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Sisay A, Asmare Z, Kumie G, Gashaw Y, Getachew E, Ashagre A, Nigatie M, Ayana S, Misganaw T, Dejazmach Z, Abebe W, Gedfie S, Tadesse S, Gashaw M, Jemal A, Kassahun W, Kidie AA, Abate BB, Mulugeta C, Alamrew A, Reta MA. Prevalence of carbapenem-resistant gram-negative bacteria among neonates suspected for sepsis in Africa: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:838. [PMID: 39155370 PMCID: PMC11330605 DOI: 10.1186/s12879-024-09747-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 08/12/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND The emergence and rapid spread of gram-negative bacteria resistant to carbapenems among newborns is concerning on a global scale. Nonetheless, the pooled estimate of gram-negative bacteria resistant to carbapenem that cause neonatal sepsis in developing nations remains unknown. Thus, this study aimed to determine the combined prevalence of gram-negative bacteria resistant to carbapenem in African newborns who were suspected of having sepsis. METHODS All studies published from January 1, 2010, up to December 30, 2023, from PubMed, Science Direct, Scopus electronic databases, and the Google Scholar search engine were researched. Isolates tested for carbapenem from neonates with sepsis, English language papers conducted in Africa, and cross-sectional and cohort studies papers were included. Using PRISMA guidelines, we systematically reviewed and meta-analyzed studies that assessed the prevalence of carbapenem-resistant gram-negative bacteria. The "Joanna Briggs Institute" was used critically to evaluate the quality of the included studies. The data analysis was carried out using STATA™ version 17. Heterogeneity across the studies was evaluated using Q and I 2 tests. The subgroup analysis was done and, funnel plot and Egger's regression test were used to detect publication bias. A sensitivity analysis was conducted. RESULTS All 36 studies were included in the meta-analysis and systematic review. The pooled prevalence of carbapenem resistance in Africa was 30.34% (95% CI 22.03-38.64%). The pooled estimate of gram-negative bacteria resistant to imipenem, and meropenem was 35.57% (95% CI 0.67-70.54%) and 34.35% (95% CI 20.04% - 48.67%), respectively. A. baumannii and Pseudomonas spp. had pooled prevalence of 45.9% (95% CI 33.1-58.7%) and 43.0% (95% CI 23.0-62.4%), respectively. Similarly, Pseudomonas spp. and A. baumannii also exhibited strong meropenem resistance, with a pooled prevalence of 29.2% (95% CI 4.8-53.5%) and 36.7% (95% CI 20.1-53.3%), respectively. E. coli and K. pneumoniae were the two most common isolates. CONCLUSION There should be urgent antimicrobial stewardship practices, strengthened surveillance systems and effective treatment for neonates with sepsis. There was remarkable variation in resistance across the continent.
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Affiliation(s)
- Assefa Sisay
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Zelalem Asmare
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Getinet Kumie
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Yalewayker Gashaw
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Ermias Getachew
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Agenagnew Ashagre
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Marye Nigatie
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Sisay Ayana
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Tadesse Misganaw
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Zelalem Dejazmach
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Wagaw Abebe
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Solomon Gedfie
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Selamyhun Tadesse
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Muluken Gashaw
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Abdu Jemal
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Woldeteklehymanot Kassahun
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Atitegeb Abera Kidie
- Department of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Biruk Beletew Abate
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Chalie Mulugeta
- Department of Midwifery, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Abebaw Alamrew
- Department of Midwifery, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Melese Abate Reta
- Department of Medical Laboratory Sciences, College of Health Sciences, Woldia University, Woldia, Ethiopia
- Research Centre for Tuberculosis and Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, Prinshof 0084, South Africa
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Melariri H, Freercks R, van der Merwe E, Ham-Baloyi WT, Oyedele O, Murphy RA, Claasen C, Etusim PE, Achebe MO, Offiah S, Melariri PE. The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis. EClinicalMedicine 2024; 71:102571. [PMID: 38606166 PMCID: PMC11007440 DOI: 10.1016/j.eclinm.2024.102571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Background Hospital-acquired infections (HAI) are a leading cause of morbidity and mortality globally. These infections are diverse, but the majority are lower respiratory tract infection (LRTI), surgical site infection (SSI), bloodstream infection (BSI), and urinary tract infection (UTI). For most sub-Saharan African countries, studies revealing the burden and impact of HAI are scarce, and few systematic reviews and meta-analysis have been attempted. We sought to fill this gap by reporting recent trends in HAI in sub-Saharan Africa (SSA) with attention to key patient populations, geographic variation, and associated mortality. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a literature search of six electronic databases (Web of Science, Pubmed, APA PsycInfo, CINAHL, Embase, and the Cochrane Library) to identify studies assessing the prevalence of HAI in SSA countries. Studies published between 01 January 2014 and 31 December 2023 were included. We applied no language or publication restrictions. Record screening and data extractions were independently conducted by teams of two or more reviewers. Using the R software (version 4.3.1) meta and metafor packages, we calculated the pooled prevalence estimates from random-effect meta-analysis, and further explored sources of heterogeneity through subgroup analyses and meta-regression. This study is registered with PROSPERO, CRD42023433271. Findings Forty-one relevant studies were identified for analysis, consisting of 15 from West Africa (n = 2107), 12 from Southern Africa (n = 2963), 11 from East Africa (n = 2142), and 3 from Central Africa (n = 124). A total of 59.4% of the patient population were associated with paediatric admissions. The pooled prevalence of HAI was estimated at 12.9% (95% CI: 8.9-17.4; n = 7336; number of included estimates [k] = 41, p < 0.001). By subregions, the pooled current prevalence of HAI in the West Africa, Southern Africa, East Africa and Central Africa were estimated at 15.5% (95% CI: 8.3-24.4; n = 2107; k = 15), 6.5% (95% CI: 3.3-10.7; n = 2963; k = 12), 19.7% (95% CI: 10.8-30.5; n = 2142; k = 11) and 10.3% (95% CI: 1.1-27.0; n = 124; k = 3) of the patient populations respectively. We estimated mortality resulting from HAI in SSA at 22.2% (95% CI: 14.2-31.4; n = 1118; k = 9). Interpretation Our estimates reveal a high burden of HAI in SSA with significant heterogeneity between regions. Variations in HAI distribution highlight the need for infection prevention and surveillance strategies specifically tailored to enhance prevention and management with special focus on West and East Africa, as part of the broader global control effort. Funding No funding was received for this study.
