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Fitzgerald FC, Zingg W, Chimhini G, Chimhuya S, Wittmann S, Brotherton H, Olaru ID, Neal SR, Russell N, da Silva ARA, Sharland M, Seale AC, Cotton MF, Coffin S, Dramowski A. The Impact of Interventions to Prevent Neonatal Healthcare-associated Infections in Low- and Middle-income Countries: A Systematic Review. Pediatr Infect Dis J 2022; 41:S26-S35. [PMID: 35134037 PMCID: PMC8815829 DOI: 10.1097/inf.0000000000003320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinically suspected and laboratory-confirmed bloodstream infections are frequent causes of morbidity and mortality during neonatal care. The most effective infection prevention and control interventions for neonates in low- and middle-income countries (LMIC) are unknown. AIM To identify effective interventions in the prevention of hospital-acquired bloodstream infections in LMIC neonatal units. METHODS Medline, PUBMED, the Cochrane Database of Systematic Reviews, EMBASE and PsychInfo (January 2003 to October 2020) were searched to identify studies reporting single or bundled interventions for prevention of bloodstream infections in LMIC neonatal units. RESULTS Our initial search identified 5206 articles; following application of filters, 27 publications met the inclusion and Integrated Quality Criteria for the Review of Multiple Study Designs assessment criteria and were summarized in the final analysis. No studies were carried out in low-income countries, only 1 in Sub-Saharan Africa and just 2 in multiple countries. Of the 18 single-intervention studies, most targeted skin (n = 4) and gastrointestinal mucosal integrity (n = 5). Whereas emollient therapy and lactoferrin achieved significant reductions in proven neonatal infection, glutamine and mixed probiotics showed no benefit. Chlorhexidine gluconate for cord care and kangaroo mother care reduced infection in individual single-center studies. Of the 9 studies evaluating bundles, most focused on prevention of device-associated infections and achieved significant reductions in catheter- and ventilator-associated infections. CONCLUSIONS There is a limited evidence base for the effectiveness of infection prevention and control interventions in LMIC neonatal units; bundled interventions targeting device-associated infections were most effective. More multisite studies with robust study designs are needed to inform infection prevention and control intervention strategies in low-resource neonatal units.
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Affiliation(s)
- Felicity C. Fitzgerald
- From the Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Walter Zingg
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gwendoline Chimhini
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Zimbabwe
| | - Simbarashe Chimhuya
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Zimbabwe
| | - Stefanie Wittmann
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Brotherton
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Unit, The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Ioana D. Olaru
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samuel R. Neal
- From the Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Neal Russell
- Paediatric Infectious Diseases Research Group, St George’s University of London, United Kingdom
| | - André Ricardo Araujo da Silva
- Laboratory of Teaching of Prevention and Control of Healthcare-Associated Infections, Federal Fluminense University, Brazil
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George’s University of London, United Kingdom
| | - Anna C. Seale
- From the Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mark F. Cotton
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Stellenbosch University, South Africa, and
| | - Susan Coffin
- Children’s Hospital of Philadelphia, Pennsylvania, Philadelphia
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Stellenbosch University, South Africa, and
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Molina García A, Cross JH, Fitchett EJ, Kawaza K, Okomo U, Spotswood NE, Chiume M, Ezeaka VC, Irimu G, Salim N, Molyneux EM, Lawn JE. Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review. EClinicalMedicine 2022; 44:101259. [PMID: 35059614 PMCID: PMC8760419 DOI: 10.1016/j.eclinm.2021.101259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements). METHODS Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively. FINDINGS 3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control. INTERPRETATION The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap. FUNDING This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).
