Water Sanitation and Hygiene, and Antibiotics Stewardship in Kenyan Hospitals, 2017-2019

This work was carried in Kenyan public hospital the main aim was to assess hospitals Infection Prevention and Control (IPC) and Antibiotic Stewardship(ABS) capacity as part of tracking and tackling efforts to limit antimicrobial resistance in Kenya. We redesigned an existing WASH facility improvement tool to collect data across 16 county hospitals with a total of 116 wards. There were 65 indicators in 4 domains used for this assessment that is 14 indicators for water, Sanitation 22 indicators, hygiene 18 indicators and 11 for organisational management domain. 32 of these indicators were also assessed at ward level. Addition modifications on the tool allowed us to contrast performance by assessing infrastructural, material and human resources to support WASH services, We the WASH facility tool to to allocate responsibilities at a more health systems level allowing for different levels of hospital leadership to be accountable for the implementation and subsequent improvement of WASH in hospitals.
Antibiotic Stewardship -
We examined prescription patterns and explored to what extent guidelines are available and how they might influence treatment appropriateness in Kenya. Data on antimicrobial usage were collected from hospitalised patients using a point prevalence survey across 14 Kenyan public hospitals spanning antimicrobials prescribed, laboratory investigations, clinical diagnoses and physical availability of treatment guidelines.<p>Global under-5 deaths have halved in the last 20 years(1). However, reduction in the neonatal mortality rate has lagged greatly behind other advances, and now contributes over 40% of all child mortality in many countries (1). Yet, prior research in low and middle income countries (LMICs) suggests sick newborns often do not receive the interventions they need to ensure their disability free survival.

Infections are estimated to cause 40% of all neonatal deaths in LMICs (2), where the burden health care-associated infections (HCAIs) is also up to 20 times higher than in industrialised countries (3) and where antibiotic resistant HCAIs are rapidly increasing (4) due to increases in antibiotic use, rising rates of hospitalisation, and high prevalence HCAIs (5) not matched with increases in hospital resources and measures to prevent these. Resistant infections often lead to longer hospitalizations (6), thus increasing opportunity for transmission to other inpatients in care, and subsequent transmission into the community following hospital discharge. The potential societal impact of bacterial antibiotic resistance (BAR) infections in sick newborns in LMICs, is reflected in the 58,000 deaths attributable to antibiotic resistant neonatal sepsis in India alone (5) compared to the 23,000 deaths each year across all population age groups in the United States (7).

The much-needed attention to improve newborn health, has triggered multiple stakeholders to propose the 'Every Newborn: an action plan to end preventable deaths' (8), which seeks to improve the quality of care to ultimately end preventable newborn deaths. HCAIs, reflect breakdown in infection prevention and control (IPC) measures, which combined with injudicious use of antibiotics contribute to emergence of resistant HCAIs in neonatal units (9), and are the most frequent preventable adverse event in healthcare delivery worldwide (3). Intervention bundles comprising behavioural, environmental and antibiotic stewardship components (10), could prevent many HCAIs (11-13), and improved provision of high-quality, basic care in resource-limited hospitals could deliver up to a 71% reduction in neonatal mortality (14,15).

Initiatives to improve quality and safety in healthcare, however, too often result in limited changes for the better and are often hard to replicate in new contexts (16). In this pump-priming grant, we seek to address key formative stages of the MRC framework for complex interventions (17,18) by generating contextual knowledge of the health system traits and behaviours that need to be understood prior to formulation and implementation of behavioural/integrated interventions to attain best IPC and antibiotic stewardship (IPC-ABS) practice required to reduce HCAIs and BAR in resource-limited healthcare facilities delivering care to sick newborns. In our approach, we draw from elements of the theory of change (ToC) (19,20), by first identifying the desired long-term goals and then working back from these to identify all the conditions that must be in place for the goals to occur. This proposed pump-priming grant includes research that aims to:
a. Facilitate the development of appropriate, evidence based interventions based on a critical analysis of the policy, organisational and practice environments and current management, team and individual behaviours relevant to IPC-ABS, aimed at limiting BAR in high-risk populations in Kenyan facilities;
b. Help identify context-appropriate clinical and performance indicators for use in monitoring and evaluation of IPC-ABS interventions;
c. Highlight challenges in the uptake of policy into effective IPC-ABS practice;
d. Increase capability and motivation to limit BAR and improve safety in hospitals;
e. Initiate a process of building research capacity around IPC-ABS in Kenya.
We expect proposed interventions to be generalizable to other inpatient settings in East African hospitals that share similar challenges.</p>