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Affiliation(s)
- Herbert Melariri
- Department of Otorhinolaryngology, Port Elizabeth Provincial Hospital, South Africa
- School of Medicine, Nelson Mandela University, South Africa
| | - Robert Freercks
- School of Medicine, Nelson Mandela University, South Africa
- Division of Nephrology and Hypertension, Livingstone Tertiary Hospital, South Africa
| | - Elizabeth van der Merwe
- School of Medicine, Nelson Mandela University, South Africa
- Department of Adult Critical Care, Livingstone Tertiary Hospital, South Africa
| | | | - Opeoluwa Oyedele
- Department of Computing, Mathematical and Statistical Sciences, University of Namibia, Namibia
- Department of Environmental Health, Nelson Mandela University, South Africa
| | - Richard A. Murphy
- White River Junction Veterans Affairs Medical Center, White River Junction, VT, United States
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Paschal Emeka Etusim
- Unit of Public Health/Environmental Parasitology and Entomology, Abia State University, Uturu, Nigeria
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Mabena FC, Olwagen CP, Phosa M, Ngwenya IK, Van der Merwe L, Khan A, Mwamba TM, Mpembe R, Magobo RE, Govender NP, Velaphi SC, Madhi SA. Bacterial and Candida Colonization of Neonates in a Regional Hospital in South Africa. Pediatr Infect Dis J 2024; 43:263-270. [PMID: 38381956 DOI: 10.1097/inf.0000000000004177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Neonatal colonization with multidrug-resistant (MDR) Enterobacter spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterococcus faecium (ESKAPE) and Candida spp. often precedes invasive hospital-acquired infections. We investigated the prevalence and dynamics of neonatal ESKAPE and Candida spp. colonization from hospital admission until discharge (or death) and followed up for invasive disease. METHODS Prospective longitudinal surveillance for neonatal ESKAPE and Candida spp. colonization was conducted over 6 months at a South African regional hospital. Neonates enrolled at birth had swabs (nasal, 2× skin and rectal) collected within 24 hours and every 48-96 hours thereafter, until discharge or death. ESKAPE and Candida spp. were cultured for and antimicrobial susceptibility was performed on bacterial isolates. Whole-genome sequencing was undertaken on paired samples with the same bacterial species from colonizing and invasive disease episodes in the same child. RESULTS Of 102 enrolled neonates, 79% (n = 81) were colonized by ≥1 ESKAPE organism by time of discharge or death. Forty-four percent (36/81) were colonized within 24 hours of birth. Common colonizers were K. pneumoniae (70%; n = 57) and Enterobacter spp. (43%; n = 35). Almost all MDR organisms (93%) were Gram-negative. Forty-two (45%, 42/93) newborns acquired Candida spp. (skin only) colonization, commonly Candida parapsilosis (69%; n = 29). For 2 children with K. pneumoniae colonization and sepsis, the bloodstream and colonizing isolates were genetically different, whereas the single A. baumannii colonizing and blood isolate pair were genetically identical. CONCLUSIONS We report a high prevalence of MDR ESKAPE and Candida spp. colonization in a regional neonatal unit. Interventions to reduce the high incidence of hospital-acquired neonatal infections should include reducing high colonization rates.
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Affiliation(s)
- Fikile C Mabena
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
- Department of Paediatrics and Child Health, University of the Witwatersrand
| | - Courtney P Olwagen
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Matshie Phosa
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Innocent K Ngwenya
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Lara Van der Merwe
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Aaliyah Khan
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Tshiama M Mwamba
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Ruth Mpembe
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Rindidzani E Magobo
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Nelesh P Govender
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- School of Pathology, University of the Witwatersrand
| | | | - Shabir A Madhi
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
- Infectious Disease and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
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Tshitangano TG. Case Study Protocol to Evaluate the Impact of Training Intervention on Cleaners' Knowledge Level, Perceptions and Practices regarding Correct Cleaning Techniques at Selected Care Facilities in Limpopo Province, South Africa. NURSING REPORTS 2024; 14:328-339. [PMID: 38391070 PMCID: PMC10885113 DOI: 10.3390/nursrep14010025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
Despite being preventable, healthcare-associated infections are known primary causes of patient mortality and morbidity, threatening global public health. Though it is believed that one competent and dedicated cleaning staff member given the right tools and enough time can prevent more health-care-associated infectious diseases than a room full of doctors and nurses can cure, it was discovered in Letaba Hospital of the Limpopo Province, South Africa, that knowledge and practices of infection control among cleaning staff were not optimal. The proposed study aims to evaluate the impact of training interventions on cleaners' knowledge levels and practices. In Phase 1, cleaners' pre-training knowledge level, practices, and perceptions regarding correct cleaning techniques will be assessed through qualitative, individual, in-depth interviews. The initial question will read, "Describe the steps you follow when cleaning at this health facility and why?" In Phase 2a, a cleaning training program will be developed based on the South African Qualification Authority ID 118730 Healthcare Cleaner: Occupational Certificate Curriculum and the Center for Diseases Control and ICAN's Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. In Phase 2b, a cleaning training intervention will be implemented. In Phase 3, cleaners' post-training knowledge level, practices, and perceptions will be reassessed and compared to pre-training findings. The Standard Protocol Items: Recommendations for an Interventional Trial, commonly known as SPIRIT, guided the development of this protocol. This protocol received ethical clearance number FHS/22/PH/04/3005 in August 2023 from the University of Venda Human and Clinical Trials Research Ethics Committee. The protocol approval was granted by the Limpopo Provincial Department of Health (LP_2022-05-028) in October 2023. This protocol is registered with the South African National Clinical Trial Registry. The findings of this study may provide baseline data upon which healthcare facilities' cleaner training qualification curriculum may be developed. In addition, this protocol contributes to the application of qualitative methodology in an intervention trial.
