Room for Improvement: Results of a Baseline Evaluation of Environmental Cleaning in a Resource-Limited Neonatal Unit

Abstract

Background: Contamination of the near-patient hospital environment including work surfaces and equipment, contributes to skin colonization and subsequent invasive bacterial infections in hospitalized neonates. In resource-limited settings, cleaning of the neonatal ward environment and equipment is seldom standardized and infrequently audited. Methods: A baseline multimodal assessment of surface and equipment cleaning was performed in a 30-bed high-care neonatal ward in Cape Town, South Africa, October 7–9, 2019. Adequacy of routine cleaning was evaluated using ATP bioluminescence assays, fluorescent ultraviolet (UV) markers, and quantitative bacterial surface cultures. For flat surfaces (eg, tables, incubators, trolleys), a 10×10-cm template was used to standardize the swab inoculum; for small equipment and devices with complex surfaces (eg, humidifiers, suction apparatus, stethoscopes), a standard swabbing protocol was developed for each item. Swabs in liquid transport medium were processed in the laboratory by vortexing for 30 seconds, plating onto blood and MacConkey agars, and incubating at 37°C for 48 hours. Manual counting of bacterial colony forming units was performed, followed by conventional biochemical testing and/or VITEK automated identification. Results: Of 100 swabs (58 from surfaces and 42 from equipment), 11 yielded growth of known neonatal pathogens (Enterobacteriaceae, A. baumannii, P. aeruginosa, S. aureus, S. agalactiae, and enterococci), 36 isolated potential neonatal pathogens (mostly coagulase-negative staphylococci). In addition, 4 grew environmental organisms and 49 showed no growth. The highest aerobic colony counts (ACCs) were obtained from swabs of suction tubing, milk kitchen surfaces, humidifiers, and sinks; the median ACC from swabs with any bacterial growth (n = 51) was 3 (IQR, 1–22). Only 40% of the 100 surface and equipment swabs had ATP values <200 relative light units (RLU) threshold for cleanliness. Median ATP values were 301 (IQ range, 179–732) RLUs for surface swabs versus 230 (IQ range, 78–699) RLUs for equipment swabs (P = .233). Of the 100 fluorescent UV markers placed on near-patient surfaces and high-touch equipment, only 23% had been removed after 2 staff shift changes (24 hours later). Surfaces had a higher proportion of UV marker removal than equipment (19 of 58 [32.8%] vs 4 of 42 [9.5%]; P = .008). Conclusions: Environmental cleaning of this neonatal ward was suboptimal, especially for equipment. Improvement of environmental cleaning practices is an important intervention for neonatal infection prevention in resource-limited settings. Future studies should evaluate the impact of staff training, environmental cleaning tools and repeated audit with feedback, on the adequacy of cleaning in neonatal wards.

Funding: Funding: for the laboratory work was provided by The Society for Healthcare Epidemiology of America (SHEA) International Ambassador Alumni Research Award and a South African Medical Research Council Self-initiated Research (SIR) Grant to Angela Dramowski, who is supported by a NIH Fogarty Emerging Global Leader Award K43 TW010682.

Disclosures: None