Developing and implementing a family-led infection prevention bundle for hospitalized neonates

For many neonatal units in resource-limited settings, family involvement in patient care is both a logistic necessity and a cultural norm. However, incorporating families into hospital infection prevention and control (IPC) activities remains under-implemented and under-studied. We developed a family-led infection prevention (FLIP) bundle for a neonatal unit in Botswana and evaluated its impact on multidrug-resistant organism (MDRO) colonization, bloodstream infection (BSI) incidence, and all-cause mortality.

The FLIP bundle was developed with input from a multidisciplinary group of stakeholders including subject matter experts, staff, and families. The bundle components consisted of staff-led family orientation on (1) hand hygiene, (2) twice-weekly neonatal skin cleansing with 2% aqueous chlorhexidine gluconate, (3) lactation support, and (4) skin-to-skin contact. The bundle was implemented over 18 months (August 2023-January 2025) at a 33-bed neonatal unit in Botswana during which time it was iteratively revised based on process metric performance. MDRO colonization was assessed twice-monthly using perirectal and skin swabs to detect extended-spectrum cephalosporin-resistant and carbapenem-resistant Enterobacterales and Acinetobacter spp. BSI incidence was determined from growth on neonatal blood cultures, excluding contaminants. In-hospital mortality data were extracted from hospital records. Colonization, BSI, and mortality rates were compared before and after pilot and continuation phases using two-proportion z-tests and Chi-square tests.

Implementation of the FLIP bundle was temporally associated with a significant relative reduction in all-cause mortality by 28% across the unit, decreasing from 15.4% (165/1069) pre-FLIP to 11.1% (208/1866) during FLIP (p < 0.001). BSI incidence decreased modestly from 11.3% (121/1069) to 9.7% (181/1866) during FLIP (p = 0.14). MDRO colonization trends showed mixed results, with initial improvements to Acinetobacter spp. colonization but an overall 9.4% increase in skin MDRO colonization observed (p < 0.001) in the implementation period.

Implementation of the FLIP bundle demonstrated the potential of systematically engaging families in neonatal IPC programs, with a notable improvement in infant survival observed. The lack of clear improvement in BSI incidence and MDRO colonization prevalence may reflect incomplete adoption or poor impact of the bundle and highlights that FLIP should be used in conjunction with robust healthcare worker-led IPC measures.