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Affiliation(s)
- Takalani Grace Tshitangano
- Department of Public Health, Faculty of Health Sciences, University of Venda, Thohoyandou 0950, South Africa
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Thomas R, Ondongo-Ezhet C, Motsoaledi N, Sharland M, Clements M, Velaphi S. Incidence, pathogens and antimicrobial resistance of blood and cerebrospinal fluid isolates from a tertiary neonatal unit in South Africa: A 10 year retrospective review. PLoS One 2024; 19:e0297371. [PMID: 38241304 PMCID: PMC10798535 DOI: 10.1371/journal.pone.0297371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/29/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To determine trends in incidence, etiology and antimicrobial susceptibility of blood and cerebrospinal fluid (CSF) culture confirmed infections in hospitalized infants in a large tertiary neonatal unit in South Africa. METHODS Single-center, retrospective review of laboratory records of bacteria and fungi, and their susceptibility profiles, isolated from blood and CSF of infants hospitalized in the neonatal unit at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from 1st January 2010 to 31st December 2019. Laboratory data on isolates and their antimicrobial susceptibilities were collected. Coagulase-negative Staphylococcus, Corynebacteria and Bacillus spp. were excluded. Patient-level clinical and laboratory data were not available. RESULTS There were 8,319 significant isolates, giving an infection rate of 14.3/1000 patient-days. Infection rates increased from 12.0 to 15.7/1000 patient-days (estimated average yearly change 0.6[95%CI, 0.5-0.7];p = <0.001). Gram-negative infection rates increased from 4.3 to 10.8/1000 patient-days (estimated average yearly change 0.7[95%CI,0.6-0.8];p = <0.001). The 2 most commonly isolated Gram-negative organisms were Acinetobacter baumannii (44%) and Klebsiella pneumoniae (39%). Carbapenem resistance was seen in 31% of all Gram-negatives and increased over time (estimated average yearly change 4.8%[95%CI,4.2%-5.3%];p<0.001). Gram-positive infection rates decreased (estimated average yearly change -0.1[95%CI,-0.2- -0.05];p = <0.001). Staphylococcus aureus was the most common Gram-positive isolated. Rates of methicillin-resistant Staphylococcus aureus decreased from 91% to 55%(estimated average yearly change -2.8%[95%CI,-3.5%-2%],p< 0.001). Rates of fungal isolates decreased (estimated average yearly change -0.06[95%CI,-0.1 --0.02]);p = 0.007). Candida parapsilosis (52%) and Candida albicans (35%) were the most common fungi isolated. CONCLUSIONS There has been a marked overall increase in rates of blood and/or CSF infections, with an absolute increase in Gram-negative infections observed, replacing Gram-positive and fungal pathogens. Extended spectrum beta-lactamase Gram-negative isolates are being replaced by carbapenem resistance, with around one third of all significant Gram-negative isolates now carbapenem resistant. Research into hospital based novel treatment and prevention interventions for neonatal sepsis should be urgently prioritized.
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Affiliation(s)
- Reenu Thomas
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Claude Ondongo-Ezhet
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Nini Motsoaledi
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mike Sharland
- St. Georges, University of London, London, United Kingdom
| | | | - Sithembiso Velaphi
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Baillie VL, Madhi SA, Ahyong V, Olwagen CP. Metagenomic sequencing of post-mortem tissue samples for the identification of pathogens associated with neonatal deaths. Nat Commun 2023; 14:5373. [PMID: 37666833 PMCID: PMC10477270 DOI: 10.1038/s41467-023-40958-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023] Open
Abstract
Postmortem minimally invasive tissue sampling together with the detailed review of clinical records has been shown to be highly successful in determining the cause of neonatal deaths. However, conventional tests including traditional culture methods and nucleic acid amplification tests have periodically proven to be insufficient to detect the causative agent in the infectious deaths. In this study, metagenomic next generation sequencing was used to explore for putative pathogens associated with neonatal deaths in post-mortem blood and lung tissue samples, in Soweto, South Africa. Here we show that the metagenomic sequencing results corroborate the findings using conventional methods of culture and nucleic acid amplifications tests on post-mortem samples in detecting the pathogens attributed in the causal pathway of death in 90% (18/20) of the decedents. Furthermore, metagenomic sequencing detected a putative pathogen, including Acinetobacter baumannii, Klebsiella pneumoniae, Escherichia coli, and Serratia marcescens, in a further nine of 11 (81%) cases where no causative pathogen was identified. The antimicrobial susceptibility profile was also determined by the metagenomic sequencing for all pathogens with numerous multi drug resistant organism identified. In conclusion, metagenomic sequencing is able to successfully identify pathogens contributing to infection associated deaths on postmortem blood and tissue samples.
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Affiliation(s)
- Vicky L Baillie
- South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa.
