Healthcare-associated Infections in Very Low Birth-weight Infants in a South African Neonatal Unit: Disease Burden, Associated Factors and Short-term Outcomes.

BACKGROUND: Infection is a leading cause of death among very low birth-weight (VLBW) infants in resource-limited settings. METHODS: We performed a retrospective review of healthcare-associated infection (HAI) episodes among VLBW infants from January 1, 2016, to December 31, 2017. The epidemiology, causative organisms and short-term outcomes were analyzed. Logistic regression was used to investigate for factors associated with development of HAI. RESULTS: During the study period, 715 VLBW infants with suspected HAI were investigated, including 162/715 (22.7%) proven and 158/715 (22.1%) presumed HAI. Of the proven infections, 99/162 (61.1%) contained at least one Gram-negative organism per blood culture; 84/162 (51.9%) single Gram-negative organisms and 15/162 (9.3%) polymicrobial growth. Independent factors associated with development of any HAI included low gestational age, small for gestational age, indwelling central venous catheter and invasive ventilation. Compared with infants in whom HAI had been excluded, infants with HAI were more likely to be diagnosed with necrotizing enterocolitis (5.6% vs. 23.1%; P < 0.001) and bronchopulmonary dysplasia (1.0% vs. 4.4%; P = 0.007). Infants with any HAI also had a longer hospital stay [44 (25-65) vs. 38 (26-53) days; P < 0.001] and increased mortality [90/320 (28.1%) vs. 21/395 (5.3%); P < 0.001] compared with infants who did not develop HAI episodes. CONCLUSIONS: Proven and presumed HAI are a major contributor to neonatal morbidity and mortality; further research is urgently needed to better understand potential targets for prevention and treatment of HAI in resource-limited neonatal units.

Performance Comparison of Infection Prediction Scores in a South African Neonatal Unit: A Retrospective Case-Control Study.

Background and objectives: Infection prediction scores are useful ancillary tests in determining the likelihood of neonatal hospital-acquired infection (HAI), particularly in very low birth weight (VLBW; <1,500 g) infants who are most vulnerable to HAI and have high antibiotic utilization rates. None of the existing infection prediction scores were developed for or evaluated in South African VLBW neonates. Methods: We identified existing infection prediction scores through literature searches and assessed each score for suitability and feasibility of use in resource-limited settings. Performance of suitable scores were compared using a retrospective dataset of VLBW infants (2016-2017) from a tertiary hospital neonatal unit in Cape Town, South Africa. Sensitivity, specificity, predictive values, and likelihood ratios were calculated for each score. Results: Eleven infection prediction scores were identified, but only five were suitable for use in resource-limited settings (NOSEP1, Singh, Rosenberg, and Bekhof scores). The five selected scores were evaluated using data from 841 episodes of HAI in 659 VLBW infants. The sensitivity for the scores ranged between 3% (NOSEP1 ≥14; proven and presumed infection), to a maximum of 74% (Singh score ≥1; proven infection). The specificity of these scores ranged from 31% (Singh score ≥1; proven and presumed infection) to 100% (NOSEP1 ≥11 and ≥14, NOSEP-NEW-1 ≥11; proven and presumed infection). Conclusion: Existing infection prediction scores did not achieve comparable predictive performance in South African VLBW infants and should therefore only be used as an adjunct to clinical judgment in antimicrobial decision making. Future studies should develop infection prediction scores that have high diagnostic accuracy and are feasible to implement in resource-limited neonatal units.