Maternal and neonatal outcomes of COVID-19 in a high-risk pregnant cohort with and without HIV.

BACKGROUND: The impact of SARS-CoV-2 infection in pregnant women living with HIV (PLHIV) has not been described previously. OBJECTIVES: To describe the clinical presentation and outcomes of a cohort of women with high-risk pregnancies with confirmed COVID-19 to determine whether risk factors for disease severity and adverse outcomes of COVID-19 differed in pregnant women without HIV compared with PLHIV. METHODS: We prospectively enrolled pregnant women with COVID-19 attending the high-risk obstetric service at Tygerberg Hospital, Cape Town, South Africa, from 1 May to 31 July 2020, with follow-up until 31 October 2020. Women were considered high risk if they required specialist care for maternal, neonatal and/or anaesthetic conditions. Common maternal or obstetric conditions included hypertensive disorders, morbid obesity (body mass index (BMI) ≥40 kg/m2) and diabetes. Information on demographics, clinical features, and maternal and neonatal outcomes was collected and compared for PLHIV v. pregnant women without HIV. RESULTS: One hundred women (72 without HIV and 28 PLHIV) with high-risk pregnancies had laboratory-confirmed COVID-19. Among the 28 PLHIV, the median (interquartile range) CD4 count was 441 (317 - 603) cells/µL, and 19/26 (73%) were virologically suppressed. COVID-19 was diagnosed predominantly in the third trimester (81%). Obesity (BMI ≥30 in n=61/81; 75%) and hypertensive disorders were frequent comorbidities. Of the 100 women, 40% developed severe or critical COVID-19, 15% required intensive care unit admission and 6% needed invasive ventilation. Eight women died, 1 from advanced HIV disease complicated by bacteraemia and urosepsis. The crude maternal mortality rate was substantially higher in women with COVID-19 compared with all other deliveries at our institution during this period (8/91 (9%) v. 7/4 058 (0.2%); p<0.001). Neonatal outcomes were favourable. No significant differences in COVID-19 risk factors, disease severity, and maternal/neonatal outcome were noted for PLHIV v. those without HIV. CONCLUSIONS: In this cohort of high-risk pregnant women, the impact of COVID-19 was severe, significantly increasing maternal mortality risk compared with baseline rates. Virally suppressed HIV infection was not associated with worse COVID-19 outcomes in pregnancy.

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

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.

Hospital-based evaluation of tuberculosis-exposed neonates: An approach to complement the South African national guidance.

The South African National Department of Health published updated guidelines in 2019 for the prevention of mother-to-child transmission of communicable diseases. The proposed management of a neonate born to a mother with tuberculosis (TB) was included, and recommended referral of all symptomatic TB-exposed neonates to hospital for TB evaluation. However, no standard approach exists for evaluating hospitalised, symptomatic TB-exposed neonates, including preterm and low-birthweight (LBW) neonates born to mothers with TB. We use a clinical case report to illustrate a suggested approach to hospital-based evaluation of TB-exposed neonates, including preterm and LBW neonates. Guidance for the interpretation of different TB screening investigations in this population is also provided.

A 'nice to have' or a 'non-negotiable': South African healthcare workers' knowledge, attitudes, practices and perceptions of vaccination

Background: Non-immune healthcare workers (HCWs) are at high risk of contracting and transmitting vaccine-preventable diseases. Data on the knowledge, attitudes and practices (KAP) of African HCWs regarding the World Health Organization (WHO)-recommended vaccinations is limited. Objectives: We aimed to describe the KAP of HCWs regarding the WHO-recommended vaccinations, namely, those against hepatitis B, polio, diphtheria, measles, rubella, meningococcus, influenza, varicella and pertussis, and to assess the facilitators of, and barriers to, HCW vaccine uptake. Methods: This was a cross-sectional study. A self-administered KAP survey was completed by 300 clinical (nurses, doctors, allied health) and non-clinical (laboratory, pharmacy, administrative, household staff and porters) HCWs at Tygerberg Hospital, Cape Town, from June to October 2018. Data were analysed using Stata Statistical Software version 13.0 IC to generate mean scores for KAP. Individual question scores were compared across job categories (clinical vs non-clinical) using Pearson's chi-square test. Results: Most of the study participants were female (n = 228, 76.0%), aged 18­40 years (n = 190, 63.3%) and employed as clinical staff (n = 252, 84.0%). The overall mean KAP scores were 57.1%, 68.4% and 39.9%, respectively; clinical HCWs scored significantly higher than non-clinical HCWs in all three topics (p < 0.001). HCWs believed vaccines to be effective (n = 254, 84.7%) and safe with few side effects (n = 219, 73.0%). Vaccine uptake was highest for hepatitis B (n = 247, 82.3%), followed by measles (n = 159, 53.0%) and diphtheria/tetanus (n = 101, 33.7%), and lowest for influenza (n = 68, 22.7%). Common reasons for vaccination included HCWs wanting to protect themselves, their families and their patients. Fear of side effects and lack of workplace access were common reasons for not vaccinating. Conclusion: Clinical HCWs had better KAP regarding vaccination than non-clinical HCWs. Strategies to improve HCW vaccine uptake should focus on vaccination education and facilitation of workplace access to vaccination.