- Wits Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa.
| | - Shabir A Madhi
- South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Wits Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
| | - Vida Ahyong
- Chan Zuckerberg Biohub, 499 Illinois St, San Francisco, CA, 94158, USA
| | - Courtney P Olwagen
- South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Wits Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
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Licona G, Ballot D, Moon TD, Banerjee R, Amorim G, Agthe AG, Weitkamp JH. Multidrug-Resistant Bacterial Infections Among Very Low Birthweight Infants With Late-Onset Sepsis in Johannesburg, South Africa. Open Forum Infect Dis 2023; 10:ofad362. [PMID: 37564739 PMCID: PMC10411040 DOI: 10.1093/ofid/ofad362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/11/2023] [Indexed: 08/12/2023] Open
Abstract
Background An estimated 2.4 million babies died within the first 28 days of life in 2020. The third leading cause of neonatal death continues to be neonatal sepsis. Sepsis-causing bacterial pathogens vary temporally and geographically and, with a rise in multidrug-resistant organisms (MDROs), pose a threat to the neonatal population. Methods This was a single-center, retrospective study of very low birth weight (VLBW) infants with late-onset sepsis (LOS) admitted to a neonatal unit in South Africa. We aimed to calculate the prevalence of multidrug-resistant (MDR) infections in this population. The data collected included demographic and clinical characteristics, length of hospital stay, risk factors for MDRO and mortality, and microbiology results. Logistic regression was used to assess the association between prespecified risk factors with MDR infections and mortality. Results Of 2570 VLBW infants admitted, 34% had LOS, of which 33% was caused by MDROs. Infection with Acinetobacter spp., Pseudomonas spp., extended-spectrum beta-lactamase Klebsiella spp., or Escherichia coli was associated with the highest mortality in the LOS cohort. Infants with congenital infections (adjusted odds ratio [aOR], 5.13; 95% CI, 1.19-22.02; P = .028) or a history of necrotizing enterocolitis (aOR, 2.17; 95% CI, 1.05-4.49; P = .037) were at significantly higher risk for MDR infections. Conclusions More than one-third of LOS cases in VLBW infants were caused by MDROs in this study. MDR infections cause substantial neonatal mortality. Antimicrobial stewardship programs, infection control protocols, and ongoing surveillance are needed to prevent further emergence and spread of MDR infections worldwide.
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Affiliation(s)
- Genesis Licona
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daynia Ballot
- Division of Neonatology, Department of Pediatrics, Charlotte Maxeke Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Troy D Moon
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gustavo Amorim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexander G Agthe
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jörn-Hendrik Weitkamp
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hu Y, Yang Y, Feng Y, Fang Q, Wang C, Zhao F, McNally A, Zong Z. Prevalence and clonal diversity of carbapenem-resistant Klebsiella pneumoniae causing neonatal infections: A systematic review of 128 articles across 30 countries. PLoS Med 2023; 20:e1004233. [PMID: 37339120 DOI: 10.1371/journal.pmed.1004233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 04/04/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Klebsiella pneumoniae is the most common pathogen causing neonatal infections, leading to high mortality worldwide. Along with increasing antimicrobial use in neonates, carbapenem-resistant K. pneumoniae (CRKP) has emerged as a severe challenge for infection control and treatment. However, no comprehensive systematic review is available to describe the global epidemiology of neonatal CRKP infections. We therefore performed a systematic review of available data worldwide and combined a genome-based analysis to address the prevalence, clonal diversity, and carbapenem resistance genes of CRKP causing neonatal infections. METHODS AND FINDINGS We performed a systematic review of studies reporting population-based neonatal infections caused by CRKP in combination with a genome-based analysis of all publicly available CRKP genomes with neonatal origins. We searched multiple databases (PubMed, Web of Science, Embase, Ovid MEDLINE, Cochrane, bioRxiv, and medRxiv) to identify studies that have reported data of neonatal CRKP infections up to June 30, 2022. We included studies addressing the prevalence of CRKP infections and colonization in neonates but excluded studies lacking the numbers of neonates, the geographical location, or independent data on Klebsiella or CRKP isolates. We used narrative synthesis for pooling data with JMP statistical software. We identified 8,558 articles and excluding those that did not meet inclusion criteria. We included 128 studies, none of which were preprints, comprising 127,583 neonates in 30 countries including 21 low- and middle-income countries (LMICs) for analysis. We found that bloodstream infection is the most common infection type in reported data. We estimated that the pooled global prevalence of CRKP infections in hospitalized neonates was 0.3% (95% confidence interval [CI], 0.2% to 0.3%). Based on 21 studies reporting patient outcomes, we found that the pooled mortality of neonatal CRKP infections was 22.9% (95% CI, 13.0% to 32.9%). A total of 535 neonatal CRKP genomes were identified from GenBank including Sequence Read Archive, of which 204 were not linked to any publications. We incorporated the 204 genomes with a literature review for understanding the species distribution, clonal diversity, and carbapenemase types. We identified 146 sequence types (STs) for neonatal CRKP strains and found that ST17, ST11, and ST15 were the 3 most common lineages. In particular, ST17 CRKP has been seen in neonates in 8 countries across 4 continents. The vast majority (75.3%) of the 1,592 neonatal CRKP strains available for analyzing carbapenemase have genes encoding metallo-β-lactamases and NDM (New Delhi metallo-β-lactamase) appeared to be the most common carbapenemase (64.3%). The main limitation of this study is the absence or scarcity of data from North America, South America, and Oceania. CONCLUSIONS CRKP contributes to a considerable number of neonatal infections and leads to significant neonatal mortality. Neonatal CRKP strains are highly diverse, while ST17 is globally prevalent and merits early detection for treatment and prevention. The dominance of blaNDM carbapenemase genes imposes challenges on therapeutic options in neonates and supports the continued inhibitor-related drug discovery.
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Affiliation(s)
- Ya Hu
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
| | - Yongqiang Yang
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
- Center for Pathogen Research, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Feng
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
- Center for Pathogen Research, West China Hospital, Sichuan University, Chengdu, China
| | - Qingqing Fang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
| | - Chengcheng Wang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
| | - Feifei Zhao
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
| | - Alan McNally
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zhiyong Zong
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Chengdu, China
- Center for Pathogen Research, West China Hospital, Sichuan University, Chengdu, China
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9
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Riddell A, Cook A, Khavessian N, Ellis S, Bilardi D, Correia E, Kostyanev T, Nardone A, Russell N, Vilken T, Stohr W, Adhisivam B, de Moraes IRA, Ahmed NU, Bekker A, Berezin EN, Boonkasidecha S, Carvalheiro CG, Chauhan P, Chiurchiù S, Chorafa E, Dramowski A, DS M, Feng J, Jia S, Kong Y, Kyohere M, Kontou A, Lochindarat S, De Luca M, Mphaphuli A, Mussi-Pinhata MM, Murunga S, Nakwa FL, Nangia S, Nassolo E, Hoang NTB, Obiero CW, Olson L, Ping W, Plakkal N, Prasad P, Preedisripipat K, Rahman SW, Seef T, Sukrakanchana PO, Thomas R, Yu Z, Zhang Q, Walker AS, Bielicki J, Heath PT, Sharland M, Munera-Huertas T. Challenges in the Implementation of the NeoOBS Study, a Global Pragmatic Observational Cohort Study, to Investigate the Aetiology and Management of Neonatal Sepsis in the Hospital Setting. Antibiotics (Basel) 2023; 12:923. [PMID: 37237826 PMCID: PMC10215156 DOI: 10.3390/antibiotics12050923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network.
