Chimhini, G

Fitzgerald, FC

Magwenzi, M

Infection Prevention in Practice

PubMed

Chimhini, G.

Magwenzi, M.

Fitzgerald, F.C.

PubMed Central

Infection Prevention and Control in low-resource settings: the need for the local, the contextual and the pragmatic

Spiral - Imperial College Digital Repository

ww.sciencedirect.comInfection Prevention in Practice 4 (2022) 100135Available online at wInfection Prevention in Practicejournal homepage: www.elsevier .com/locate/ ipipEditorialInfection Prevention and Controlin low-resource settings: the needfor the local, the contextual andthe pragmaticIn this Article Collection for IPIP, we want to celebrate thecreativity and pragmatism of our colleagues working in low-resource settings prior to SARS-CoV-2, while highlightingongoing challenges. A recurring theme of the five papers withinthe Article Collection (published in IPIP throughout 2020), isthe need to respect the ‘local’ [1,3e6]. Without understandingthe context and circumstances of individual healthcare facili-ties and infection prevention and control (IPC) practitioners,top-down initiatives will only ever be partly successful. The fivepapers discussed here describe the challenges common to low-resource settings: namely high rates of antimicrobial resistanceand healthcare acquired infections (such as surgical siteinfections), poor antimicrobial stewardship and infection pre-vention and control practices in general. They also provideinnovative pragmatic solutions to problems such as wastemanagement and effective benchmarking.Surgical site infections are particularly problematic in low-resource settings. While antimicrobial prophylaxis is a keyintervention, demands for effective stewardship necessitatelooking beyond antibiotics. In Cambodia, Fast et al. introducedand assessed the impact of a training and mentorship pro-gramme provided by The Sterile Processing Education Chari-table Trust (SPECT), aiming to improve sterile processingpractices for surgical instruments [1]. Both qualitative andquantitative assessments demonstrated improvements how-ever context-specific barriers were identified. In particularrural healthcare facilities suffered from a lack of local lead-ership and administrative buy-in, necessary for sustainingeffective practices and accessing resources.It is estimated that up to 30% of hospital admissions inAfrican settings are associated with poor infection preventionand control (IPC) practices [2], although data from low-resource settings are scanty. Kinyenje et al. establishedthat strong central leadership was exemplified by theremarkable efforts of the Tanzanian government with theintroduction of a Star Rating Assessment [3]. Health facilitiesare rated across a range of performance indicators (includingIPC), and facilities are supported in developing qualityimprovement initiatives specific to challenges identified.They found an overall improvement in adherence to IPChttps://doi.org/10.1016/j.infpip.2021.1001352590-0889/ª 2021 The Authors. Published by Elsevier Ltd on behalf of Theunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-standards from 31% to 57%- an impressive achievement,though admirably, they aim higher. In order to achieve theirgoal of 80% compliance, authors highlight the need forimplementation science and understanding of specific localcontext: for example, in some facilities, having the qualityimprovement projects disseminated in English rather thanKiswahili was a barrier to implementation.Bunduki et al.’s work from the Democratic Republic ofCongo echoes this need for local solutions, while quantifyingthe scale of the challenges confronting antimicrobial stewardsand IPC practitioners [4]. They found very poor adherence tointernational standards of surgical antimicrobial prophylaxisacross surgical and obstetric and gynaecological procedures,especially during emergency procedures, with only 18% ofantibiotic use during 265 procedures assessed as ‘rational’. Thekey issue highlighted here is the lack of local guidelines, with areliance on international guidelines leading to a high variabilityof prescriber practices dependent on their individual experi-ence and drug availability.Our work on implementing an antimicrobial stewardshipprogramme in a large Zimbabwean neonatal unit had similarfindings-we reported a very high baseline rate of antimicrobialuse-including almost universal prescription of oral amoxicillinon discharge from the unit, which is not an evidence-basedintervention [5]. We reduced this dramatically with ward-based training of junior doctors and have sustained thisreduction with monthly feedback and benchmarking using a co-developed digital quality improvement tool: the NeoTree [6]. Amajor advantage of the NeoTree is inbuilt flexibility, so theapplication platform can be altered by clinicians to addresspertinent local issues and quality improvement