Personal protective equipment (PPE) in a pandemic: Approaches to PPE preservation for South African healthcare facilities.

Personal protective equipment (PPE) is key to protecting healthcare workers from COVID-19 infection, but the pandemic has disrupted supply chains globally and necessitated rapid review of the scientific evidence for PPE re-use. In South Africa, where the COVID-19 epidemic is still developing, healthcare facilities have a short window of opportunity to improve PPE supply chains, train staff on prudent PPE use, and devise plans to track and manage the inevitable increases in PPE demand. This article discusses the available PPE preservation strategies and addresses the issue of decontamination and re-use of N95 respirators as a last-resort strategy for critical shortages during the pandemic.

Horizontal HIV transmission to children of HIV-uninfected mothers: A case series and review of the global literature.

BACKGROUND: Vertical transmission is the predominant route for acquisition of HIV infection in children, either in utero, intrapartum or postnatally through breast feeding. Less frequently, children may acquire HIV by horizontal transmission. Horizontal transmission may be healthcare-associated (infusion of HIV-contaminated blood products, use of contaminated needles, syringes and medical equipment, or through ingestion of HIV in expressed breastmilk). Community-acquired HIV transmission to children may occur following surrogate breastfeeding, pre-mastication of food, and sexual abuse. METHODS: Children with suspected horizontally acquired HIV infection were identified by retrospective folder review of existing patients (2004-2014) and by prospective interview and examination of new patients (from 2009 onwards), at a hospital-based paediatric antiretroviral clinic in Cape Town, South Africa. The global literature on horizontal HIV transmission to children (1 January 1986-1 November 2019) was reviewed, to contextualize the local findings. RESULTS: Among the 32 children with horizontal HIV transmission (15 identified retrospectively and 17 prospectively), the median age at first diagnosis was 79 months (interquartile range 28.5-91.5); most children (90.6%) had advanced HIV disease at presentation. HIV transmission was considered healthcare-associated in 15 (46.9%), community-associated in ten (31.3%), possibly healthcare or community-associated in five (15.6 %); and unknown in two children (6.3%). CONCLUSION: Horizontal HIV transmission to children is an important public health issue, with prevention efforts requiring intervention at healthcare facility- and community-level. Greater effort should be made to promptly identify and comprehensively investigate each horizontally HIV-infected child to establish possible routes of transmission and inform future prevention strategies.

National Neonatal Sepsis Task Force launch: Supporting infection prevention and surveillance, outbreak investigation and antimicrobial stewardship in neonatal units in South Africa.

Despite a substantial decline in childhood mortality rates in South Africa (SA), progress in neonatal mortality reduction has been much slower. Severe bacterial infections remain a leading cause of neonatal morbidity and a direct cause of 13.1% of neonatal deaths among babies >1 kg. The incidence of hospital-acquired infections, antimicrobial resistance and outbreaks of infections in SA neonatal units is substantial, and is possibly higher than the currently available estimates. The SA Neonatal Sepsis Task Force was launched in Port Elizabeth, SA, on 13 September 2019 to provide technical advice and guidance on surveillance for neonatal sepsis, infection prevention, case management, antimicrobial stewardship and containment of neonatal unit outbreaks.