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Affiliation(s)
- Amy Riddell
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | | | | | | | | | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerpen, Belgium
| | | | - Neal Russell
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Tuba Vilken
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerpen, Belgium
| | - Wolfgang Stohr
- MRC Clinical Trials Unit, University College London, London WC1V 6LJ, UK
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry 605006, India
| | | | | | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa
| | | | | | - Cristina G. Carvalheiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Prachi Chauhan
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi 110001, India
| | - Sara Chiurchiù
- Academic Department of Pediatrics (DPUO), Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Elisavet Chorafa
- Infectious Diseases Unit, 3rd Dept Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, 546 43 Thessaloniki, Greece
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa
| | - Madhusudhan DS
- Seth G. S. Medical College & KEM Hospital, Mumbai 400012, India
| | - Jinxing Feng
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen 518048, China
| | - Shengnan Jia
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100051, China
| | - Yuan Kong
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen 518048, China
| | - Mary Kyohere
- MUJHU Research Collaboration, Kampala P.O. Box 23491, Uganda
| | - Angeliki Kontou
- 1st Neonatology Department and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | | | - Maia De Luca
- Academic Department of Pediatrics (DPUO), Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Aripfani Mphaphuli
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa AND Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Sheila Murunga
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi P.O. Box 230, Kenya
| | - Firdose Lambey Nakwa
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 1864, South Africa
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi 110001, India
| | - Erinah Nassolo
- MUJHU Research Collaboration, Kampala P.O. Box 23491, Uganda
| | - Ngoc Thi Bin Hoang
- Department of Microbiology, Vietnam National Children’s Hospital, Hanoi 100000, Vietnam
| | - Christina W. Obiero
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi P.O. Box 230, Kenya
- Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Department of Global Health, 1081 Amsterdam, The Netherlands
| | - Linus Olson
- Department of Women’s and Children’s Health, Karolinska institutet, Stockholm, Sweden and Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Wang Ping
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry 605006, India
| | - Priyanka Prasad
- Seth G. S. Medical College & KEM Hospital, Mumbai 400012, India
| | | | | | - Tiffany Seef
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa AND Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
| | | | - Reenu Thomas
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 1864, South Africa
| | - Zhang Yu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Qiaoru Zhang
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100051, China
| | - A. Sarah Walker
- MRC Clinical Trials Unit, University College London, London WC1V 6LJ, UK
| | - Julia Bielicki
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Paul T. Heath
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Michael Sharland
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Tatiana Munera-Huertas
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
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Abrahams I, Dramowski A, Moloto K, Lloyd L, Whitelaw A, Bekker A. Colistin use in a carbapenem-resistant Enterobacterales outbreak at a South African neonatal unit. S Afr J Infect Dis 2023; 38:487. [PMID: 36756243 PMCID: PMC9900379 DOI: 10.4102/sajid.v38i1.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/05/2022] [Indexed: 02/04/2023] Open
Abstract
Background Colistin is increasingly prescribed for neonates with carbapenem-resistant Enterobacterales (CRE) infections. Objectives We described patient demographics, infection episodes, treatment and clinical outcomes, colistin related adverse events and relatedness of isolates in neonates with clinically confirmed or clinically suspected CRE infections. Method The authors retrospectively reviewed culture-confirmed and clinically suspected culture-negative CRE infections at a South African neonatal unit during a CRE outbreak. Results Fifty-three neonates (median gestational age 29 weeks and birth weight 1185 g) were included. Twenty-three of 53 neonates (43%) had culture-confirmed CRE (17 received colistin; 6 died without receiving colistin) and 30 (57%) received colistin for clinically suspected CRE infection but were ultimately culture-negative. Prior respiratory support and surgical conditions were present in 37/53 (70%) and 19/53 (36%) neonates, respectively. Crude mortality was high (20/53; 38%) with no significant difference between culture-confirmed CRE versus clinically suspected culture-negative CRE groups (10/23 [44%] vs 10/30 [33%]; p = 0.45). Hypomagnesaemia (10/38; 26%) and hypokalaemia (15/38; 40%) were frequent; acute kidney injury was rare (1/44; 2%). Three CRE infection clusters were identified by genotypic analysis of 20 available isolates (18 [90%] bla NDM-1 [New Delhi metallo-beta-lactamase], 2 [10%] bla OXA [oxacillinase]-48). Conclusion Neonates receiving colistin therapy were predominantly preterm, with multiple risk factors for infection. Colistin-associated electrolyte derangement was frequent. Over one-third of neonates died. Bla NDM-1 was the most frequent carbapenemase gene identified in the outbreak isolates. Contribution Colistin was safely used during an Enterobacterales outbreak in predominantly premature and surgical neonates. The mortality was high.
