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

Healthcare-associated infections (HAIs) and antimicrobial-resistant (AMR) infections are leading causes of neonatal morbidity and mortality, contributing to an extended hospital stay and increased healthcare costs. Although the burden and impact of HAI/AMR in resource-limited neonatal units are substantial, there are few HAI/AMR prevention studies in these settings. We reviewed the mechanism of action and evidence supporting HAI/AMR prevention interventions, including care bundles, for hospitalized neonates in low- and middle-income countries (LMIC).

SARS-CoV-2 in children and their accompanying caregivers: Implications for testing strategies in resource limited hospitals.

Background: Identification of SARS-CoV-2 infected individuals is imperative to prevent hospital transmission, but symptom-based screening may fail to identify asymptomatic/mildly symptomatic infectious children and their caregivers. Methods: A COVID-19 period prevalence study was conducted between 13 and 26 August 2020 at Tygerberg Hospital, testing all children and their accompanying asymptomatic caregivers after initial symptom screening. One nasopharyngeal swab was submitted for SARS-CoV-2 using real-time reverse-transcription polymerase chain reaction (rRT-PCR). An additional Respiratory Viral 16-multiplex rRT-PCR test was simultaneously done in children presenting with symptoms compatible with possible SARS-CoV-2 infection. Results: SARS-Co-V 2 RT-PCR tests from 196 children and 116 caregivers were included in the analysis. The SARS-CoV-2 period prevalence in children was 5.6% (11/196) versus 15.5% (18/116) in asymptomatic caregivers (p<0.01). Presenting symptoms did not correlate with SARS-CoV-2 test positivity; children without typical symptoms of SARS-CoV-2 were more likely to be positive than those with typical symptoms (10.2% [10/99] vs 1% [1/97]; p<0.01). Children with typical symptoms (97/196; 49.5%) mainly presented with acute respiratory (68/97; 70.1%), fever (17/97; 17.5%), or gastro-intestinal complaints (12/97; 12.4%); Human Rhinovirus (23/81; 28.4%) and Respiratory Syncytial Virus (18/81; 22.2%) were frequently identified in this group. Children-caregiver pairs' SARS-CoV-2 tests were discordant in 83.3%; 15/18 infected caregivers' children tested negative. Symptom-based COVID-19 screening alone would have missed 90% of the positive children and 100% of asymptomatic but positive caregivers. Conclusion: Given the poor correlation between SARS-CoV-2 symptoms and RT-PCR test positivity, universal testing of children and their accompanying caregivers should be considered for emergency and inpatient paediatric admissions during high COVID-19 community transmission periods. Universal PPE and optimising ventilation is likely the most effective way to control transmission of respiratory viral infections, including SARS-CoV-2, where universal testing is not feasible. In these settings, repeated point prevalence studies may be useful to inform local testing and cohorting strategies.

SafeHANDS: A Multimodal Hand Hygiene Intervention in a Resource-Limited Neonatal Unit.

BACKGROUND: Hand hygiene (HH) is a cornerstone of programmes to prevent healthcare associated infections (HAI) globally, but HH interventions are seldom reported from African neonatal units. METHODS: We conducted a quasi-experimental study evaluating the impact of a multi-modal intervention (SafeHANDS) on HH compliance rates, alcohol-based handrub (ABHR) usage, the Hand Hygiene Self-Assessment Framework (HHSAF) score, and healthcare-associated bloodstream infection (HA-BSI) rates at a 132-bed South African neonatal unit (4 wards and 1 neonatal intensive care unit [NICU]). The intervention included a campaign logo, HH training, maternal education leaflets, ABHR bottles for staff, and the setting of HH performance targets with feedback. Three 5-month study phases were completed in July 2020 (baseline), December 2020 (early) and May 2021 (intensive). RESULTS: A total of 2430 HH opportunities were observed: 1002 (41.3%) at baseline, 630 (25.9%) at early and 798 (32.8%) at intensive study phases. At baseline, the overall neonatal unit HH compliance rate was 61.6%, ABHR use was 70 mL/patient day, and the baseline HHSAF score was 'basic' (165). The overall neonatal unit HH compliance rate was unchanged from baseline to intensive phases (617/1002 [61.6%] vs. 497/798 [62.3%]; p = 0.797). The ABHR use remained similar between phases (70 versus 73 mL/patient day). The HHSAF score improved to 'intermediate' level (262). There was no change in the neonatal unit HA-BSI rate. CONCLUSION: Despite improvement in the HHSAF score, no improvement in overall HH compliance rates, ABHR usage, or HA-BSI rates was observed. Future HH interventions in resource-limited neonatal units should incorporate implementation science and behaviour modification strategies to better understand the barriers and facilitators of HH best practice.

Laboratory-confirmed bloodstream infections in two large neonatal units in sub-Saharan Africa.

BACKGROUND: Epidemiological data on neonatal bloodstream infections (BSI) in sub-Saharan Africa are extremely limited. METHODS: A comparative analysis of laboratory-confirmed neonatal BSI episodes was conducted retrospectively in two large neonatal units in Botswana and South Africa (January 1 to December 31, 2017). Routine laboratory and ward register data were used to determine BSI rates, the pathogen spectrum, and BSI outcomes. RESULTS: In 2017, the Princess Marina Hospital (PMH) and Tygerberg Hospital (TBH) neonatal units admitted 1187 and 2826 neonates, respectively. The BSI incidence rate was 12.1/1000 patient-days (95% confidence interval (CI) 10.2-14.3) at PMH and 3.5/1000 patient-days (95% CI 2.9-4.1) at TBH (p < 0.0001). Most BSI episodes were hospital-acquired (260/284; 91.6%). The blood culture contamination rate was substantially higher at PMH than TBH (152/1116 (13.6%) vs 122/2559 (4.8%); p < 0.001). The crude mortality rate in neonates with BSI was 21.2% (53/250) and significantly higher at TBH than PMH (38/128 (29.7%) vs 15/122 (12.3%), p = 0.001). Factors independently associated with death were birth weight <1500 g (adjusted odds ratio (aOR) 2.8, 95% CI 1.3-6.4; p = 0.02) and male sex (aOR 2.1, 95% CI 1.1-3.7; p = 0.01). Klebsiella pneumoniae was the dominant BSI pathogen in both units, accounting for two-thirds of BSI, and was associated with a large infection outbreak at PMH. Antibiotic resistance rates were substantial in both neonatal units, particularly for K. pneumoniae (98/122 (80.3%), extended-spectrum beta-lactamase (ESBL)-producers) and Staphylococcus aureus (22/33 (66.7%), methicillin-resistant). CONCLUSIONS: BSI rates and associated mortality were substantial in these two neonatal units in sub-Saharan Africa. ESBL-producing K. pneumoniae remains a leading BSI and outbreak pathogen.