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Affiliation(s)
| | - James H. Cross
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kondwani Kawaza
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Uduak Okomo
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Naomi E. Spotswood
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | | | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Kenya
| | - Nahya Salim
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Elizabeth M. Molyneux
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
| | - Joy E. Lawn
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - with the NEST360 Infection Prevention, Detection and Care Collaborative Group
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Paediatrics, Kamuzu University of Health Sciences (formerly College of Medicine, University of Malawi), Blantyre, Malawi
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Paediatrics, College of Medicine, University of Lagos, Nigeria
- Department of Paediatrics and Child Health, University of Nairobi, Kenya
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
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Dramowski A, Aucamp M, Beales E, Bekker A, Cotton MF, Fitzgerald FC, Labi AK, Russell N, Strysko J, Whitelaw A, Coffin S. Healthcare-Associated Infection Prevention Interventions for Neonates in Resource-Limited Settings. Front Pediatr 2022; 10:919403. [PMID: 35874586 PMCID: PMC9301049 DOI: 10.3389/fped.2022.919403] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Healthcare-associated infections (HAIs) and antimicrobial-resistant (AMR) infections are leading causes of neonatal morbidity and mortality, contributing to an extended hospital stay and increased healthcare costs. Although the burden and impact of HAI/AMR in resource-limited neonatal units are substantial, there are few HAI/AMR prevention studies in these settings. We reviewed the mechanism of action and evidence supporting HAI/AMR prevention interventions, including care bundles, for hospitalized neonates in low- and middle-income countries (LMIC).
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Affiliation(s)
- Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marina Aucamp
- Infection Prevention and Control Service, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Emily Beales
- Center for Neonatal and Pediatric Infection, St George's University of London, London, United Kingdom
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mark Frederic Cotton
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Felicity C Fitzgerald
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Appiah-Korang Labi
- Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
| | - Neal Russell
- Center for Neonatal and Pediatric Infection, St George's University of London, London, United Kingdom
| | - Jonathan Strysko
- Department of Paediatric and Adolescent Health, Princess Marina Hospital, Gaborone, Botswana.,Department of Global Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Andrew Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Susan Coffin
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Hussain AS, Ahmed AM, Arbab S, Ariff S, Ali R, Demas S, Zeb J, Rizvi A, Saleem A, Farooqi J. CLABSI reduction using evidence based interventions and nurse empowerment: a quality improvement initiative from a tertiary care NICU in Pakistan. Arch Dis Child 2021; 106:394-400. [PMID: 32253277 DOI: 10.1136/archdischild-2019-318779] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Central line associated bloodstream infection (CLABSI) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). We designed a CLABSI Prevention Package (CPP) to decrease NICU CLABSI rates, using evidence-proven interventions. DESIGN This was a quality improvement (QI) project. Data collection was divided into three phases (pre-implementation, implementation and post implementation). SQUIRE2.0 guidelines were used to design, implement and report this QI initiative. SETTING A tertiary care level 3 NICU at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. PATIENTS All patients admitted to the AKUH NICU from 1 January 2016 to 31 March 2018 who had a central line in place during their NICU admission. INTERVENTIONS CPP used evidence-based interventions focusing on hand hygiene, aseptic central line insertion techniques and central line care, prevention of fungal infections and nurse empowerment. MAIN OUTCOME MEASURES CLABSI rates pre and post intervention were recorded. Secondary outcomes were risk factors for CLABSI, device (central line) utilisation ratio, CLABSI related mortality and micro-organism profile. RESULTS CLABSI rates decreased from 17.1/1000 device days to 5.0/1000 device days (relative risk (RR)=0.36, CI=0.17-0.74). Device (central line) utilisation ratio declined from 0.30 to 0.25. Out of 613 patients enrolled in our study, 139 (22.7%) died. Mortality was higher in CLABSI group (n=20, 44%) as compared with non CLABSI group (n=119, 21.1%) (p<0.001). Gestational age of <27 weeks was an independent risk factor for CLABSI (RR=4.45, CI=1.10-18.25, p=0.03). A total of 158 pathogens were isolated among which 68 were associated with CLABSI. Gram-negative bacteria 31 (47.7%) were the most common cause of CLABSI. Ninety-seven (61%) micro-organisms were multi-drug resistant. CONCLUSIONS CPP was effective in decreasing NICU CLABSI rates and can be used as a model to decrease NICU CLABSI rates in low or middle-income countries.