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Affiliation(s)
- Ilhaam Abrahams
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kedisaletse Moloto
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Lizel Lloyd
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andrew Whitelaw
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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11
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Healthcare-associated Infections in Very Low Birth-weight Infants in a South African Neonatal Unit: Disease Burden, Associated Factors and Short-term Outcomes. Pediatr Infect Dis J 2022; 41:911-916. [PMID: 35980840 PMCID: PMC9555825 DOI: 10.1097/inf.0000000000003666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infection is a leading cause of death among very low birth-weight (VLBW) infants in resource-limited settings. METHODS We performed a retrospective review of healthcare-associated infection (HAI) episodes among VLBW infants from January 1, 2016, to December 31, 2017. The epidemiology, causative organisms and short-term outcomes were analyzed. Logistic regression was used to investigate for factors associated with development of HAI. RESULTS During the study period, 715 VLBW infants with suspected HAI were investigated, including 162/715 (22.7%) proven and 158/715 (22.1%) presumed HAI. Of the proven infections, 99/162 (61.1%) contained at least one Gram-negative organism per blood culture; 84/162 (51.9%) single Gram-negative organisms and 15/162 (9.3%) polymicrobial growth. Independent factors associated with development of any HAI included low gestational age, small for gestational age, indwelling central venous catheter and invasive ventilation. Compared with infants in whom HAI had been excluded, infants with HAI were more likely to be diagnosed with necrotizing enterocolitis (5.6% vs. 23.1%; P < 0.001) and bronchopulmonary dysplasia (1.0% vs. 4.4%; P = 0.007). Infants with any HAI also had a longer hospital stay [44 (25-65) vs. 38 (26-53) days; P < 0.001] and increased mortality [90/320 (28.1%) vs. 21/395 (5.3%); P < 0.001] compared with infants who did not develop HAI episodes. CONCLUSIONS Proven and presumed HAI are a major contributor to neonatal morbidity and mortality; further research is urgently needed to better understand potential targets for prevention and treatment of HAI in resource-limited neonatal units.
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12
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Mashau RC, Meiring ST, Dramowski A, Magobo RE, Quan VC, Perovic O, von Gottberg A, Cohen C, Velaphi S, van Schalkwyk E, Govender NP. Culture-confirmed neonatal bloodstream infections and meningitis in South Africa, 2014-19: a cross-sectional study. Lancet Glob Health 2022; 10:e1170-e1178. [PMID: 35839815 PMCID: PMC9296659 DOI: 10.1016/s2214-109x(22)00246-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 05/09/2022] [Accepted: 05/16/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Few population-level estimates of invasive neonatal infections have been reported from sub-Saharan Africa. We estimated the national incidence risk, aetiology, and pathogen antimicrobial susceptibility for culture-confirmed neonatal bloodstream infections and meningitis in South Africa. METHODS We conducted a cross-sectional study of neonates (<28 days of life) admitted to neonatal or paediatric wards of 256 public sector health facilities in South Africa during 2014-19. Diagnostic pathology records from Jan 1, 2014, to Dec 31, 2019, were extracted from a national pathology data warehouse. A case was defined as a neonate with at least one positive blood or cerebrospinal fluid culture during a 14-day period. Incidence risk was calculated using annual numbers of registered livebirths. Among the causative pathogens identified, we calculated the proportion of cases attributed to each of them, as well as the rates of antibiotic susceptibility of Gram-positive and Gram-negative bacteria. FINDINGS Among 43 438 records of positive cultures, there were 37 631 incident cases of neonatal infection with at least one pathogen isolated. The overall incidence risk of culture-confirmed infections was 6·0 per 1000 livebirths (95% CI 6·0-6·1). The incidence risk of late-onset sepsis (days 3-27 of life) was 4·9 per 1000 livebirths (4·9-5·0) and that of early-onset sepsis (days 0-2 of life) was 1·1 per 1000 livebirths (1·1-1·1); risk ratio 4·4 (95% CI 4·3-4·5). The cause of infection differed by syndrome, timing of infection onset, facility, and province, although Klebsiella pneumoniae (26%), Acinetobacter baumannii (13%), and Staphylococcus aureus (12%) were the dominant pathogens overall. Gram-negative bacteria had declining susceptibility to most antibiotics over the study period. INTERPRETATION We found a high incidence risk of late-onset sepsis with provincial variations, predominance of K pneumoniae, and declining antibiotic susceptibility among Gram-negative bacteria. This national surveillance in an upper-middle-income country provides a baseline burden of neonatal infections against which the impact of future clinical and public health interventions can be measured. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Rudzani C Mashau
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa.
| | - Susan T Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Rindidzani E Magobo
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Vanessa C Quan
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Olga Perovic
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Erika van Schalkwyk
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Institute of Infection and Immunity, St George's University of London, London, UK; MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
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13
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Brinkworth JF, Shaw JG. On race, human variation, and who gets and dies of sepsis. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2022. [PMCID: PMC9544695 DOI: 10.1002/ajpa.24527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jessica F. Brinkworth
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
- Department of Evolution, Ecology and Behavior University of Illinois Urbana‐Champaign Urbana Illinois USA
| | - J. Grace Shaw
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
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14
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Phungoen P, Apiratwarakul K, Lerdprawat N, Ienghong K, Sumritrin S, Boonsawat W, Sawanyawisuth K. Clinical factors predictive of Gram-negative bloodstream infection at the Emergency Department. Germs 2022; 12:231-237. [PMID: 36504606 PMCID: PMC9719383 DOI: 10.18683/germs.2022.1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 12/15/2022]
Abstract
Introduction Bloodstream infection is a common condition at the Emergency Department (ED). Appropriate antibiotic therapy is also crucial for patients with bloodstream infection particularly at the ED. This study therefore aimed to find clinical factors predictive of types of bacterial pathogens in bloodstream infection patients presenting at the ED focused on Gram-negative bacterial infections. Methods This was a retrospective study. The inclusion criteria were adult patients who were suspected for bloodstream infection defined by blood culture collection presenting at the ED and intravenous antibiotics were initiated during the ED visits. The study period was between January 1st, 2016 and December 31st, 2018. Clinical data of the eligible patients were retrieved from the ED database. Factors associated with Gram-negative infection were calculated by logistic regression analysis. Results There were 727 patients at the ED who had positive blood culture for bacteria. Of those, 504 patients (69.33%) had positive blood culture for Gram-negative bacteria. There were three independent factors for Gram-negative infection including sex, solid organ malignancy, and body temperature. The highest adjusted odds ratio (95% confidence interval) was 2.004 (1.330, 3.020) for solid organ malignancy. Conclusions Gram-negative bacterial infection was more prominent than Gram-positive bacterial infection in patients presenting at the ED (69.33%). Solid organ malignancy, being female, and a high body temperature were independent factors of Gram-negative bacterial infection.
