Hospital Acquired Infections in Developing Countries.

Dr Chungu. Dr Nchimba.

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 if known. Effective health measures are provided at birth and during the first week of life

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.

UTH
NICU: 40% mortality Septicaemia: 32%

 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

 Gram negative sepsis (klebsiella, Pseudomonas, Acinobacter ) causes 50% of infections. Associated with outbreaks because these water bugs can thrive in multi-use medicine containers, liquid soaps, antiseptic & disinfectant solutions. Even though Klebsiella believed to be maternal flora investigators in Karachi found resistance patterns conflicting as Swedish isolates were sensitive. In SA A. Baumannii emerging problem & stress importance of ongoing Microbiological surveillance.

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

ANTIMICROBIAL RESISTANCE

The powerful selective pressure of inappropriate and prolonged antimicrobial use favours the emergence and amplication of resistance in hospital nurseries.

CAUSES OF HAI IN DEVELOPING COUNTRIES

PERIPARTUM Lack of essential equipment and supplies (soap, washbasin, clean water, obstetric instruments, gloves,sterilisers, medications, cord clamps)

Failures in sterilisation/disinfection or handling/storage of multiuse resuscitation instruments, equipment and supplies, delivery surfaces, leading to contamination

Re-use of disposable supplies without safe disinfection/sterilisation procedures Inadequate hand hygiene and glove use

 Excessive vaginal examinations Lack of aseptic technique for invasive procedures and cord cutting and care

Overcrowded and understaffed labour and delivery rooms

Lack of knowledge, training, and competency regarding infection control practice and identication and management of risk factors for maternal and neonatal infection

POSTNATAL
Lack of essential equipment and supplies (soap, clean water, wash-basins, gloves, incubators, topical medications for eye and cord care) Failures in sterilisation/disinfection or handling/storage of multi-use instruments, equipment and supplies, leading to contamination Inadequate environmental cleaning and disinfection Re-use of disposable supplies without safe disinfection/sterilisation procedures Inadequate hand hygiene and glove use

 Failures in isolation procedures/inadequate isolation facilities for babies infected with antibiotic-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

 Lack of aseptic technique for invasive procedures Overuse of invasive devices and venous cutdowns Pooling or multiple use of single-use vials Lack of knowledge, training, and competency regarding infection control practice Inappropriate and prolonged use of antibiotics

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.

 Routine gowning: No benefit Appropriate cleaning and disinfection of reusable 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

OBSTETRIC
ANC: Identifies risk factors. Appropriate address of which reduce prematurity & infection. INTRAPARTUM: Reduced VEs Vulval swabbing/douching: No data. Hand washing between patients Cleaning beds. Regular ward swabs & microbiological liason

Postpartum
Prophylaxis against Ophthalmia neonatorum Early exclusive breast feeding Kangaroo Topical umbilical antiseptics: Egypt sunflower seed oil.

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.

HEALTH SYSTEMS ORIENTED SOLUTIONS

Translation of evidence into reliable sustainable practice challenging Sad because most effective interventions inexpensive Multi-faceted behaviour change. Best solutions locally driven e.g participatory intervention in Nepal Random safety audits by front line staff beneficial in the US & can be adapted to our setting

 Need to strengthen primary care Primary care to work closely with tertiary centres Infection prevention principles are hallmark Commitment needed by every stake holder.

 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

Link between Primary & Tertiary centre

Referral flow chart for Neonatal care

 DISCUSSION WAY FORWARD ? CONCLUSION?