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Affiliation(s)
- Ali Shabbir Hussain
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Anjum Mohyuddin Ahmed
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Saba Arbab
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Shabina Ariff
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Rehan Ali
- Department of Pediatrics, The Indus Hospital, Karachi, Sindh, Pakistan
| | - Simon Demas
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Jehan Zeb
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Arjumand Rizvi
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Ali Saleem
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Joveria Farooqi
- Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
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Phan HT, Vo TH, Tran HTT, Huynh HTN, Nguyen HTT, Van Nguyen T. Enhanced infection control interventions reduced catheter-related bloodstream infections in the neonatal department of Hung Vuong Hospital, Vietnam, 2011-2012: a pre- and post-intervention study. Antimicrob Resist Infect Control 2020; 9:9. [PMID: 31921415 PMCID: PMC6947938 DOI: 10.1186/s13756-019-0669-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 12/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background Catheter-related bloodstream infections (CR-BSI) cause high neonatal mortality and are related to inadequate aseptic technique during the care and maintenance of a catheter. The incidence of CR-BSI among neonates in Hung Vuong Hospital was higher than that of other neonatal care centres in Vietnam. Methods An 18-month pre- and post-intervention study was conducted over three 6-month periods to evaluate the effectiveness of the intervention for CR-BSI and to identify risk factors associated with CR-BSI. During the intervention period, we trained all nurses in the Department of Neonatology on BSI preventive practices, provided auditing and feedback about aseptic technique during catheter care and maintenance, and reorganised preparation of total parenteral nutrition. All neonates with intravenous catheter insertion ≥48 h in the pre- and post-intervention period were enrolled. A standardised questionnaire was used to collect data. Blood samples were collected for cultures. We used Poisson regression to calculate rate ratio (RR) and 95% confidence interval (CI) for CR-BSI incidence rates and logistic regression to identify risk factors associated with CR-BSI. Results Of 2225 neonates enrolled, 1027 were enrolled in the pre-intervention period, of which 53 CR-BSI cases occurred in 8399 catheter-days, and 1198 were enrolled in the post-intervention period, of which 32 CR-BSI cases occurred in 8324 catheter-days. Incidence rates of CR-BSI significantly decreased after the intervention (RR = 0.61, 95% CI 0.39-0.94). Days of hospitalisation, episodes of non-catheter-related hospital-acquired infections, and the proportion of deaths significantly decreased after the intervention (p < 0.01). The CR-BSI was associated with days of intravenous catheter (odds ratio [OR] = 1.05, 95% CI 1.03-1.08), use of endotracheal intubation (OR = 2.27, 95% CI 1.27-4.06), and intravenous injection (OR = 8.50, 95% CI 1.14-63.4). Conclusions The interventions significantly decreased the incidence rate of CR-BSI. Regular refresher training and auditing and feedback about aseptic technique during care and maintenance of catheters are critical to reducing CR-BSI.