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Affiliation(s)
- Pariwat Phungoen
- MD, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Korakot Apiratwarakul
- MD, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Nunchalit Lerdprawat
- MD, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Kamonwon Ienghong
- MD, Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Sumana Sumritrin
- MSc, Accidental and Emergency Unit, Division of Nursing, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Watchara Boonsawat
- MD, PhD, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Kittisak Sawanyawisuth
- MD, PhD, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand,Corresponding author: Kittisak Sawanyawisuth,
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15
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Okoye CA, Nweze E, Ibe C. Invasive candidiasis in Africa, what is the current picture? Pathog Dis 2022; 80:6572357. [PMID: 35451463 DOI: 10.1093/femspd/ftac012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/23/2022] [Accepted: 04/20/2022] [Indexed: 11/14/2022] Open
Abstract
Invasive candidiasis is a serious, progressive, and potentially deadly infection that can affect the brain, heart, bones, eyes, and other parts of the body. It is associated with risk factors such as the use of indwelling medical devices and prolonged hospital stay, and broad-spectrum antibiotics use. It is especially seen in immunocompromised individuals such as patients with prolonged hospital stay, gastrointestinal surgery, haematological malignancies, and respiratory diseases. We have conducted a systematic search of literature using a select group of database and appropriate search words and found that in Africa, there are 18,293 documented/reported cases of invasive candidiasis in the last few decades (1976-2021) and 16,636(91%) were cases of candidaemia. South Africa had the highest number of reported cases - 15,002(82%), which may be due to underreporting of cases in other countries. HIV positive persons with invasive candidiasis in Africa accounted for 1,052(5.8%). C. albicans was the most frequently isolated species 6,328(32.6%), followed by Candida parapsilosis 5,910(30.4%), and Candida auris 1,505(7.8%). Due to the affordability and availability of blood culture, it was used for diagnosis in most of the studies examined, while a few studies combined other techniques and just 3 studies from 2 countries used serological tests. Echinocandins are recommended as first-line therapy but are only available in 12 countries and are highly priced. The use of fluconazole because of its availability and relatively inexpensive nature has led to increased resistance of Candida species to the drug.
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Affiliation(s)
- Chinonyelum A Okoye
- Departments of Microbiology, Faculty of Biological Sciences, Abia State University, Uturu, Nigeria
| | - Emeka Nweze
- Microbiology University of Nigeria Nsukka, Faculty of Biological Sciences, Enugu State, Nigeria
| | - Chibuike Ibe
- Departments of Microbiology, Faculty of Biological Sciences, Abia State University, Uturu, Nigeria
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16
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Vurayai M, Strysko J, Kgomanyane K, Bayani O, Mokomane M, Machiya T, Arscott-Mills T, Goldfarb DM, Steenhoff AP, McGann C, Nakstad B, Gezmu A, Richard-Greenblatt M, Coffin S. Characterizing the bioburden of ESBL-producing organisms in a neonatal unit using chromogenic culture media: a feasible and efficient environmental sampling method. Antimicrob Resist Infect Control 2022; 11:14. [PMID: 35074019 PMCID: PMC8785036 DOI: 10.1186/s13756-021-01042-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/05/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Infections due to extended spectrum beta-lactamase producing organisms (ESBL) have emerged as the leading cause of sepsis among hospitalized neonates in Botswana and much of sub-Saharan Africa and south Asia. Yet, ESBL reservoirs and transmission dynamics within the neonatal intensive care unit (NICU) environment are not well-understood. This study aimed to assess the efficiency and feasibility of a chromogenic-culture-media-based environmental sampling approach to characterize the ESBL bioburden within a NICU. METHODS A series of four point-prevalence surveys were conducted at a 36-bed NICU at a public tertiary referral hospital in Botswana from January-June 2021. Samples were collected on 4 occasions under semi-sterile technique using 1) flocked swabs & templates (flat surfaces); 2) sterile syringe & tubing (water aspiration); and 3) structured swabbing techniques (hands & equipment). Swabs were transported in physiological saline-containing tubes, vortexed, and 10 µL was inoculated onto chromogenic-agar that was selective and differential for ESBL (CHROMagar™ ESBL, Paris, France), and streaking plates to isolate individual colonies. Bacterial colonies were quantified and phenotypically characterized using biochemical identification tests. RESULTS In total, 567 samples were collected, 248 (44%) of which grew ESBL. Dense and consistent ESBL contamination was detected in and around sinks and certain high-touch surfaces, while transient contamination was demonstrated on medical equipment, caregivers/healthcare worker hands, insects, and feeding stations (including formula powder). Results were available within 24-72 h of collection. To collect, plate, and analyse 50 samples, we estimated a total expenditure of $269.40 USD for materials and 13.5 cumulative work hours among all personnel. CONCLUSIONS Using basic environmental sampling and laboratory techniques aided by chromogenic culture media, we identified ESBL reservoirs (sinks) and plausible transmission vehicles (medical equipment, infant formula, hands of caregivers/healthcare workers, & insects) in this NICU environment. This strategy was a simple and cost-efficient method to assess ESBL bioburden and may be feasible for use in other settings to support ongoing infection control assessments and outbreak investigations.
