Preventing Bloodstream Infections and Death in Zambian Neonates: Impact of a Low-cost Infection Control Bundle

Clin Infect Dis. 2019 Sep 27;69(8):1360-1367. doi: 10.1093/cid/ciy1114.


Background: Sepsis is a leading cause of neonatal mortality in low-resource settings. As facility-based births become more common, the proportion of neonatal deaths due to hospital-onset sepsis has increased.

Methods: We conducted a prospective cohort study in a neonatal intensive care unit in Zambia where we implemented a multifaceted infection prevention and control (IPC) bundle consisting of IPC training, text message reminders, alcohol hand rub, enhanced environmental cleaning, and weekly bathing of babies ≥1.5 kg with 2% chlorhexidine gluconate. Hospital-associated sepsis, bloodstream infection (BSI), and mortality (>3 days after admission) outcome data were collected for 6 months prior to and 11 months after bundle implementation.

Results: Most enrolled neonates had a birth weight ≥1.5 kg (2131/2669 [79.8%]). Hospital-associated mortality was lower during the intervention than baseline period (18.0% vs 23.6%, respectively). Total mortality was lower in the intervention than prior periods. Half of enrolled neonates (50.4%) had suspected sepsis; 40.8% of cultures were positive. Most positive blood cultures yielded a pathogen (409/549 [74.5%]), predominantly Klebsiella pneumoniae (289/409 [70.1%]). The monthly rate and incidence density rate of suspected sepsis were lower in the intervention period for all birth weight categories, except babies weighing <1.0 kg. The rate of BSI with pathogen was also lower in the intervention than baseline period.

Conclusions: A simple IPC bundle can reduce sepsis and death in neonates hospitalized in high-risk, low-resource settings. Further research is needed to validate these findings in similar settings and to identify optimal implementation strategies for improvement and sustainability.

Clinical trials registration: NCT02386592.

Keywords: Klebsiella pneumoniae; Zambia; chlorhexidine; infection prevention; neonatal sepsis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Infective Agents, Local / administration & dosage*
  • Bacteremia / epidemiology
  • Bacteremia / microbiology
  • Bacteremia / prevention & control*
  • Birth Weight
  • Chlorhexidine / administration & dosage
  • Chlorhexidine / analogs & derivatives*
  • Cohort Studies
  • Hospital Mortality
  • Hospitals
  • Humans
  • Infant
  • Infant Mortality
  • Infant, Newborn
  • Infection Control* / methods
  • Intensive Care Units, Neonatal
  • Perinatal Death / prevention & control
  • Prospective Studies
  • Sepsis / epidemiology
  • Sepsis / microbiology
  • Sepsis / mortality
  • Sepsis / prevention & control*
  • Zambia / epidemiology


  • Anti-Infective Agents, Local
  • chlorhexidine gluconate
  • Chlorhexidine

Associated data