Reducing Neonatal Mortality via Intensified Infection Prevention

7/30/2019 Reducing Neonatal Mortality via Intensified Infection Prevention

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Hospital Acquired Infections inDeveloping Countries.

Dr Chungu.Dr Nchimba.


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Neonatal Mortality

Global situation 40% of all under-five child deaths are among newborn

neonates.

Estimated 4 million annual neonatal deaths worlwide

More than 50% of these deaths are clustered in only six

countries: China, Democratic Republic of the Congo, Ethiopia, India,

Nigeria, and Pakistan

India contributes the highest: 25% attributed to LBW 25%

Up to two thirds of newborn deaths can be prevented ifknown.

Effective health measures are provided at birth and duringthe first week of life


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Local Situation.

Zambian IMR stands at 70/1000

NMR 30/1000

This constitutes 43% of IMR More than 50% of births delivered at home

23% assisted by TBA, 25% by relative 5% no

assistance.


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UTH

NICU: 40% mortality

Septicaemia: 32%


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Perinatal-neonatal period carries the highest

risk of mortality and morbidity in the lifespan

of a human being

126 DALYs annually, or 8.3 % of the global

disease burden (63million DALYs for ischemic

heart disease)

Rates are unacceptably high and more needs

to be done to reduce HAI


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Gram negative sepsis (klebsiella, Pseudomonas,Acinobacter) causes 50% of infections.

Associated with outbreaks because these water bugs

can thrive in multi-use medicine containers, liquidsoaps, antiseptic & disinfectant solutions.

Even though Klebsiella believed to be maternal florainvestigators in Karachi found resistance patternsconflicting as Swedish isolates were sensitive.

In SAA. Baumanniiemerging problem & stressimportance of ongoing Microbiological surveillance.

C di i l di hi h


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Conditions leading to higher HAI

Burden in

Developing Countries Inadequate hygiene conditions

Poor infrastructure

Inadequate / insufficient equipment

Lack of microbiological information Understaffing

Overcrowding

Lack of knowledge and low staff preparedness

Inappropriate use of antibiotics

More diseased population Unfavorable social background

Lack of national policies and programs

Costs falling on individual patients


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ANTIMICROBIAL RESISTANCE


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The powerful selective pressure of

inappropriate and prolonged antimicrobial use

favours the emergence and amplification of

resistance in hospital nurseries.


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CAUSES OF HAI IN DEVELOPING COUNTRIES

PERIPARTUM

Lack of essential equipment and supplies (soap, washbasin, cleanwater, obstetric instruments, gloves,sterilisers, medications, cordclamps)

Failures in sterilisation/disinfection or handling/storage of multi-use resuscitation instruments, equipment and supplies, deliverysurfaces, leading to contamination

Re-use of disposable supplies without safe disinfection/sterilisationprocedures

Inadequate hand hygiene and glove use


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Excessive vaginal examinations

Lack of aseptic technique for invasive procedures and cordcutting and care

Overcrowded and understaffed labour and delivery rooms

Lack of knowledge, training, and competency regardinginfection control practice and identification andmanagement of risk factors for maternal and neonatalinfection


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POSTNATAL

Lack of essential equipment and supplies (soap, cleanwater, wash-basins, gloves, incubators, topicalmedications for eye and cord care)

Failures in sterilisation/disinfection or handling/storageof multi-use instruments, equipment and supplies,leading to contamination

Inadequate environmental cleaning and disinfection

Re-use of disposable supplies without safedisinfection/sterilisation procedures

Inadequate hand hygiene and glove use


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Failures in isolation procedures/inadequateisolation facilities for babies infected withantibiotic-resistant or highly transmissible

pathogens Overcrowded and understaffed nurseries

Unhygienic bathing and skin care

Lack of early and exclusive breastfeeding

Contaminated bottle feedings

Absence of mother-baby cohorting


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Lack of aseptic technique for invasiveprocedures

Overuse of invasive devices and venous cut-

downs Pooling or multiple use of single-use vials

Lack of knowledge, training, and competency

regarding infection control practice Inappropriate and prolonged use of

antibiotics


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Standard Infection Control Practices.

Handwashing

Low cost handrub can be prepared by hospital

pharmacies (Glycerin, Sorbitol, Isopropylene)

Addition of 0.5% chlorhexidine prolongs

bactericidal action, though expensive

Studies have shown impressive colonisation

reduction in late onset infection when used by

NICU personnel.


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Routine gowning: No benefit

Appropriate cleaning and disinfection ofreusable items.

Reprocessing errors (chemicals, timing )associated with high pseudomonas species

Phillipines: Local handrub. Bedside infection

prevention checklist Argentina: NICU guidelines on suctioning, IV

catheters and infusions


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OBSTETRIC

ANC: Identifies risk factors. Appropriate addressof which reduce prematurity & infection.

INTRAPARTUM:

Reduced VEs

Vulval swabbing/douching: No data.

Hand washing between patients

Cleaning beds.

Regular ward swabs & microbiological liason


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Postpartum

Prophylaxis against Ophthalmia neonatorum

Early exclusive breast feeding

Kangaroo Topical umbilical antiseptics: Egypt sunflower

seed oil.


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A study in Panama showed lower antibiotic

resistance rates by discontinuing empiric

antimicrobial treatment for early onset

infection after 3 days if

Infants doing well

Cultures negative

Lab markers of infection were normal.


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HEALTH SYSTEMS ORIENTED

SOLUTIONS

Translation of evidence into reliable sustainablepractice challenging

Sad because most effective interventions

inexpensive Multi-faceted behaviour change.

Best solutions locally driven e.g participatoryintervention in Nepal

Random safety audits by front line staff beneficialin the US & can be adapted to our setting


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Need to strengthen primary care

Primary care to work closely with tertiary

centres

Infection prevention principles are hallmark

Commitment needed by every stake holder.


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Microbiological surveillance in close

association with the lab

In India IMCI is IMNCI a deliberate initiative in

2003 to equip primary level to manage

neonates.

1st level hospitals equipped with skill to

manage uncomplicated neonates


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Link between Primary & Tertiary

centre


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Referral flow chart for Neonatal care


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DISCUSSION

WAY FORWARD ?CONCLUSION?

Reducing Neonatal Mortality via Intensified Infection Prevention

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