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.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.

The WASH assessment was carried out at ward level and at facility level in a sample of 16 public hospitals in Kenya. The selection of these hospitals was purposeful and based on links developed from ongoing work to improve clinical information as part of a collaboration between the Kenya Medical Research Institute -Wellcome Trust Research Programme and the Ministry of Health. The data collection tool was the Water Sanitation and Hygiene Facility Improvement tool (WASH FIT) developed by the World Health Organization. The assessment included inpatient wards in the paediatric, medical, surgical and neonatal departments but excluded units not present in all hospitals (i.e. critical care, Ear Nose and Throat (ENT), eye, renal and psychiatric units). In each eligible ward, ward assessment forms were completed. Once these ward level inspections were complete, there was an inspection of the entire facility, including the laundry, kitchen, outpatient areas and the external environment. At facility level, there were a total of 65 WASH indicators to be assessed spread across 4 domains. Each indicator was assessed by direct observation and the score determined by team consensus on a three-point scale (meets = 2, partially meets = 1, or does not meet = 0 the required standard). At ward level, 34 of the 65 indicators were assessed and scored with the same three point system. Through a process of stakeholder engagement, each of the 65 indicators was assigned to one of three persons/groups who would be responsible to improve these indicators. These are the county government, Hospital Management or the hospital infection prevention and control committee. Antibiotics Stewardship Patient-Level Data collection At the patient level, data were collected on the patients' age, sex, weight, hospital department,  date of admission or of surgery in the case of surgical patients, date of survey and diagnoses. For the diagnosis, there were a total of 46 possible options provided, 45 of these were categorised by the anatomical system involved. Data are provided on the antimicrobial type, posology, start and stop dates among others. Microbiology, antibiotic susceptibility and biomarker (C-reactive protein; procalcitonin or other) test results used to inform the diagnosis and treatment choice, were also collected for each patient where available.