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Affiliation(s)
- Hang Thi Phan
- 1Department of Infection Control, Hung Vuong Hospital, 128 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam
| | - Thuan Huu Vo
- 2Hung Vuong Hospital, 128 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam
| | - Hang Thi Thuy Tran
- 1Department of Infection Control, Hung Vuong Hospital, 128 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam
| | - Hanh Thi Ngoc Huynh
- 1Department of Infection Control, Hung Vuong Hospital, 128 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam
| | - Hong Thi Thu Nguyen
- 1Department of Infection Control, Hung Vuong Hospital, 128 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam
| | - Truong Van Nguyen
- 1Department of Infection Control, Hung Vuong Hospital, 128 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam
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Payne V, Hall M, Prieto J, Johnson MJ. Reply to: 'Research on infection prevention bundles: hidden risk of bias?'. Arch Dis Child Fetal Neonatal Ed 2020; 105:112-113. [PMID: 31235614 DOI: 10.1136/archdischild-2018-315974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Victoria Payne
- School of Health Sciences, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mike Hall
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jacqui Prieto
- School of Health Sciences, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark J Johnson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
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7
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Good infection prevention practices in three Brazilian hospitals: Implications for patient safety policies. J Infect Public Health 2019; 12:619-624. [DOI: 10.1016/j.jiph.2019.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/23/2019] [Accepted: 02/11/2019] [Indexed: 11/22/2022] Open
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Payne V, Hall M, Prieto J, Johnson M. Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2018; 103:F422-F429. [PMID: 29175985 DOI: 10.1136/archdischild-2017-313362] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/30/2017] [Accepted: 09/06/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) are associated with increased mortality, prolonged hospitalisation and increased healthcare costs. Care bundles have reduced CLABSIs in adult intensive care units (ICUs) but replication in paediatric ICUs has had inconsistent outcomes. A systematic review was performed to assess the evidence for the efficacy of care bundles in reducing CLABSIs in the neonatal unit (NNU). METHODS MEDLINE, CINAHL and EMBASE were searched from January 2010 up to January 2017. The Cochrane Library, Web of Science, Zetoc and Ethos were searched for additional studies. Randomised controlled trials (RCTs), quasi-experimental and observational studies were eligible. The primary outcome measure was CLABSI rates per 1000 central line, or patient, days. A meta-analysis was performed using random effects modelling. RESULTS Twenty-four studies were eligible for inclusion: six were performed in Europe, 12 were in North America, two in Australia and four were in low/middle-income countries. Five were observational studies and 19 were before and after quality improvement studies. No RCTs were found. Meta-analysis revealed a statistically significant reduction in CLABSIs following the introduction of care bundles (rate ratio=0.40 (CI 0.31 to 0.51), p<0.00001), which equates to a 60% reduction in CLABSI rate. CONCLUSION There is a substantial body of quasi-experimental evidence to suggest that care bundles may reduce CLABSI rates in the NNU, though it is not clear which bundle elements are effective in specific settings. Future research should focus on determining what processes promote the effective implementation of infection prevention recommendations, and which elements represent essential components of such care bundles.
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Affiliation(s)
- Victoria Payne
- Faculty of Health Sciences, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mike Hall
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jacqui Prieto
- Faculty of Health Sciences, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Johnson
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
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Lavallée JF, Gray TA, Dumville J, Russell W, Cullum N. The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implement Sci 2017; 12:142. [PMID: 29187217 PMCID: PMC5707820 DOI: 10.1186/s13012-017-0670-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles. METHODS This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups. RESULTS In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness). CONCLUSIONS Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain. TRIAL REGISTRATION PROSPERO, CRD42016033175.
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Affiliation(s)
- Jacqueline F. Lavallée
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
- Manchester Centre for Health Psychology, University of Manchester, Manchester, England
| | - Trish A. Gray
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
| | - Jo Dumville
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
| | - Wanda Russell
- Primary Care & Research Services, Keele University, Newcastle-under-Lyme, England
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
- Research and Innovation Division, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, England
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10
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Mishra SB, Misra R, Azim A, Baronia AK, Prasad KN, Dhole TN, Gurjar M, Singh RK, Poddar B. Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India. Int J Qual Health Care 2017; 29:63-67. [PMID: 27940521 DOI: 10.1093/intqhc/mzw144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 11/17/2016] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India. Design This prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center. Setting We conducted this study over a period of 16 months at a tertiary care referral medical center. Participants All patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled. Intervention and main outcome measures Patient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done. Results There were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality. Conclusions Our results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses' chart for site inspection and alerts in all shifts are some measures planned at our center.