Transmission of multidrug-resistant Gram-negative bacteria from colonized mothers to their infants: a systematic review and meta-analysis.

BACKGROUND: Neonatal sepsis remains a leading cause of neonatal mortality. Maternal bacterial colonization plays a major role in transmission to the infant, with potential for subsequent development of neonatal sepsis with maternally derived strains. AIM: To review the molecular evidence supporting transmission of multidrug-resistant Gram-negative bacteria (MDR-GNB) from colonized mothers to their infants and the risk factors for MDR-GNB transmission. METHODS: PubMed and Scopus were searched for studies investigating the mechanisms, risk factors for and/or scale of transmission of MDR-GNB from colonized mothers to their infants. Random effects meta-analyses were performed to determine pooled proportions of MDR-GNB transmission and the neonatal outcomes of transmission. FINDINGS: Eight studies were included in the narrative description and six in the meta-analysis. Five studies used pulsed-field gel electrophoresis to assess relatedness of isolates from colonized mothers and their infants. Pooled proportion of MDR-GNB transmission from colonized mothers to their infants was 27% (95% confidence interval (CI): 8-47%). Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae were the most frequently studied MDR-GNB pathogens transmitted between mother-infant pairs. Following mother-to-infant transmission of an MDR-GNB pathogen, the pooled proportion for the outcome of neonatal colonization was 19% (95% CI: 3-35%). CONCLUSION: This systematic review strongly supports MDR and/or ESBL Enterobacteriaceae transmission from colonized mothers to their infants, with subsequent infant colonization. The risk factors contributing to transmission of MDR-GNB between colonized mothers and their infants warrants further research.

Personal protective equipment (PPE) in a pandemic: Approaches to PPE preservation for South African healthcare facilities

Personal protective equipment (PPE) is key to protecting healthcare workers from COVID-19 infection, but the pandemic has disrupted supply chains globally and necessitated rapid review of the scientific evidence for PPE re-use. In South Africa, where the COVID-19 epidemic is still developing, healthcare facilities have a short window of opportunity to improve PPE supply chains, train staff on prudent PPE use, and devise plans to track and manage the inevitable increases in PPE demand. This article discusses the available PPE preservation strategies and addresses the issue of decontamination and re-use of N95 respirators as a last-resort strategy for critical shortages during the pandemic

Tuberculosis transmission in a hospitalised neonate: Need for optimised tuberculosis screening of pregnant and postpartum women.

A recent fatal case of confirmed nosocomial tuberculosis (TB) transmission to a neonate in a kangaroo mother care (KMC) unit highlighted the infection risk to hospitalised neonates in South Africa, a high-burden TB setting. The index case was a 9-week-old infant who presented to another hospital's intensive care unit with severe respiratory distress shortly after discharge from the KMC unit. Contact tracing identified that the infant had been exposed to a postpartum woman with undiagnosed pulmonary TB while in the KMC unit. Molecular testing confirmed nosocomial transmission between the index case and the presumed source case in the KMC unit. We describe the subsequent process of tracing other TB-exposed infants and mothers, the difficulty in confirming TB infection/disease in pregnancy, and the provision of isoniazid preventive therapy in this cohort. We discuss the practical implementation of TB screening approaches in maternity and neonatal wards in high-burden TB settings.

Neonatal listeriosis during a countrywide epidemic in South Africa: A tertiary hospital's experience.

BACKGROUND: A countrywide epidemic of Listeria monocytogenes (LM) in South Africa began in the first quarter of 2017, rapidly becoming the world's largest LM outbreak to date. METHODS: We describe the clinical course of neonates with culture-confirmed LM infection admitted to a tertiary neonatal unit at Tygerberg Hospital, Cape Town (1 January 2017 - 31 January 2018). Current epidemic LM cases were compared with a historical cohort of sporadic neonatal LM cases at our institution (2006 - 2016). The global literature on epidemic neonatal LM outbreaks (1 January 1978 - 31 December 2017) was reviewed. RESULTS: Twelve neonates (median gestational age 35 weeks, median birth weight 2 020 g) were treated for confirmed LM bacteraemia in 2017/18, presenting at a median age of 0.5 days. In 5 cases, neurolisteriosis was suspected. Three neonates died (25.0%) v. 8/13 neonatal deaths (61.6%) in the sporadic listeriosis cohort (2006 - 2016) (p=0.075). The institution's neonatal LM infection incidence increased significantly in 2017 from a historical rate of 0.17/1 000 live births to 1.4/1 000 (p<0.001). During the current LM epidemic, the crude neonatal fatality rate exceeded the average calculated global epidemic neonatal LM mortality (3/12 (25.0%) v. 50/290 (17.2%); p=0.448). Possible factors contributing to the high mortality rate in this epidemic LM neonatal cohort may include more virulent disease associated with sequence type 6 and the predominance of early-onset disease. CONCLUSIONS: Epidemic neonatal listeriosis at Tygerberg Hospital was associated with a predominance of bacteraemic, early-onset disease. Listeriosis-associated mortality rates were higher than previously published, but lower than the rate in a historical institutional cohort.