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Affiliation(s)
- Moses Vurayai
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.
| | - Jonathan Strysko
- Department of Paediatric & Adolescent Health, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, USA.,Botswana-UPenn Partnership, Gaborone, Botswana
| | | | - One Bayani
- Department of Paediatric & Adolescent Health, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Margaret Mokomane
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | | | - Tonya Arscott-Mills
- Department of Paediatric & Adolescent Health, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, USA.,Botswana-UPenn Partnership, Gaborone, Botswana
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Andrew P Steenhoff
- Department of Paediatric & Adolescent Health, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, USA.,Botswana-UPenn Partnership, Gaborone, Botswana.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Carolyn McGann
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Britt Nakstad
- Department of Paediatric & Adolescent Health, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.,Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alemayehu Gezmu
- Department of Paediatric & Adolescent Health, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | | | - Susan Coffin
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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17
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Holgate SL, Bekker A, Pillay-Fuentes Lorente V, Dramowski A. Errors in Antimicrobial Prescription and Administration in Very Low Birth Weight Neonates at a Tertiary South African Hospital. Front Pediatr 2022; 10:838153. [PMID: 35311044 PMCID: PMC8927727 DOI: 10.3389/fped.2022.838153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Antimicrobial prescription and administration-related errors occur frequently in very low birth weight (VLBW; <1,500 g) neonates treated for bloodstream infections (BSI). METHODS Antimicrobial prescriptions for the treatment of laboratory-confirmed BSI were retrospectively analyzed for VLBW neonates at Tygerberg Hospital, Cape Town, South Africa (1 July 2018 - 31 December 2019), describing antimicrobial type, indication, duration of therapy and BSI outcomes. The prevalence of, and risk factors for prescription (dose, interval) and administration errors (hang-time, delayed/missed doses) were determined. RESULTS One hundred and sixty-one BSI episodes [16 (9.9%)] early-onset, 145 [90.1%] healthcare-associated) affected 141 neonates (55% male, 25% born to mothers living with HIV, 46% <1,000 g birth weight) with 525 antimicrobial prescription episodes [median 3.0 (IQR 2-4) prescriptions/BSI episode]. The median duration of therapy for primary BSI, BSI-associated with meningitis and BSI-associated with surgical infections was 9, 22, and 28 days, respectively. The prevalence of dose and dosing interval errors was 15.6% (77/495) and 16.4% (81/495), respectively with prescription errors occurring most commonly for piperacillin-tazobactam and vancomycin given empirically. Administration errors were less frequent [3.8% (219/5,770) doses missed; 1.4% (78/5,770) delayed], however 64% had a hang-time (time from sepsis diagnosis to 1st dose of antimicrobial) exceeding 60 min. On multivariable analysis, postnatal age >7 days was associated with prescription errors (p = 0.028). The majority of neonates with BSI required escalation of respiratory support (52%) and 26% required intensive care admission. Despite fair concordance between empiric antimicrobial/s prescription and pathogen susceptibility (74.5%), BSI-attributable mortality in this cohort was 30.4%. CONCLUSION VLBW neonates with BSI's were critically ill and had high mortality rates. Hang-time to first antimicrobial administration was delayed in two-thirds of BSI episodes and prescription errors affected almost 1 in 6 prescriptions. Targets for intervention should include reducing hang-time, use of standardized antimicrobial dosing guidelines and implementation of antimicrobial stewardship recommendations.
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Affiliation(s)
- Sandi L Holgate
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Veshni Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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18
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Sowden M, van Niekerk E, Bulabula ANH, Dramowski A, Whitelaw A, Twisk J, van Weissenbruch MM. Impact of a multi-strain probiotic administration on peri-rectal colonization with drug-resistant Gram-negative bacteria in preterm neonates. Front Pediatr 2022; 10:1002762. [PMID: 36405834 PMCID: PMC9667553 DOI: 10.3389/fped.2022.1002762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Infections caused by drug resistant Gram-negative bacteria (DR-GNB) are a major health concern for hospitalized preterm neonates, globally. The aim of this study was to investigate the effect of a multi-strain probiotic on the incidence of rectal colonization with DR-GNB in preterm neonates. METHODS A double-blind, placebo-controlled, randomized clinical trial was conducted including 200 neonates, randomly allocated to a multi-strain probiotic (n = 100) or placebo (n = 100). RESULTS Fifteen percent of the neonates showed peri-rectal colonization with DR-GNB on the day of enrolment indicating probable maternal-to-neonate (vertical) bacterial transmission or environmental acquisition at time of delivery, with no difference between groups. Acquisition of further DR-GNB colonization was rapid, with an increase from 15% on the day enrolment to 77% by day 7 and 83% by day 14 of life. By day 7 (corresponding to early gut colonization), neonates in the probiotic group were 57% less likely to have peri-rectal DR-GNB colonization [OR: 0.43 (0.20-0.95); p = 0.04] and by day 14 (corresponding to late gut colonization), neonates in the probiotic group were 93% less likely to have peri-rectal DR-GNB colonization [OR: 0.07 (0.02-0.23); p < 0.001]. CONCLUSION Hospitalized neonates showed substantial peri-rectal colonization with DR-GNB at enrolment and further rapid acquisition of DR-GNB in the first 2 weeks of life. The use of a multi-strain probiotic was effective in reducing early and late neonatal gut colonization with DR-GNB. CLINICAL TRIAL REGISTRATION The trial was registered at the Pan African Clinical Trial Registry (PACTR202011513390736).
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Affiliation(s)
- Marwyn Sowden
- Division of Human Nutrition, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Evette van Niekerk
- Division of Human Nutrition, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Andrew Whitelaw
- Division of Medical Microbiology, University of Stellenbosch, Cape Town, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Jos Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam, Netherlands
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19
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NeoCLEAN: a multimodal strategy to enhance environmental cleaning in a resource-limited neonatal unit. Antimicrob Resist Infect Control 2021; 10:35. [PMID: 33579364 PMCID: PMC7881651 DOI: 10.1186/s13756-021-00905-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/03/2021] [Indexed: 11/26/2022] Open
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. Supplementary information The online version contains supplementary material available at 10.1186/s13756-021-00905-y.
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