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Affiliation(s)
- S B Mishra
- Department of Critical Care Medicine, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - R Misra
- Department of Microbiology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - A Azim
- Department of Critical Care Medicine, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - A K Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - K N Prasad
- Department of Microbiology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - T N Dhole
- Department of Microbiology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - M Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - R K Singh
- Department of Critical Care Medicine, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
| | - B Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow 226014, India
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11
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Curan GRF, Rossetto EG. INTERVENTIONS TO DECREASE CATHETER-ASSOCIATED BLOODSTREAM INFECTIONS IN NEWBORNS: AN INTEGRATIVE REVIEW. TEXTO & CONTEXTO ENFERMAGEM 2017. [DOI: 10.1590/0104-07072017005130015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: to perform an integrative review of strategies presented in care bundles to decrease central catheter-associated bloodstream infection among newborns. . Method a search was conducted of the Cochrane Library, IBECS, PubMed, Lilacs, Medline and Scielo catalogues, using the terms "bundle", "catheter-related infection", "infection control", "prevention", "evidence-based nursing"," evidence-based medicine" and" central venous catheter". Inclusion criteria were: papers published from 2009 to April 2014; written in Portuguese, English or Spanish; addressing both neonatal and pediatric populations or just neonatal populations; describing the use and/or assessing care bundles or protocols to control central catheter-associated infection. Results fifteen studies published between 2009 and 2013 were selected. The main information extracted from the studies was systematized as: 1) measures adopted to prevent central catheter-associated bloodstream infection according to level of scientific evidence, and 2) strategies used to implement evidence into health practice. Conclusion there was a variety of practices adopted, some of which are consistent with scientific evidence and some of which are not. Systematization conducted in this study is expected to contribute to practice, facilitating the use of the best evidence in each context, and research indicating gaps in knowledge to be explored in future studies
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12
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Medeiros FDVA, Alves VH, Valete COS, Paiva ED, Rodrigues DP. A correlação entre procedimentos assistenciais invasivos e a ocorrência de sepse neonatal. ACTA PAUL ENFERM 2016. [DOI: 10.1590/1982-0194201600079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo: Correlacionar os procedimentos assistenciais invasivos realizados nos recém-nascidos de muito baixo peso com a ocorrência de sepse neonatal. Métodos: Estudo de coorte retrospectivo, longitudinal, por meio de pesquisa de dados secundários, durante os anos de 2008-2012. As características dos recém-nascidos foram analisadas pelo teste de Mann-Whitney (médias) e o teste do qui quadrado para comparação de frequências. Todas as variáveis com significância de p<0,20 na análise bivariada compuseram um modelo de regressão logística. Resultados: Os dados demonstraram quatorze recém-nascidos com episódio de sepse tardia. A idade gestacional média foi de trinta semanas. Gênero feminino e parto cesáreo foram os mais frequentes. O peso de nascimento e o uso do cateter umbilical arterial explicaram a ocorrência de sepse, tendo este oferecido 8,5 vezes maior risco para o desfecho. Conclusão: Acessos vasculares necessitam rigor nas técnicas de inserção e manuseio para a melhoria dos indicadores de saúde.
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13
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The Use and Effectiveness of Bundles for Prevention of Central Line-Associated Bloodstream Infections in Neonates: A Review of the Literature. J Perinat Neonatal Nurs 2016; 30:148-59. [PMID: 27104606 DOI: 10.1097/jpn.0000000000000171] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Central line-associated bloodstream infections (CLABSIs) are an important cause of increased morbidity, mortality, and costs in neonatal intensive care unit (NICU) patients. In recent years, central line bundles have been developed and implemented as a means to reduce infection rates in intensive care units. The objective of this review was to describe central line bundles that are utilized in the neonatal population and evaluate the current evidence on the effectiveness of bundles for prevention of CLABSIs in the NICU. This review shows that care bundles have been successfully used in NICUs (as part of both single-site quality improvement initiatives and large multisite collaboratives) to decrease CLABSI rates. The individual components that comprise the bundle between individual studies varied, but all studies showed a significant reduction in CLABSI rates. The pre- and postintervention design employed by these studies does not allow for conclusions to be drawn as to what specific bundle components are most effective in reducing rates. Further research is needed both to examine the effectiveness of specific components or combinations of components in the bundle and to examine factors that are associated with implementation and adherence to bundles.