Interventions to prevent urinary catheter-associated infections in children and neonates: a systematic review.

INTRODUCTION: Few data are available to inform strategies for the prevention of catheter-associated urinary tract infection (CAUTI) in children and neonates. Many recommendations are derived from studies in adults and cannot be applied to the paediatric population. OBJECTIVE: This study was aimed to identify all studies that measured the efficacy of an intervention for the prevention of CAUTI in children and neonates. METHODS: A systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was conducted. Eligible studies published between January 1st, 1995 and December 31st, 2017, were identified in PubMed, the Cochrane Database of Systematic Reviews, LILACS, SciELO and DOAJ if applying an intervention with the aim of CAUTI prevention in inpatient children, infants or neonates. The following study designs were included: controlled and non-controlled before-and-after studies, (controlled) interrupted time series analyses and randomized controlled trials. Quantitative or qualitative studies on interventions in both adults and children were eligible if data on children could be extracted. Reviews, case series, letters, notes, conference abstracts and opinion articles were excluded. RESULTS: Of 99 articles identified, six were included in the final analysis, after consensus from three independent investigators. Four studies used a multimodal strategy (using at least four or more different components at the same time) as follows: aseptic rules during catheter insertion and removal; cleaning the urethral meatus with sterile water; use of a new silicone catheter per insertion with a closed sterile drainage system by a sterile technique; daily evaluation of catheter requirement; placement of indwelling urinary catheters only for approved indications; reducing of urinary catheter days and positioning of the patient and collection device to assist in urine drainage. One study tested periurethral cleaning intervention to reduce CAUTI. One study described the association of the presence of a physician safety champion with urinary catheter device utilization ratios. Catheter-associated UTI reduction rates were reported in four studies; three achieved statistically significant decreases in CAUTI rates. Positive results were achieved only when a multimodal strategy was used with at least four or more components. This strategy could be adopted for paediatric healthcare institutions to reduce CAUTI rates in children and neonates. CONCLUSION: Evidence exists to support the use of a multimodal strategy for CAUTI reduction in hospitalized children and neonates.

Paediatric antimicrobial use at a South African hospital.

BACKGROUND: Data on antimicrobial use among hospitalized children in Africa are very limited due to the absence of electronic prescription tracking. METHODS: This study evaluated antimicrobial consumption rates, the antimicrobial spectrum used, and the indications for therapy on a paediatric ward and in the paediatric intensive care unit (PICU) at Tygerberg Hospital, Cape Town, South Africa. Antimicrobial prescription and patient demographic data were collected prospectively from May 10, 2015 to November 11, 2015. For the same period, data on antimicrobials dispensed and costs were extracted from the pharmacy electronic medicine management system. The volume of antimicrobials dispensed (dispensing data) was compared with observed antimicrobial use (prescription data). RESULTS: Of the 703 patients admitted, 415/451 (92%) paediatric ward admissions and 233/252 (92%) PICU admissions received ≥1 antimicrobials. On the ward, 89% of prescriptions were for community-acquired infections; 29% of PICU antimicrobials were prescribed for healthcare-associated infections. Ampicillin and third-generation cephalosporins were the most commonly prescribed agents. Antimicrobial costs were 67541 South African Rand (ZAR) (5680 United States Dollars (USD)) on the ward and 210484 ZAR (17702 USD) in the PICU. Ertapenem and meropenem were the single largest contributors to antimicrobial costs on the ward (43%) and PICU (30%), respectively. The volume of antimicrobials dispensed by the pharmacy (dispensing data) differed considerably from observed antimicrobial use (prescription data). CONCLUSIONS: High rates of antimicrobial consumption were documented. Community-acquired infections were the main indication for prescription. Although pharmacy dispensing data did not closely approximate observed use, this represents a promising method for antimicrobial usage tracking in the future.

