Elsevier

The Lancet

Volume 365, Issue 9465, 26 March–1 April 2005, Pages 1175-1188
The Lancet

Review
Hospital-acquired neonatal infections in developing countries

https://doi.org/10.1016/S0140-6736(05)71881-XGet rights and content

Summary

Hospital-born babies in developing countries are at increased risk of neonatal infections because of poor intrapartum and postnatal infection-control practices. We reviewed data from developing countries on rates of neonatal infections among hospital-born babies, range of pathogens, antimicrobial resistance, and infection-control interventions. Reported rates of neonatal infections were 3–20 times higher than those reported for hospital-born babies in industrialised countries. Klebsiella pneumoniae, other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp), and Staphylococcus aureus were the major pathogens among 11 471 bloodstream isolates reported. These infections can often present soon after birth. About 70% would not be covered by an empiric regimen of ampicillin and gentamicin, and many might be untreatable in resource-constrained environments. The associated morbidity, mortality, costs, and adverse effect on future health-seeking behaviour by communities pose barriers to improvement of neonatal outcomes in developing countries. Low-cost, “bundled” interventions using systems quality improvement approaches for improved infection control are possible, but should be supported by evidence in developing country settings.

Section snippets

Definition of hospital-acquired neonatal infections

Traditionally neonatal infections have been divided into early-onset infections (those presenting within the first 72 h of life) related to maternal risk factors and birth canal acquisition, and late-onset infections (those presenting after 72 h of life) related to acquisition in the home or hospital environment.44 However, these tidy definitions break down in developing-country settings, where highly unclean delivery practices increase the risk of infection. Failure to use fastidious aseptic

Rates of neonatal infection

Neonatal infections are estimated to cause 1·6 million annual deaths or 40% of all neonatal deaths in developing countries.4 In a comprehensive review of community and facility-based data, neonatal infection as a proportion of all causes of death in the neonatal period ranged from 4% to 56% in 17 hospital-based studies, and 8–84% in 24 community-based studies.5 Three-quarters of these deaths are in south Asia and sub-Saharan Africa.1 Neonatal infection as a cause of death in all newborns ranged

Pathogens of neonatal infections in developing countries

Gram-negative rods are major pathogens of neonatal sepsis in developing countries. A review of 11 471 bloodstream samples showed that gram-negative rods were isolated from at least 60% of positive blood cultures in all the developing regions of the world (table 1).8, 26, 28, 29, 30, 31, 41, 51, 52, 53, 55, 56, 59, 60, 62, 63, 64, 65, 66, 67, 68, 70, 71, 73, 75, 85, 89, 90, 91, 92, 93, 94, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120

Antimicrobial resistance

Antimicrobial resistance has reached alarming levels in nurseries in developing countries, even excluding strains from reported outbreaks, which tend to be caused by multidrug-resistant bacteria (table 3).22, 28, 29, 31, 53, 54, 56, 57, 59, 62, 63, 64, 66, 68, 71, 73, 75, 89, 92, 93, 94, 100, 101, 104, 106, 107, 108, 112, 113, 115, 117, 118, 119, 121, 122, 123, 135, 136, 137, 138, 139, 140 Klebsiella spp are intrinsically resistant to ampicillin, and gentamicin-resistance rates as high as 71%

Why are health-care-associated neonatal infections in developing countries so frequent?

Babies are born without an endogenous microbial flora and rapidly become colonised with microbes encountered in the maternal genital tract and their immediate postnatal environment.44 Since their immature immune systems are unable to provide a robust defence against virulent pathogens, neonates are at increased risk of developing invasive infections if exposed to pathogenic microorganisms.125 Premature neonates are at especially high risk of infection because of lack of protective maternal

Interventions to prevent health-care-associated infections

Comprehensive interventions for prevention and management of neonatal infections in developing countries have recently been described.5, 11, 151, 152 This section focuses on interventions likely to prevent hospital-acquired neonatal infections.

Research to fill key knowledge gaps

Many unresolved issues exist, but the research agenda needs to be strategic in view of the limited funding resources. We recommend a focus on several critical knowledge gaps.

As noted previously, understanding the factors affecting obstetric and neonatal care in hospitals in developing countries that lead to high infection rates requires a systems perspective and detailed assessment of the entire process of care delivery (eg, patient population and flow, referral systems, key health-care

Surveillance of key performance measures

Effective health-systems improvement efforts need accurate information. Surveillance is necessary to define the extent of the problem and assess the effect of infection-control interventions. Surveillance in health-care facilities in the poorest regions for only the most basic outcomes, such as neonatal mortality, possibly adjusted by birthweight and duration of hospitalisation should be sufficient. Surveillance for infections such as sepsis and omphalitis without additional microbiological

Collaborative efforts to improve health-care systems

The goal of improving hospital-based care of newborn babies and reducing high rates of infections can only be achieved by the collaborative efforts of clinicians, nurses, microbiologists, hospital administrators, public-health professionals, health policymakers, and users, who must be brought together on a common platform. As noted in the report of the Task Force on Health Systems Research, scarce resources are currently being wasted on flawed or ineffective care in developing countries.188

Search strategy and selection criteria

We searched PubMed for all studies published from 1990 to 2004, which reported incidence, aetiology, antimicrobial resistance, or outbreaks of neonatal infections in hospital settings in developing countries. We used combinations of search terms: [neonat* OR newborn*] AND [infection* OR sepsis OR septic* OR “nosocomial infection”] along with [center(s) OR unit(s) OR nursery OR nurseries OR hospital(s) OR NICU] and also with the term “resistance”. We did separate searches for outbreak

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