A framework for preventing healthcare-associated infection in neonates and children in South Africa

Healthcare-associated infection (HAI) is a frequent and serious complication affecting 4 - 8% of hospitalised children and neonates in high-income countries. The burden of HAI in South African (SA) paediatric and neonatal wards is substantial but underappreciated, owing to a lack of HAI surveillance and reporting. Maternal and child health and infection prevention are priority areas for healthcare quality improvement in the National Core Standards programme. Despite increasing recognition in SA, infection prevention efforts targeting hospitalised children and neonates are hampered by health system, institutional and individual patient factors. To ensure safe healthcare delivery to children, a co-ordinated HAI prevention strategy should promote development of infection prevention norms and policies, education, patient safety advocacy, healthcare infrastructure, surveillance and research. We present a framework for SA to develop and expand HAI prevention in hospitalised neonates and children

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

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

Surveillance of healthcare-associated infection in hospitalised South African children: Which method performs best?

Background. In 2012, the South African (SA) National Department of Health mandated surveillance of healthcare-associated infection (HAI), but made no recommendations of appropriate surveillance methods.Methods. Prospective clinical HAI surveillance (the reference method) was conducted at Tygerberg Children’s Hospital, Cape Town, from 1 May to 31 October 2015. Performance of three surveillance methods (point prevalence surveys (PPSs), laboratory surveillance and tracking of antimicrobial prescriptions) was compared with the reference method using surveillance evaluation guidelines. Factors associated with failure to detect HAI were identified by logistic regression analysis.Results. The reference method detected 417 HAIs among 1 347 paediatric hospitalisations (HAI incidence of 31/1000 patient days; 95% confidence interval (CI) 28.2 - 34.2). Surveillance methods had variable sensitivity (S) and positive predictive value (PPV): PPS S = 24.9% (95% CI 21 - 29.3), PPV = 100%; laboratory surveillance S = 48.4% (95% CI 43.7 - 53.2), PPV = 55.2% (95% CI 50.1 - 60.2); and antimicrobial prescriptions S = 66.4% (95% CI 61.8 - 70.8%), PPV = 88.5% (95% CI 84.5 - 91.6). Combined laboratory-antimicrobial surveillance achieved superior HAI detection (S = 84.7% (95% CI 80.9 - 87.8%), PPV = 97% (95% CI 94.6 - 98.4%)). Factors associated with failure to detect HAI included patient transfer (odds ratio (OR) 2.0), single HAI event (OR 2.8), age category 1 - 5 years (OR 2.1) and hospitalisation in a general ward (OR 2.3).Conclusions. Repeated PPSs, laboratory surveillance and/or antimicrobial prescription tracking are feasible HAI surveillance methods for low-resource settings. Combined laboratory-antimicrobial surveillance achieved the best sensitivity and PPV. SA paediatric healthcare facilities should individualise HAI surveillance, selecting a method suited to available resources and practice context

Bacterial pathogens and resistance causing community acquired paediatric bloodstream infections in low- and middle-income countries: a systematic review and meta-analysis

Background Despite a high mortality rate in childhood, there is limited evidence on the causes and outcomes of paediatric bloodstream infections from low- and middle-income countries (LMICs). We conducted a systematic review and meta-analysis to characterize the bacterial causes of paediatric bloodstream infections in LMICs and their resistance profile. Methods We searched Pubmed and Embase databases between January 1st 1990 and October 30th 2019, combining MeSH and free-text terms for “sepsis” and “low-middle-income countries” in children. Two reviewers screened articles and performed data extraction to identify studies investigating children (1 month-18 years), with at least one blood culture. The main outcomes of interests were the rate of positive blood cultures, the distribution of bacterial pathogens, the resistance patterns and the case-fatality rate. The proportions obtained from each study were pooled using the Freeman-Tukey double arcsine transformation, and a random-effect meta-analysis model was used. Results We identified 2403 eligible studies, 17 were included in the final review including 52,915 children (11 in Africa and 6 in Asia). The overall percentage of positive blood culture was 19.1% [95% CI: 12.0–27.5%]; 15.5% [8.4–24.4%] in Africa and 28.0% [13.2–45.8%] in Asia. A total of 4836 bacterial isolates were included in the studies; 2974 were Gram-negative (63.9% [52.2–74.9]) and 1858 were Gram-positive (35.8% [24.9–47.5]). In Asia, Salmonella typhi (26.2%) was the most commonly isolated pathogen, followed by Staphylococcus aureus (7.7%) whereas in Africa, S. aureus (17.8%) and Streptococcus pneumoniae (16.8%) were predominant followed by Escherichia coli (10.7%). S. aureus was more likely resistant to methicillin in Africa (29.5% vs. 7.9%), whereas E. coli was more frequently resistant to third-generation cephalosporins (31.2% vs. 21.2%), amikacin (29.6% vs. 0%) and ciprofloxacin (36.7% vs. 0%) in Asia. The overall estimate for case-fatality rate among 8 studies was 12.7% [6.6–20.2%]. Underlying conditions, such as malnutrition or HIV infection were assessed as a factor associated with bacteraemia in 4 studies each. Conclusions We observed a marked variation in pathogen distribution and their resistance profiles between Asia and Africa. Very limited data is available on underlying risk factors for bacteraemia, patterns of treatment of multidrug-resistant infections and predictors of adverse outcomes