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14
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Ista E, van der Hoven B, Kornelisse RF, van der Starre C, Vos MC, Boersma E, Helder OK. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2016; 16:724-734. [PMID: 26907734 DOI: 10.1016/s1473-3099(15)00409-0] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections. METHODS We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models. FINDINGS We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2-46·3; IQR 3·1-9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6-31·1; 4·8-9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6-24·1; 3·7-16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2-4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8-10·9) to 2·5 per 1000 catheter-days (1·4-4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39-0·50, p<0·0001; I(2)=89%). INTERPRETATION Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs. FUNDING None.
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Affiliation(s)
- Erwin Ista
- Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
| | | | - René F Kornelisse
- Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Cynthia van der Starre
- Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, Netherlands
| | - Eric Boersma
- Department of Cardiology, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam, Netherlands
| | - Onno K Helder
- Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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15
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Marang-van de Mheen PJ, van Bodegom-Vos L. Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement. BMJ Qual Saf 2015; 25:118-29. [DOI: 10.1136/bmjqs-2014-003787] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 07/01/2015] [Indexed: 11/04/2022]
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16
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Late onset sepsis in newborn babies: epidemiology and effect of a bundle to prevent central line associated bloodstream infections in the neonatal intensive care unit. Braz J Infect Dis 2015; 19:52-7. [PMID: 25523073 PMCID: PMC9425250 DOI: 10.1016/j.bjid.2014.09.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/18/2014] [Accepted: 09/17/2014] [Indexed: 11/20/2022] Open
Abstract
Aim We assessed late onset sepsis (LOS) rates of neonates in a neonatal intensive care unit (NICU) before and after implementing an evidence-based bundle to prevent these infections in a country with poor resources. Methods We evaluate trends of LOS between October 2010 and August 2012 in a large tertiary hospital in Brazil. We designed a protocol based of CDC guidelines for insertion of maintenance of central venous catheter targeted to reduction of bloodstream infections. During this period two major events occurred: a great increase of LOS rates in January months and relocation of the unit to a provisory place. Additionally we evaluated the risk factors and etiology of these infections. Results A total of 112 (20.3%) cases defined as LOS were found. The overall incidence rate of LOS in the study was 16.1/1000 patient/days and 23.0/1000 CVC-days. Our monthly rates data of LOS/1000 patient-day reveal fluctuations over the studied period, with incidence rates of these infections in staff vacation period (January 2011 and 2012) significantly higher (59.6/1000 patients-days) than compared with the other months rates (16.6/1000 patients-days) (IRR = 3.59; p < 0.001). As opposite, the incidence rates of LOS during relocation period was lower (10.3/1000 patients-days) when compared with baseline period 26.7/1000 patients-days (IRR = 2.59; p = 0.007). After the intervention period, these rates decreased in the post intervention period, when compared with preintervention 14.7/1000 patients-days and 23.4/1000 patients-days, respectively (IRR = 1.59; p = 0.04). Conclusion Through simple infection control measures, LOS can be successfully controlled especially in NICUs of limited resources countries such as ours.