Healthcare-associated infections in paediatric and neonatal wards: A point prevalence survey at four South African hospitals.

BACKGROUND: Healthcare-associated infections (HAIs) cause substantial morbidity, mortality and healthcare costs. The prevalence of neonatal/paediatric HAI at South African (SA) district and regional hospitals is unknown. OBJECTIVES: To document HAI rates, antimicrobial use for HAI, infection prevention staffing, hand hygiene (HH) provisions and HH compliance rates in neonatal and paediatric wards in two district and two regional hospitals in the Western Cape Province, SA. METHODS: An HAI point prevalence survey (PPS) was conducted in neonatal and paediatric wards at two district and two regional hospitals in the Western Cape during December 2016, applying National Healthcare Safety Network HAI definitions. HAI events and antimicrobial therapy active at 08h00 on the PPS day and during the preceding 7 days (period prevalence) were documented. Provisions for HH and HH compliance rates were observed on each ward using the World Health Organization's HH surveillance tool. RESULTS: Pooled point and period HAI prevalence were 9.9% (15/151; 95% confidence interval (CI) 6 - 15.8) and 12.6% (19/151; 95% CI 8 - 18.9), respectively. Hospital-acquired pneumonia (5/15, 33.3%), bloodstream infection (3/15, 20.0%) and urinary tract infection (3/15, 20.0%) were predominant HAI types. Risk factors for HAI were a history of recent hospitalisation (8/19, 42.1% v. 17/132, 12.9%; p<0.001) and underlying comorbidity (17/19, 89.5% v. 72/132, 54.5%; p<0.004). HH provisions (handwash basins/alcohol hand rub) were available and functional. HH compliance was higher in neonatal than in paediatric wards (125/243, 51.4% v. 25/250, 10.0%; p<0.001). Overall HH compliance rates were higher among mothers (46/107, 43.0%) than nurses (73/265, 27.8%) and doctors (29/106, 27.4%). CONCLUSIONS: Neonatal and paediatric HAIs are common adverse events at district and regional hospitals. This at-risk population should be prioritised for HAI surveillance and prevention through improved infection prevention practices and HH compliance.

Neonatal and paediatric bloodstream infections: Pathogens, antimicrobial resistance patterns and prescribing practice at Khayelitsha District Hospital, Cape Town, South Africa.

BACKGROUND: The epidemiology of neonatal and paediatric community-acquired and healthcare-associated bloodstream infections (BSI) at South African (SA) district hospitals is under-researched. OBJECTIVE: Retrospective review of neonatal and paediatric BSI (0 - 13 years) at Khayelitsha District Hospital, Cape Town, SA, over 3 years (1 March 2012 - 28 February 2015). METHODS: We used laboratory, hospital, patient and prescription data to determine BSI rates, blood culture yield and contamination rates, pathogen profile, antimicrobial resistance, patient demographics, BSI outcome and antibiotic prescribing practice. RESULTS: From 7 427 blood cultures submitted, the pathogen yield was low (2.1%, 156/7 427) while blood culture contamination rates were high (10.5%, 782/7 427). Paediatric and neonatal BSI rates were 4.5 and 1.4/1 000 patient days, respectively. Gram-positive BSI predominated (59.3%); Staphylococcus aureus (26.8%) and Escherichia coli (21.6%) were common pathogens. The median patient age was 3 months, with a predominance of males (57.7%) and a 12.8% prevalence of HIV infection. Crude BSI-associated mortality was 7.1% (11/156), the death rate being higher in neonates than in infants and children (6/40 (15.0%) v. 5/116 (4.3%), respectively; p=0.03) and in patients with Gram-negative compared with Gram-positive bacteraemia (6/66 (9.1%) v. 5/89 (5.6%), respectively; p=0.5). Most BSI episodes were community-acquired (138/156; 88.5%), with high levels of extended-spectrum ß-lactamase (ESBL) carriage among Klebsiella pneumoniae and E. coli isolates (5/5 (100%) and 8/33 (24.2%), respectively). Antimicrobial management of BSI was inappropriate in 30.6% of cases (45/147), including incorrect empirical antibiotic (46.7%), dual antibiotic cover (33.3%) and inappropriately broad-spectrum antibiotic use (17.8%). CONCLUSIONS: Antimicrobial-resistant pathogens (notably ESBL-producing Enterobacteriaceae) were common in community-acquired BSI. Paediatric clinicians at district hospitals require ongoing training in antibiotic stewardship and blood culture sampling.

