Prematurity Clinical Trial
Official title:
Impact of 1% Chlorhexidine Gluconate and/or Emollient on Neonatal Bacterial Colonization Dynamics
This study will evaluate the effect of skin antisepsis and/or emollient therapy on bacterial colonization dynamics in very low birth weight, hospitalized infants. Bacterial swabs from 5 body sites will be collected at baseline, day 3, day 8 and day 13 following study arm assignment. Study outcomes include changes in bacterial colony counts, burden of gram-negative and gram-positive pathogens and overall skin score.
Despite substantial global decline in childhood mortality rates, equivalent progress in
neonatal mortality reduction has not been achieved. Severe bacterial infection affects
approximately 6.9 million neonates and causes an estimated 750 000 deaths in low-middle
income countries (LMIC) annually. The neonatal period extends from birth to 28 days of life,
although neonatal hospitalization episodes (and therefore infection risk) are often
substantially prolonged in preterm infants. In South Africa, infections account for 13.8% of
neonatal mortality (following prematurity and intrapartum hypoxia). The South African
Perinatal Problem Identification Programme (PPIP) cites nosocomial infection as the second
most prevalent avoidable factor in neonatal deaths. Developing new approaches to prevent
infection in hospitalized and preterm newborns in LMIC is key to achieving the Sustainable
Development targets for under-five child survival.
The risk for hospital-onset sepsis in African neonates is disproportionately high and
influenced by many factors including: high rates of prematurity and low birth weight;
increasing in-hospital births, understaffing of maternity and neonatal services and limited
implementation of infection prevention practices. Of infections among hospitalized neonates
in high-income settings, hospital-acquired bloodstream infections (HA-BSI) predominate,
accounting for 57% of infections. Research addressing the problem of hospital-onset neonatal
infection should therefore focus on BSI prevention. A key target for sepsis reduction is
prevention of intrapartum and post-delivery acquisition of bacterial colonization. Although
the pathogenesis of bacterial colonization preceding invasive infection is well-accepted,
there is limited data describing neonatal bacterial colonization dynamics in low-resource
settings. Full characterization of timing, source and route of bacterial acquisition,
flora/pathogen distribution, balance and changes over time is needed to identify all
potential targets for neonatal BSI prevention.
Emollient therapy and reduction of pathogen colonization through skin antisepsis, are
potentially useful targets for reducing risk of hospital-acquired BSI in neonates. Emollients
(oils, creams and ointments) have been applied daily or bi-daily in neonatal research and
routine practice settings, to promote skin integrity in preterm infants <37 weeks' gestation.
The postulated mechanism of effect is improved skin barrier function and promotion of normal
flora colonization, which may prevent pathogen ingress and subsequent invasive infection. A
2016 Cochrane review of emollient therapy for sepsis prevention in preterm infants found no
evidence of reduced mortality or bloodstream infection rates, but the authors concluded that
further studies in low-resource settings were warranted.
Chlorhexidine gluconate (CHG) is a bisbiguanide molecule with broad-spectrum antiseptic
activity producing membrane disruption through increased cell permeability and bacterial
lysis. Efficacy and safety of daily CHG bathing to prevent pediatric bacteremia was
established in a multicenter, cluster-randomized trial for infants >2 months in intensive
care (ICU) using 2% CHG-impregnated cloths. Three high-quality studies of newborn CHG skin or
cord cleansing showed reduced neonatal mortality and omphalitis in community-based neonates.
Safety of topical CHG application for neonates has been established at concentrations ≤1%,
although there is little data available on its use in premature, hospitalized neonates.
CHG skin cleansing and emollient therapy are potentially useful interventions for prevention
of hospital-acquired BSI in neonates from low-resource settings. In addition, these
interventions are suitable for inclusion in a neonatal sepsis prevention care bundle, should
they be found to be effective, safe and feasible. In addition these interventions would be
low-cost, easily scalable and potentially, a maternally-administered intervention. This study
will evaluate the effect of skin antisepsis and/or emollient therapy on bacterial
colonization dynamics in very low birth weight, hospitalized infants. Bacterial swabs from 5
body sites will be collected at baseline, day 3, day 8 and day 13 following study arm
assignment. Study outcomes include changes in bacterial colony counts, burden of
gram-negative and gram-positive pathogens and overall skin score.
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