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17
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Genotypic study documents divergence in the pathogenesis of bloodstream infection related central venous catheters in neonates. Braz J Infect Dis 2014; 18:387-93. [PMID: 24690430 PMCID: PMC9427472 DOI: 10.1016/j.bjid.2013.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 11/15/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate the pathogenesis of bloodstream infection by Staphylococcus epidermidis, using the molecular epidemiology, in high-risk neonates. Methods We conducted a prospective study of a cohort of neonates with bloodstream infection using central venous catheters for more than 24 h. “National Healthcare Safety Network” surveillance was conducted. Genotyping was performed by DNA fingerprinting and mecA genes and icaAD were detected by multiplex-PCR. Results From April 2006 to April 2008, the incidence of bloodstream infection and central venous catheter-associated bloodstream infection was 15.1 and 13.0/1000 catheter days, respectively, with S. epidermidis accounting for 42.9% of episodes. Molecular analysis was used to document the similarity among six isolates of bloodstream infection by S. epidermidis from cases with positive blood and central venous catheter tip cultures. Fifty percent of neonates had bloodstream infection not identified as definite or probable central venous catheter-related bloodstream infection. Only one case was considered as definite central venous catheter-related bloodstream infection and was extraluminally acquired; the remaining were considered probable central venous catheter-related bloodstream infections, with one probable extraluminally and another probable intraluminally acquired bloodstream infection. Additionally, among mecA+ and icaAD+ samples, one clone (A) was predominant (80%). A polyclonal profile was found among sensitive samples that were not carriers of the icaAD gene. Conclusions The majority of infections caused by S. epidermidis in neonates had an unknown origin, although 33.3% appeared to have been acquired intraluminally and extraluminally. We observed a polyclonal profile between sensitive samples and a prevalent clone (A) between resistant samples.
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18
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Vélez LF, Sanitato M, Barry D, Alilio M, Apfel F, Coe G, Garcia A, Kaufman M, Klein J, Kutlesic V, Meadowcroft L, Nilsen W, O'Sullivan G, Peterson S, Raiten D, Vorkoper S. The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence. JOURNAL OF HEALTH COMMUNICATION 2014; 19 Suppl 1:89-121. [PMID: 25207449 PMCID: PMC4205911 DOI: 10.1080/10810730.2014.939313] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.
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Affiliation(s)
| | - Mary Sanitato
- Bureau for Global Health, U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
| | - Donna Barry
- Center for American Progress
,
Washington
,
District of Columbia
,
USA
| | - Martin Alilio
- U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
| | - Franklin Apfel
- World Health Communication Associates
,
Somerset
,
United Kingdom
| | - Gloria Coe
- U.S. Agency for International Development
,
Washington
,
District of Columbia
,
USA
| | - Amparo Garcia
- U.S. Forest Service
,
Washington
,
District of Columbia
,
USA
| | - Michelle Kaufman
- Center for Communication Programs
, Johns Hopkins Bloomberg School of Public Health
,
Baltimore
,
Maryland
,
USA
| | - Jonathan Klein
- American Academy of Pediatrics
,
Elk Grove Village
,
Illinois
,
USA
| | - Vesna Kutlesic
- National Institutes of Health
,
Bethesda
,
Maryland
,
USA
| | | | - Wendy Nilsen
- Office of Behavioral and Social Sciences Research
, National Institutes of Health
,
Bethesda
,
Maryland
,
USA
| | | | | | - Daniel Raiten
- National Institutes of Health
,
Bethesda
,
Maryland
,
USA
| | - Susan Vorkoper
- National Institutes of Health
,
Bethesda
,
Maryland
,
USA
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19
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Ballot DE, Bosman N, Nana T, Ramdin T, Cooper PA. Background changing patterns of neonatal fungal sepsis in a developing country. J Trop Pediatr 2013; 59:460-4. [PMID: 23803724 DOI: 10.1093/tropej/fmt053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Candida albicans is the predominant isolate in many neonatal fungal bloodstream infections (BSIs), so fluconazole is used as empiric antifungal therapy. AIM To determine the predominant organisms, antifungal sensitivity patterns, clinical and demographic risk factors and crude mortality rate in neonatal fungal BSI cases. SUBJECTS AND METHODS This is a review of all neonatal fungal BSI cases between January 2007 and December 2011. RESULTS Fifty-nine patients were included in the study. Candida parapsilosis (54.2%) was isolated in majority of the cases, followed by C. albicans (27.1%). Fluconazole resistance was present in 16 of 32 cases of C. parapsilosis versus 1 of 16 cases of C. albicans (P = 0.003). Mortality rate was 45.8%. Surgical problems were present in 55.9%. Death was significantly associated with lower birth weight (P = 0.046) and necrotizing enterocolitis (P = 0.034). CONCLUSIONS The increase in neonatal fungal BSI and resistant organisms highlights the need to review use of routine empiric fluconazole and to implement preventive measures.
