. Potential interventions include multimodal cleaning interventions ( 70 ), nurse training in disinfection methods, ( 79 ) and using surface materials with antimicrobial properties ( 88 ).…”