本研究在肯尼亚公立医院开展，核心目标为评估医院感染预防与控制（Infection Prevention and Control, IPC）及抗生素管理（Antibiotic Stewardship, ABS）能力，作为肯尼亚追踪并遏制抗菌药物耐药性防控工作的组成部分。我们对现有供水、卫生与个人卫生（Water, Sanitation and Hygiene, WASH）设施改善工具进行重新设计，用于覆盖肯尼亚16所县级医院共116个病房的数据采集。本次评估共设置4大类65项指标：其中水相关指标14项、卫生设施相关指标22项、个人卫生相关指标18项、组织管理相关指标11项，其中32项指标同时在病房层面开展评估。我们对该工具进行了额外优化，通过评估支撑WASH服务的基础设施、物资与人力资源，实现不同机构间的绩效对比；同时通过该WASH工具明确更细化的卫生系统层级职责，让不同层级的医院领导层对医院WASH工作的落实与后续改进承担责任。

抗生素管理（ABS）
我们分析了肯尼亚的抗菌药物处方模式，并探究当地抗菌药物指南的可及性及其对治疗合理性的影响程度。我们通过时点患病率调查（point prevalence survey），从14所肯尼亚公立医院的住院患者中收集数据，内容涵盖抗菌药物处方情况、实验室检查结果、临床诊断以及治疗指南的实体可获取情况。

过去20年，全球5岁以下儿童死亡率已下降一半[1]。然而新生儿死亡率的降幅远落后于其他领域，目前在诸多国家中，新生儿死亡占儿童总死亡的比例超过40%[1]。既往针对中低收入国家（Low and Middle Income Countries, LMICs）的研究显示，患病新生儿往往无法获得保障其无残疾生存所需的干预措施。

据估算，在LMICs中，感染导致40%的新生儿死亡[2]；当地医疗保健相关感染（Healthcare-Associated Infections, HCAIs）的负担也高达工业化国家的20倍[3]，且由于抗菌药物使用增加、住院率上升以及HCAIs高负担未匹配相应的医院资源与防控措施[5]，耐药性HCAIs正快速蔓延[4]。耐药性感染往往会延长住院时间[6]，进而增加住院患者间的传播风险，并在患者出院后进一步扩散至社区。中低收入国家患病新生儿的细菌性抗菌药物耐药（Bacterial Antibiotic Resistance, BAR）感染所带来的潜在社会影响可见一斑：仅在印度，每年就有5.8万例死亡可归因于耐药性新生儿败血症[5]，而美国全年所有年龄组人群因耐药菌感染导致的死亡人数仅为2.3万例[7]。

全球对改善新生儿健康的迫切关注，促使多方利益相关者提出了《每一名新生儿：终结可预防死亡行动计划》[8]，该计划旨在提升医疗服务质量，最终终结可预防的新生儿死亡。HCAIs反映了感染预防与控制措施的失效，加之抗菌药物的不合理使用，共同导致了新生儿病房耐药性HCAIs的出现[9]，同时也是全球医疗服务中最常见的可预防不良事件[3]。包含行为干预、环境改善与抗生素管理的综合干预包[10]可有效预防多数HCAIs[11-13]，而在资源匮乏的医院中，优化基础优质护理的提供可使新生儿死亡率降低多达71%[14,15]。

然而，多数旨在提升医疗质量与安全的举措往往收效甚微，且难以在新的场景中复制[16]。本种子资助项目旨在针对复杂干预措施的英国医学研究理事会（Medical Research Council, MRC）框架的关键形成阶段[17,18]开展工作，通过梳理卫生系统的特征与行为模式，为制定并落实可实现最佳IPC-ABS实践的行为/综合干预措施提供必要的情境化知识，以降低资源匮乏医疗机构中针对患病新生儿的HCAIs与BAR发生率。本研究采用变革理论（Theory of Change, ToC）的相关要素[19,20]，首先明确预期的长期目标，再反向推导实现该目标所需具备的全部条件。本拟申请的种子资助项目包含以下研究目标：
a. 针对与IPC-ABS相关的政策、组织与实践环境，以及当前的管理、团队与个体行为开展批判性分析，据此制定适用于肯尼亚医疗机构高危人群BAR防控的循证干预方案；
b. 确定适配当地情境的临床与绩效指标，用于IPC-ABS干预措施的监测与评估；
c. 梳理政策落地为有效IPC-ABS实践过程中面临的挑战；
d. 提升医疗机构限制BAR传播、提升医疗安全的能力与主观能动性；
e. 启动肯尼亚IPC-ABS领域的研究能力建设工作。

我们预期，本次提出的干预方案可推广至面临类似挑战的东非医院其他住院诊疗场景。