Reducing nosocomial infection and improving rational antibiotic use in children in Yogyakarta, Indonesia

Abstract

Background: Nosocomial infections cause significant morbidity and mortality in developed and developing countries. Prevention of nosocomial infection is central to providing high quality, safe healthcare. Transmission of microorganisms between patients by healthcare workers and irrational antibiotic use have been identified as preventable etiological factors for nosocomial infections.

Aims: To develop multifaceted infection control and antibiotic stewardship programs and evaluate the effectiveness of these measures on nosocomial infection, antibiotic use, hand hygiene compliance, and mortality.

Methods: An uncontrolled before-and-after study was conducted over 27 months involving around 2600 patients at the Dr Sardjito teaching hospital in Yogyakarta, Indonesia. Patients who were admitted to the PICU and general paediatric wards for more than 48 hours were included. All eligible children were observed daily to see whether they fulfilled criteria for nosocomial infections. The assessment of nosocomial infections was made based on the United States Centers for Disease Control and Prevention (CDC) criteria. Irrational antibiotic use was assessed when patients presented with community-acquired infection or were treated with antibiotics. The standard for empirical antibiotic prescribing was on the recommendations contained in the WHO Pocketbook of Hospital Care for Children. Hand hygiene compliance was observed directly among the healthcare workers using the “Five moments for hand hygiene” observation form. In the pre-intervention period, the proportion of nosocomial infection, irrational antibiotic use and hand hygiene compliance were prospectively collected over 12 months. The multifaceted intervention, including hand hygiene campaigns, antibiotic guidelines based on the WHO Pocketbook of Hospital Care for Children, and other elementary infection control practices, was implemented over 3 months. The means of intervention included lectures, trainings, outreach visit, reminders, audit and performance feedback. In the post-intervention period, identical data collection was prospectively collected over 12 months as outlined in the pre-intervention period. The outcome measures in the pre-and-post intervention periods were compared. The 2 statistics or Fisher Exact Test were used to analyze the various proportions by comparing the pre-intervention and the post-intervention period. A probability value < 0.05 was considered to denote statistical significance. The relative risk (RR) reduction and its confidence interval (CI) were also provided to compare the effect of the interventions between both periods.

Results: This study found a large burden of nosocomial infection in children in Indonesia. The incidence of nosocomial infection was 22.6% (277/1227) and mortality in children with nosocomial infection was 24.5% (68/277). A multifaceted intervention on infection control and antibiotic stewardship was effective in reducing nosocomial infection and improving rational use of antibiotics. In all wards combined, compliance with the interventions lead to a reduction of nosocomial infections, from 277/1227 (22.6%) to 123/1419 (8.6%) [RR (95%CI) 0.38 (0.31-0.46)]. Irrational antibiotic use declined from 336/780 episodes of antibiotic use (43%) to 182/882 episodes of antibiotic use (20.6%) [RR (95%CI) 0.46 (0.40-0.55)]. Hand hygiene compliance increased from 319/1690 observed episodes of patient care (18.9%) to 1125/1789 observed episodes of patient care (62.9%) [RR 3.33 (95%CI) (2.99-3.70)]. Risk of in-hospital mortality decreased from 127/1227 (10.4%) to 114/1419 (8%) [RR (95%CI) 0.78 (0.61-0.97)].

Conclusions: Multifaceted interventions, including hand hygiene campaigns and antibiotic stewardship, are effective in reducing nosocomial infections, improving rational use of antibiotics, improving hand hygiene compliance, and reducing mortality in children in Yogyakarta, Indonesia.