Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review

Abstract

Background: Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements).

Methods: Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively.

Findings: 3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control.

Interpretation: The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap.

Funding: This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).

Keywords: 3 + I Framework, (1) Primary Prevention (2) Detection (3) Case Management + Implementation; ERIC, Expert Recommendations for Implementing Change; HCAI, Health Care-Associated Infections; LMIC, Low- and Middle-Income Countries; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews; care bundles; health care-associated infections; infection prevention and control; low- and middle-income countries; neonatal units; scoping review.

Figure 1

PRISMA flow diagram of study selection. Abbreviations: n = number of records; HCAI = health care-associated infections.

Figure 2

Word cloud with the terminology used to name the care bundles. The world cloud visually represents the names used to describe care bundles depicted in different sizes based on the frequency of their use in the 44 included studies: the higher the frequency of a name, the bigger its appearance in the cloud. Frequencies of the names: Measures = 13 (30%); Bundle = 9 (21%); Quality Improvement = 5 (11%); Programme = 4 (9%); Package = 3 (7%); Multifaceted Intervention = 2 (5%); Precautions = 1 (2%); Strategies = 1 (2%); Practices = 1 (2%); Options = 1 (2%); Multidimensional Approach = 1 (2%); Response = 1 (2%); Intervention = 1 (2%); Interventions = 1 (2%).

Figure 3

Frequency of the groups of bundle elements (3a) and frequency of the types of infection prevention and care bundles (3b). Colour legend: Figure 3a: Salmon = primary prevention; Violet = detection; Burgundy = case management; Blue = implementation. Figure 3b: Red = Type 1 – primary prevention; Grey = Type 2 – detection; Green = Type 3 – case management; Dark blue = Type 4 – implementation; Yellow = Type 5 – composite. After the creation of the four groups of the 3 + I Classification Framework using the bundle elements (i.e., prevention, detection, case management and implementation, represented in Figure 3a with their frequencies), whole bundles were also categorised into groups, according to the types of elements each one was made of (e.g., if one bundle contained four primary prevention elements, the whole bundle was categorised in primary prevention -Type 1- bundles. If one bundle contained a mixture of prevention, detection, case management, or implementation elements then the whole bundle was categorised into the composite -Type 5- group bundle). These are represented in Figure 3b.