Preventing Bloodstream Infections and Death in Zambian Neonates: Impact of a Low-cost Infection Control Bundle

Abstract

Background Sepsis is a leading cause of neonatal mortality in low-resource settings. As facility-based births become more common, the proportion of neonatal deaths due to hospital-onset sepsis has increased. Methods We conducted a prospective cohort study in a neonatal intensive care unit in Zambia where we implemented a multifaceted infection prevention and control (IPC) bundle consisting of IPC training, text message reminders, alcohol hand rub, enhanced environmental cleaning, and weekly bathing of babies ≥1.5 kg with 2% chlorhexidine gluconate. Hospital-associated sepsis, bloodstream infection (BSI), and mortality (>3 days after admission) outcome data were collected for 6 months prior to and 11 months after bundle implementation. Results Most enrolled neonates had a birth weight ≥1.5 kg (2131/2669 [79.8%]). Hospital-associated mortality was lower during the intervention than baseline period (18.0% vs 23.6%, respectively). Total mortality was lower in the intervention than prior periods. Half of enrolled neonates (50.4%) had suspected sepsis; 40.8% of cultures were positive. Most positive blood cultures yielded a pathogen (409/549 [74.5%]), predominantly Klebsiella pneumoniae (289/409 [70.1%]). The monthly rate and incidence density rate of suspected sepsis were lower in the intervention period for all birth weight categories, except babies weighing <1.0 kg. The rate of BSI with pathogen was also lower in the intervention than baseline period. Conclusions A simple IPC bundle can reduce sepsis and death in neonates hospitalized in high-risk, low-resource settings. Further research is needed to validate these findings in similar settings and to identify optimal implementation strategies for improvement and sustainability. Clinical Trials Registration NCT02386592.

Healthcare worker perceptions of the implementation context surrounding an infection prevention intervention in a Zambian neonatal intensive care unit

“…In this study, we utilized interview methods to uncover the perceptions of doctors and nurses working in a Zambian NICU during the implementation phase of a study to evaluate a low-cost infection prevention bundle. Implementation of the bundle was successful --rates of sepsis, BSIs and death among neonates in the NICU declined during the study period [17]. The concurrent qualitative study revealed important insights into the implementation context that can be strategically leveraged to spread and sustain the effects of the intervention.…”

“…Our team recently completed a large observational cohort study to measure the impact of a low-cost infection prevention bundle on rates of neonatal hospital-acquired bloodstream infections (BSIs) as well as overall mortality in a large Zambian NICU [17]. Implementation of the bundle led to an observed reduction in rates of suspected sepsis, BSIs and death among neonates in the NICU.…”

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

“…Ours is the rst study to evaluate the potential of environmental cleaning as a standalone HAI prevention intervention, with only one prior study including cleaning in a neonatal infection prevention bundle. 20 Furthermore, the key contribution of hospital cleaners and cleaning practices to patient safety is underappreciated in many LMIC settings 24 , despite the substantial risk of pathogen transmission from environmental reservoirs. [4][5][6] In this paper, we report the impact of a multimodal intervention (neoCLEAN) on the adequacy of surface and equipment cleaning in a South African neonatal ward using bacterial cultures, ATP assays and UV marker removal rates.…”

“…16,18 In contrast to the extensive experience with hospital cleaning bundles in high-income settings, there are few published reports on their use in low-resource setting and in particular, African country neonatal units. 19,20 As hospital cleaning bundles are key tools for HAI prevention 17 , research is needed to measure their impact on cleaning practices in resource-limited settings. Therefore, we assessed the impact of a multimodal intervention on the adequacy of surface and equipment cleaning in a South African neonatal ward.…”

Interventions to prevent neonatal healthcare-associated infections in low-resource settings: a systematic review

“…Of note, although our initial search captured a large number of potentially eligible studies, full text review led to 40/120 (33%) papers being excluded due to not including mandatory criteria required by ICROMS, or having a low score for study design/analysis quality. Thus some geographical areas were not well represented-in particular sub-Saharan Africa with only one study included 34 . This highlights the challenges for clinicians in LMIC settings to identify and implement contextually appropriate evidence-based guidelines.…”