Health care associated infections are infections that people acquire during their stay in hospital. Children - and babies in particular - are most at risk for hospital-acquired pneumonia, bloodstream and urinary tract infections.
Children who are malnourished or living with HIV are more susceptible to these infections partly because their immune systems are compromised. Infections happen when bacteria, viruses or fungi are transmitted during a hospital stay, either through direct contact with contaminated hands, surfaces or equipment, or by breathing in micro-organisms.
These infections are the most frequent complication of health care worldwide. In America and Europe, between 4% and 5% of hospitalised children contract infections during their stay. Data from several South American countries shows that health care associated infections affect up to 6% of children. The problem is also significant in Africa. But there aren't reliable estimates, particularly for children.
To gain a better understanding of the scale of the problem in South Africa we analysed children admitted to the wards and intensive care unit at Tygerberg Children's Hospital. Situated in the Western Cape it's one of South Africa's leading children hospitals. We found that just under a quarter of the children admitted over one year acquired new infections while hospitalised.
The infections collectively resulted in these children spending an extra 2 300 days in hospital and taking an additional 2400 days of antibiotics during the course of their admission. The cost of these largely preventable infections exceeded R60 million for the year.
The consequences for both patients and the health care system are significant. Patients suffer, endure prolonged hospitalisation and in some cases, die. For hospitals, it's an additional burden on overcrowded and shortstaffed wards. It also means that less beds are available for new patients, particularly in the intensive care unit.
Our study shows that there's an urgent need for more staff and resources to run health care associated infection surveillance and prevention programmes for hospitalised children and newborn babies.
But considering the human resource challenges and the high case loads at most South African hospitals, our study shows that there is an accurate, feasible and efficient way of doing this surveillance despite the circumstances.
Measuring and monitoring
In wealthy countries infection incidents and rates are meticulously documented and reported. This means that outbreaks are detected early and hospitalised children protected.
But very few hospitals in developing countries have this capability. In South Africa, all hospitals are expected to comply with the minimum infection prevention standard introduced in 2011.
But in the most recent audit, less than half of private and public health care facilities received acceptable infection prevention standards ratings. This is due to a lack of infection prevention human resources and health care epidemiology expertise.
It's particularly important that hospitals monitor the number of infections that children in neonatal and paediatric wards acquire.
We tried to identify an accurate and feasible way of doing surveillance that would allow hospitals to track these rates in paediatric wards. To do this we looked at how three alternate surveillance methods compared to the gold standard surveillance tool.
The gold standard is the continuous clinical surveillance of patients to identify new infections as they develop. This method is extremely time and labour-intensive. And it relies on complicated definitions designed for use in high-income hospital settings where high rates of laboratory testing occur.
There are three alternative surveillance methods. These include point prevalence surveys, laboratory surveillance and antibiotic prescription surveillance.
With point prevalence surveys, all admitted patients are reviewed on a given day to establish the number of active hospital-acquired infections. But this method only provides a "snapshot" and must be repeated regularly to establish infection trends.
Laboratory surveillance detects hospital-acquired pathogens in the specimens submitted by the treating doctors. This method produces variable results. But it is dependent on how frequently specimens are submitted when patients' deteriorate.
Antibiotic prescription surveillance looks at all drugs prescribed for inpatients to identify those who may have acquired an infection. This is easiest to apply if a hospital or ward reserves particular antibiotics to treat these infections.
We found that by combining the laboratory and antibiotic prescription surveillance methods, it was possible to accurately identify 85% of children who had picked up an infection in hospital.
It only took 15 hours each month compared to the traditional surveillance method of 120 hours a month. It also needed far less expertise to implement.
Understanding what contributed to the infections is linked to monitoring the infections. This is important to eliminate the problems.
Three main health system factors played a role in our study. There was a major shortage of isolation beds. In particular, there was a shortage of isolation beds with the correct ventilation systems to reduce the spread of airborne illnesses such as tuberculosis.
Secondly, health care workers failed to timeously identify infectious patients that required isolation.
And thirdly, we found infections were also potentially spread as a result of challenges with cleaning paediatric isolation rooms. Few hospitals in South Africa have standardised cleaning methods and the adequacy of environmental disinfection is seldom evaluated.
Underfunded and ignored
Hospital-acquired infections remain an under-appreciated and underfunded public health problem in most African countries. This is due to a lack of information of the extent of the problem.
More resources should be allocated to infection prevention programmes to improve the outcomes of hospitalised children and newborns in South Africa.
Angela Dramowski received funding from the Medical Research Council of South Africa's Clinician Researcher Programme and a Discovery Foundation Academic Fellowship. Photo credit: Dalton Dingelstad photography for the Discovery Foundation