Role of antimicrobial stewardship programmes in children: a systematic review.

The United Nations and the World Health Organization have designated antimicrobial resistance (AMR) as a major health priority and developed action plans to reduce AMR in all healthcare settings. Establishment of institutional antimicrobial stewardship programmes (ASPs) is advocated as a key intervention to reduce antibiotic consumption in hospitals and address high rates of multi-drug-resistant (MDR) bacteria. PUBMED and the Cochrane Database of Systematic Reviews (January 2007-March 2017) were searched to identify studies reporting the effectiveness of ASPs in general paediatric wards and paediatric intensive care units (PICUs) for reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, and antibiotic resistance and healthcare-associated infections (HAIs). Neonatal units and antifungal agents were excluded. Of 2509 titles and abstracts, nine articles were eligible for inclusion in the final analysis. All studies reported a reduction in the use of broad-spectrum/restricted antibiotics or antibiotic consumption. One study reported a reduction in HAIs in a PICU, and another study evaluated bacterial resistance, showing no effect following ASP implementation. Prospective audit on antibiotic use was the most common ASP core component (eight of nine studies). Antibiotic pre-authorization was described in two studies. Other described interventions were the provision of guidelines or written information (five of nine studies), and training of healthcare professionals (one study). There is limited evidence for a reduction in antibiotic consumption and use of broad-spectrum/restricted agents following ASP implementation specifically in PICUs. Data evaluating the impact of ASPs on HAIs and AMR in PICUs are lacking. In addition, there is limited information on effective components of a successful ASP in PICUs.

Central-line-associated bloodstream infections in a resource-limited South African neonatal intensive care unit.

BACKGROUND: The rate of central-line-associated bloodstream infection (CLABSI) in South African (SA) public sector neonatal intensive care units (NICUs) is unknown. Tygerberg Children's Hospital (TCH), Cape Town, introduced a neonatal CLABSI surveillance and prevention programme in August 2012. OBJECTIVES: To describe CLABSI events and identify risk factors for development of CLABSI in a resource-limited NICU. METHODS: A retrospective case-control study was conducted using prospectively collected NICU CLABSI events matched to four randomly selected controls, sampled from the NICU registry between 9 August 2012 and 31 July 2014. Clinical data and laboratory records were reviewed to identify possible risk factors, using stepwise forward logistic regression analysis. RESULTS: A total of 706 central lines were inserted in 530 neonates during the study period. Nineteen CLABSI events were identified, with a CLABSI rate of 5.9/1 000 line days. CLABSI patients were of lower gestational age (28 v. 34 weeks; p=0.003), lower median birth weight (1 170 g v. 1 975 g; p=0.014), had longer catheter dwell times (>4 days) (odds ratio (OR) 5.1 (95% confidence interval (CI) 1.0 - 25.4); p=0.04) and were more likely to have had surgery during their NICU stay (OR 3.5 (95% CI 1.26 - 10); p=0.01). Significant risk factors for CLABSI were length of stay >30 days (OR 20.7 (95% CI 2.1 - 203.2); p=0.009) and central-line insertion in the operating theatre (OR 8.1 (95% CI 1.2 - 54.7); p=0.03). Gram-negative pathogens predominated (12/22; 54%), with most isolates (10/12; 83%) exhibiting multidrug resistance. CONCLUSION: The TCH NICU CLABSI rate is similar to that reported from resource-limited settings, but exceeds that of high-income countries. Prolonged NICU stay and central-line insertion in the operating theatre were important risk factors for CLABSI development. Intensified neonatal staff training regarding CLABSI maintenance bundle elements and hand hygiene are key to reducing CLABSI rates.