Identifying missed opportunities for early intervention among HIV-infected paediatric admissions at Chris Hani Baragwanath hospital, Soweto, South Africa

Background and design. HIV is a major contributor to childhood morbidity and mortality in South Africa. We describe HIV prevalence, disease profile, outcome and missed opportunities for early intervention in a cohort of HIV-infected children admitted to Chris Hani Baragwanath Hospital’s general paediatric wards between 1 October 2007 and 31 December 2007.Results. Of 1 510 admissions, 446 (29.5%) were HIV infected. Many children (238, 54.1%) were newly diagnosed in hospital and most had advanced HIV disease (405, 92%). The principal admission diagnoses were pneumonia (165, 37.5%), gastro-enteritis (97, 22%), sepsis (86, 19.5%) and tuberculosis (92, 21%). Of children identified as HIV infected before admission, 128/202 (63.4%) were not accessing antiretroviral treatment (ART), although 121/128 (94.5%) met ART eligibility criteria. Of 364 ART-naïve eligible children, only 15 (4.1%) were commenced on ART as inpatients. Problems with PMTCT implementation in infants under 6 months (N=166) included lack of maternal antenatal HIV testing (51, 30.7%); poor uptake of maternal/infant nevirapine prophylaxis (60, 36.2%); limited use of co-trimoxazole (CTX) prophylaxis (44/147, 29.9%); and delayed infant HIV polymerase chain reaction testing (98/147, 87.5%). Of infants known to be HIV infected prior to hospitalisation, 37/51 (73%) had not initiated ART. The in-hospital case fatality rate (CFR) among HIV-infected children was triple that of the combined HIV-uninfected, exposed and unknown group (12% v. 3.6%). Infants <12 months of age accounted for 73.6% of all HIV-related deaths (CFR 17.1%).Conclusions. HIV remains highly prevalent and contributes to significant in-hospital mortality. Missed opportunities for PMTCT, HIV diagnosis and ART initiation are frequent. Interventions to optimise paediatric HIV outcomes should target maternal HIV diagnosis, early infant diagnosis, uptake of CTX prophylaxis and prompt initiation of ART, especially among infants. Hospitalised ART-eligible children should be prioritised for inpatient initiation of ART

Paediatric ART outcomes in a decentralised model of care in Cape Town, South Africa

Background. Although subSaharan Africa faces the world’s largest paediatric HIV epidemic, only 1 in 4 children has access to combination antiretroviral therapy (ART). A decentralised approach to HIV care is  advocated, but programmes in resourcelimited settings encounter many challenges to community-initiated paediatric ART implementation.Methods. A retrospective cohort analysis of 613 children receiving ART between 2004 and 2009 was performed in seven physician-run primary healthcare (PHC) clinics in Cape Town. Baseline characteristics, serial CD4+, viral load (VL) levels and status at study closure were collected.Results. Two subgroups were identified: children who were initiated on ART in a PHC clinic (n=343) and children who were down-referred from tertiary hospitals (n=270). The numbers of children initiated on ART in PHC increased sevenfold over the study period. Down-referred children were severely ill at ART initiation, with higher VLs, lower CD4+ counts and higher rates of tuberculosis co-infection (25.3% v. 16.9%; p=0.01). Median time to virological suppression was 29 weeks in PHC-ART initiates and 44 weeks in children down-referred (p<0.0001). Children down-referred to PHC either maintained or gained virological suppression. Longitudinal cohort analysis demonstrated sustained VL suppression >80%, high rates of immune reconstitution and low mortality.Conclusions. Increasing numbers of children are initiated on ART in PHC settings and achieve comparable immunological, virological and survival outcomes, suggesting successful decentralisation of paediatric HIV care. Down-referral of children with adherence-related virological failure may  assist with attainment of virological suppression and sparing use of  second-line medications