Johannesburg - Neonatal wards in Gauteng are under severe pressure and unless effective action is taken to provide more beds and staff, there will continue to be a high number of avoidable baby deaths.
Jack Bloom, the DA’s Gauteng Shadow Health MEC, said he remained concerned that effective action was not being taken against klebsiella-related deaths at other Gauteng hospitals.
Last November and December, 10 babies died following an outbreak of antibiotic resistant bacteria CRE (Carbapenem-resistant Enterobacteriaceae) at Tembisa Hospital.
Health officials said the 44-bed neonatal unit often admitted close to 90 patients while understaffing and poor hygiene control were also blamed for the deadly outbreak.
Six babies died of antibiotic-resistant klebsiella at the Thelle Mogoerane Regional Hospital in 2018, but “it seems that lessons that should have been learnt there were not applied elsewhere”, said Bloom.
Nine babies died of necrotising enterocolitis at the Rahima Moosa Hospital in 2018 “but it is still unclear what was the cause of this infection”, he said.
Bloom said he didn’t know “why there hasn’t been more outrage” about the high rate of baby deaths at the George Mukhari Hospital.
On November 27 Health MEC Bandile Masuku revealed in a reply to questions by Bloom that 140 babies died of klebsiella at George Mukhari Hospital in 2018 compared to 48 klebsiella deaths in 2013.
“This is a threefold increase,” said Bloom.
Masuku blamed prematurity as the main reason as premature babies were more prone to infections and their management was more complex.
But Bloom was not satisfied. “The causes of the sharp rise in baby deaths should have received urgent attention and action taken particularly in the case of klebsiella, which is linked to poor infection controls.”
Klebsiella pneumoniae was an extremely common cause of neonatal infections with a mortality rate between 18% and 68%, said Professor Theunis Avenant, paediatric infectious diseases specialist at the University of Pretoria.
“It’s the most reported causative organism in neonatal outbreaks in our country, but also from high-income countries. It must be remembered that not all outbreaks are reported in medical literature nor the popular press, and that the frequency of these outbreaks are much more common than we think.”
Information for specific private sector neonatal units was not freely available. “Outbreaks due to klebsiella may be extremely difficult to control and in many cases closure of a unit is necessary to achieve this. Some reported outbreaks have lasted for several months.
“A further complicating factor is that the organisms currently present in our units are in many cases multidrug resistant. This limits the number of antibiotics available to treat the infections.”
Babies admitted in the neonatal units were extremely small and vulnerable. “With the progress made during the last few years, the number of viable very premature babies have increased tremendously.
“(Their) immune systems have not fully developed yet and they are highly susceptible to infection. Their skins and gastrointestinal systems offer very little protection to infection because of its immaturity.”
These babies had frequent infectious disease exposure through contact with health care staff, parents, equipment and the hospital environment.
“In an overcrowded environment, the spread of infections is increased. In many cases, one staff member needs to look after many babies, potentially spreading infection through shared equipment or via handling the infants.
“Babies lying close to each other makes proper cleaning and ward hygiene very difficult. A large number of nurses, students, doctors and parents in units also contribute to the spread of infections.
“With the current overwhelming number of very premature babies admitted to our large neonatal units, it would be very difficult to prevent further outbreaks.”
Proper infection control practices such as hand hygiene were vital as first steps to reduce these outbreaks.
“Solutions need, however, be sought in creating much more space and care for these vulnerable infants. In some cases relatively easy solutions are available such as transferring stable premature babies out to kangaroo mother care units as to free up space for new admissions. In many cases this is already being done.”
The “absolute insistence” on exclusive breastfeeding of babies decreased infections. “Where own mother’s milk is not available, donor breastmilk should be used.”
Antibiotic stewardship was crucial. “Taking extreme care in how antibiotics are used in hospitals may limit the number of drug-resistant infections and make outbreaks less likely and easier to manage.”
Dealing with neonatal unit outbreaks was extremely complex, he said. “The pressure on our healthcare facilities is increasing daily and innovative solutions will have to be implemented to prevent further unnecessary neonatal deaths.”
Guy Richards, a critical care professor at Wits University, said antibiotic resistant klebsiella bacteria was increasingly common all over the world.
“Some countries are worse than others. Greece and Italy are particularly bad and we are not very good either. It’s present in all our hospitals in SA - state and private.”
While overcrowding and staff shortages played a role in these outbreaks, the most common culprit was poor infection control.
“Infection prevention and control does become more difficult in crowded environments ...
“It’s a matter of education. It’s about surveillance to determine when you have those organisms in your unit and then declaring you have an outbreak. Sometimes it’s even closing a unit, disinfecting and starting again. It’s about re-educating staff with regards to handwashing, getting proper sterilisation of bottles or feeding tubes and all the rest of it. It’s a process.”
Renay van Wyk, a lecturer in the department of environmental health at the University of Johannesburg, said the main factors were “administrative, environmental, patient vulnerability and pathogen load”.
“To prevent klebsiella infections between patients, healthcare personnel must follow specific infection control precautions.
“These may include strict adherence to hand hygiene and wearing gowns and gloves when they enter rooms where patients with klebseilla-related illnesses are housed. Healthcare facilities must also follow strict cleaning procedure to prevent the spread.”
Infection control was vital, she said. “Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings.
“The environment in a healthcare facility can also be a source of infection, with micro-organisms spread through air, water or surfaces.
“Patients in health facilities are more vulnerable than the general population due to underlying illness, greater fragility (such as for premature babies, the elderly and immuno-compromised patients) and exposure to invasive medical procedures.”
Prioritising environmental and personal hygiene and controlling the spread of infection through isolation was crucial, she said.
Action plan to curb neonatal deaths
The Gauteng Department of Health stated that following the deadly outbreak at Tembisa Hospital, a stakeholders’ meeting was convened to discuss overcrowding in the neonatal ward, staff shortages, infrastructure, inappropriate equipment storage and difficulties in isolating infected infants.
The following measures were taken to prevent further infections in the neonatal unit:
A quality improvement plan has been created and implemented with immediate effect.
Additional professional nurses have been deployed to help at the neonatal unit.
Approval to divert new admissions to the Kalafong Hospital and Steve Biko Academic Hospital has been granted in principle.
An external infection prevention and control audit is to be conducted on a date to be provided by the provincial quality assurance directorate.
The national health laboratory services infection control service is to provide technical support assistance to audit Gauteng Department of Health neonatal units.
The national Institute for Communicable Diseases is to allocate resources to develop a dashboard to monitor laboratory confirmed neonatal infections at facility level.