Development of an algorithm to prevent neonatal healthcare-associated infections (HAIs): A multimodal approach

Abstract

Background: The current study is carried out with an aim to explore the spectrum of microorganism causing HAIs and to develop prevention bundle (algorithm) for neonatal healthcare-associated infections (HAIs) using the multimodal approach to overcome adaptation and training limitations. Methods and materials: A cross-sectional study was carried out for 19 months among 1233 neonate admitted for >48 hours at level III Neonatal Intensive Care Unit (NICU) identifying cases of HAIs (Using CDC & WHO criteria). The International expert proposal for interim definitions for acquired resistance was used for identifying Multi-drug resistance (MDR), extreme-drug resistance (XDR) and pan-drug resistance (PDR) strains. Root cause analysis using open-ended questionnaire, multiple observations, and failure mode effect analysis was done. Multiple in-depth interviews of the experts from neonatology and microbiology were carried out. System process mapping for various process & critical task involved in NICU against evidence was recorded to prevent HAIs, that brought the development of three major processes out of eighteen processes. The training videos were developed to prevent HAIs. Results: Among 1233 patients 118 neonates (9.6/100 admissions) acquired HAIs. The BacT/Alert culture showed 34% positivity for 474 blood/ fluid samples of these patients sent for investigation. Common pathogens isolated include Klebsiella pneumoniae (35%), coagulase-negative Staphylococcus aureus (CONS) (32%), Acinetobacter baumanii (12%), Enterobacter cloacae (8%), E. coli (8%) and others (5%). MDR, XDR, PDR microorganism identified were Klebsiella pneumoniae (66%, 19%, 4%), Acinetobacter baumanii (0%, 39%, 28%), E. coli (22%, 11%, 33%) and Enterobacter cloacae (46%, 18%, 9%). Common antibiotics used therapeutically for neonates acquiring HAIs were Amikacin, Piperacillin-Tazobactam, and Ampicillin among 95%, 78%, and 64% respectively. The frequent cause of HAIs were improper hand-washing, multiple procedures, improper device disinfection. Three process algorithm [(1) Nursing care process; (2) vascular access process; (3) cardiopulmonary resuscitation management process] identifying critical step preventing HAIs were developed. Conclusion: Presence of MDR, XDR and PDR demands the institution of antimicrobial stewardship. High vigilance on infection control measures, system process mapping of the individual healthcare setting and strict adherence to the algorithms is the need of an hour to prevent neonatal HAIs.