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Affiliation(s)
- Daynia E Ballot
- Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
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20
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Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S. Interventions to improve professional adherence to guidelines for prevention of device-related infections. Cochrane Database Syst Rev 2013:CD006559. [PMID: 23543545 DOI: 10.1002/14651858.cd006559.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections. OBJECTIVES To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence. SEARCH METHODS We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information. MAIN RESULTS We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times. AUTHORS' CONCLUSIONS The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.
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Affiliation(s)
- Gerd Flodgren
- Department of Public Health, University of Oxford, Oxford, UK.
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21
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Brachine JDP, Peterlini MAS, Pedreira MDLG. Método bundle na redução de infecção de corrente sanguínea relacionada a cateteres centrais: revisão integrativa. Rev Gaucha Enferm 2012; 33:200-10. [DOI: 10.1590/s1983-14472012000400025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Trata-se de uma revisão integrativa da literatura, que objetivou identificar intervenções baseadas em evidência que compõem o método bundle, designados à redução de infecção de corrente sanguínea relacionada ou associada a cateter intravenoso central. Para a coleta de dados online, em bases nacionais e internacionais, foram utilizados a palavra-chave bundle e os descritores catheter-related infection, infection control e central venous catheterization, resultando, após aplicação dos critérios de inclusão, amostra de quinze artigos. Este trabalho evidenciou cinco intervenções como as mais frequentemente empregadas na construção dos bundles: higienização das mãos, gluconato de clorexidina como antisséptico para pele, uso de barreira máxima de precaução durante a inserção cateter, evitar acessar veia femoral e verificar necessidade diária de permanência do cateter, com sua remoção imediata quando não mais indicado. A maioria dos estudos demonstrou resultados estatisticamente significantes na redução de infecção de corrente sanguínea relacionada ou associada a cateter intravenoso central.
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22
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Hübner NO, Fleßa S, Jakisch R, Assadian O, Kramer A. Review of indicators for cross-sectoral optimization of nosocomial infection prophylaxis - a perspective from structurally- and process-oriented hygiene. GMS KRANKENHAUSHYGIENE INTERDISZIPLINAR 2012; 7:Doc15. [PMID: 22558049 PMCID: PMC3334955 DOI: 10.3205/dgkh000199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the care of patients, the prevention of nosocomial infections is crucial. For it to be successful, cross-sectoral, interface-oriented hygiene quality management is necessary. The goal is to apply the HACCP (Hazard Assessment and Critical Control Points) concept to hospital hygiene, in order to create a multi-dimensional hygiene control system based on hygiene indicators that will overcome the limitations of a procedurally non-integrated and non-cross-sectoral view of hygiene. Three critical risk dimensions can be identified for the implementation of three-dimensional quality control of hygiene in clinical routine: the constitution of the person concerned, the surrounding physical structures and technical equipment, and the medical procedures. In these dimensions, the establishment of indicators and threshold values enables a comprehensive assessment of hygiene quality. Thus, the cross-sectoral evaluation of the quality of structure, processes and results is decisive for the success of integrated infection prophylaxis. This study lays the foundation for hygiene indicator requirements and develops initial concepts for evaluating quality management in hygiene.
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