targets-e.g.antimicrobial stewardship. Decreasing costs of tablets andsmart phones alongside increasing technology literacy amonghealthcare workers in low-resource settings mean digitalinnovations such as NeoTree have enormous potential.We must continue to advocate for locally driven, creativesolutions to the problems we face as IPC practitioners in low-resource settings-such as that exemplified by Myneedu andAggarwal, using microwave technology to safely dispose of thevast quantities of Mycobacterium tuberculosis positive sputumproduced in one of India’s largest specialist tuberculosis hos-pitals [7]. Dealing with 30e35 litres of infectious sputum a dayis not feasible with an autoclave, and the current combinationof 5% phenol and boiling required excessive human manipu-lation and had poor compliance. Their elegant and effectivesolution of using microwave technology (in particular using amicrowave robust to power fluctuations such as frequentlyaffect our hospitals in Zimbabwe) is something with greatpotential for emulation in similar settings.Healthcare Infection Society. This is an open access articlenc-nd/4.0/).Editorial / Infection Prevention in Practice 4 (2022) 1001352In summary, we salute the efforts of our colleagues in otherlow-resource settings in their pragmatism and perseveranceto improve IPC despite considerable extrinsic challenges andrisks (including to their own health with SARS-CoV2). To ach-ieve our goals, we must focus on the local: empowering andlistening to our IPC colleagues in smaller, district and ruralfacilities to ensure our plans and strategies are workablecontextually. Organisations such as the Infection ControlAfrica Network (ICAN) can amplify our voices and ensure thatwe can advocate effectively for the resources we need tokeep our patients and our fellow healthcare workers safe inthese troubled times.IPIP has signed up to the Research4Life program, meaningauthors from institutions within low and middle incomecountries will not be charged open access fees forpublication.Conflict of interest statementWe declare we have no conflicts of interest.FundingWe received no specific funding for this editorial. FF issupported by the Academy of Medical Sciences, the funders ofthe Starter Grant for Clinical Lecturers scheme and UCL GreatOrmond Street NIHR Biomedical Research Centre.References[1] Fast O, Dosani A, Uzoka F-M, Cuncannon A, Cheav S. Improvingsterile processing practices in Cambodian healthcare facilities.Infection Prevention in Practice 2020;2:100101.[2] Bagheri Nejad S, Allegranzi B, Syed SB, Ellis B. Pittet D Health-care-associated infection in Africa: a systematic review. Bulletinof the World Health Organization 2011;89:757e65.[3] Kinyenje E, Hokororo J, Eliakimu E, Yahya T, Mbwele B,Mohamed M, et al. Status of Infection Prevention and Control inTanzanian Primary Health Care Facilities: Learning From StarRating Assessment. Infection Prevention in Practice2020;2:100071.[4] Bunduki GK, Mukululi MP, Masumbuko CK. Uwonda SA Complianceof antibiotics used for surgical site infection prophylaxis amongpatients undergoing surgery in a Congolese teaching hospital.Infection Prevention in Practice 2020;2:100075.[5] Chimhini G, Chimhuya S, Madzudzo L, Heys M, Crehan C,Robertson V, et al. Auditing use of antibiotics in Zimbabweanneonates. Infection Prevention in Practice 2020;2:100046.[6] Gannon H, Chimhuya S, Chimhini G, Neal SR, Shaw LP, Crehan C,et al. Electronic application to improve management of infectionsin low-income neonatal units: pilot implementation of the NeoTreebeta app in a public sector hospital in Zimbabwe. BMJ Open Qual2021;10:e001043. https://doi.org/10.1136/bmjoq-2020-001043.[7] Myneedu VP. Aggarwal A Disposal of the large volume of sputumpositive for Mycobacterium tuberculosis by using microwave ster-ilisation technology as an alternative to traditional autoclaving in atertiary respiratory care hospital in Delhi, India. Infection Pre-vention in Practice 2020;2:100072.G. Chimhinia, M. Magwenzib,c, F.C. Fitzgeraldd,e,*aChild and Adolescent Health Unit, Faculty of Medicine andHealth Sciences, University of Zimbabwe, Harare, ZimbabwebDepartment of Health Sciences, Bindura University of ScienceEducation, Bindura, ZimbabwecInfection Control Association of Zimbabwe, Harare,ZimbabwedUCL Great Ormond Street Institute of Child Health,University College London, London, UKeBiomedical Research and Training Institute, Harare,Zimbabwe* Corresponding author. Address: Felicity Fitzgerald, UCLGreat Ormond Street Institute of Child Health, 30 GuilfordStreet, London WC1N 1EH, UK.E-mail address: felicity.fitzgerald@ucl.ac.uk (F.C. Fitzgerald)Available online 2 April 2021

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Infection Prevention and Control in low-resource settings: the need for the local, the contextual and the pragmatic

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