Simplified antibiotic regimens for treatment of clinical severe infection in the outpatient setting when referral is not possible for young infants in Pakistan (Simplified Antibiotic Therapy Trial [SATT]): a randomised, open-label, equivalence trial

What Can We Do About Antimicrobial Resistance?

Antimicrobial resistance is of global concern, and preserving the ability of many antimicrobials to kill disease-causing bacteria is likely to become more challenging over time. However, we are speeding up this process dramatically by using antibiotics too much or in the wrong way. Respecting simple key principles of optimal antibiotic prescribing together with commitment to further research in this area from the pediatric community is essential to extend the lifeline of antibiotics for the most vulnerable patients without limiting access to antibiotics for those children who require treatment.

Community-based antibiotic delivery for possible serious bacterial infections in neonates in low- and middle-income countries

BACKGROUND

The recommended management for neonates with a possible serious bacterial infection (PSBI) is hospitalisation and treatment with intravenous antibiotics, such as ampicillin plus gentamicin. However, hospitalisation is often not feasible for neonates in low- and middle-income countries (LMICs). Therefore, alternative options for the management of neonatal PSBI in LMICs needs to be evaluated.

OBJECTIVES

To assess the effects of community-based antibiotics for neonatal PSBI in LMICs on neonatal mortality and to assess whether the effects of community-based antibiotics for neonatal PSBI differ according to the antibiotic regimen administered.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 3), MEDLINE via PubMed (1966 to 16 April 2018), Embase (1980 to 16 April 2018), and CINAHL (1982 to 16 April 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials.

SELECTION CRITERIA

We included randomised, quasi-randomised and cluster-randomised trials. For the first comparison, we included trials that compared antibiotics which were initiated and completed in the community to the standard hospital referral for neonatal PSBI in LMICs. For the second comparison, we included trials that compared simplified antibiotic regimens which relied more on oral antibiotics than intravenous antibiotics to the standard regimen of seven to 10 days of injectable penicillin/ampicillin with an injectable aminoglycoside delivered in the community to treat neonatal PSBI.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Group. The primary outcomes were all-cause neonatal mortality and sepsis-specific neonatal mortality. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

For the first comparison, five studies met the inclusion criteria. Community-based antibiotic delivery for neonatal PSBI reduced neonatal mortality when compared to hospital referral only (typical risk ratio (RR) 0.82, 95% confidence interval (CI) 0.68 to 0.99; 5 studies, n = 125,134; low-quality evidence). There was, however, a high level of statistical heterogeneity (I² = 87%) likely, due to the heterogenous nature of the study settings as well as the fact that four of the studies provided various co-interventions in conjunction with community-based antibiotics. Community-based antibiotic delivery for neonatal PSBI showed a possible effect on reducing sepsis-specific neonatal mortality (typical RR 0.78, 95% CI 0.60 to 1.00; 2 studies, n = 40,233; low-quality evidence).For the second comparison, five studies met the inclusion criteria. Using a simplified antibiotic approach resulted in similar rates of neonatal mortality when compared to the standard regimen of seven days of injectable procaine benzylpenicillin and injectable procaine benzylpenicillin and injectable gentamicin delivered in community-settings for neonatal PSBI (typical RR 0.81, 95% CI 0.44 to 1.50; 3 studies, n = 3476; moderate-quality evidence). In subgroup analysis, the simplified antibiotic regimen of seven days of oral amoxicillin and injectable gentamicin showed no difference in neonatal mortality (typical RR 0.84, 95% CI 0.47 to 1.51; 3 studies, n = 2001; moderate-quality evidence). Two days of injectable benzylpenicillin and injectable gentamicin followed by five days of oral amoxicillin showed no difference in neonatal mortality (typical RR 0.88, 95% CI 0.29 to 2.65; 3 studies, n = 2036; low-quality evidence). Two days of injectable gentamicin and oral amoxicillin followed by five days of oral amoxicillin showed no difference in neonatal mortality (RR 0.67, 95% CI 0.24 to 1.85; 1 study, n = 893; moderate-quality evidence). For fast breathing alone, seven days of oral amoxicillin resulted in no difference in neonatal mortality (RR 0.99, 95% CI 0.20 to 4.91; 1 study, n = 1406; low-quality evidence). None of the studies in the second comparison reported the effect of a simplified antibiotic regimen on sepsis-specific neonatal mortality.

AUTHORS' CONCLUSIONS

Low-quality data demonstrated that community-based antibiotics reduced neonatal mortality when compared to the standard hospital referral for neonatal PSBI in resource-limited settings. The use of co-interventions, however, prevent disentanglement of the contribution from community-based antibiotics. Moderate-quality evidence showed that simplified, community-based treatment of PSBI using regimens which rely on the combination of oral and injectable antibiotics did not result in increased neonatal mortality when compared to the standard treatment of using only injectable antibiotics. Overall, the evidence suggests that simplified, community-based antibiotics may be efficacious to treat neonatal PSBI when hospitalisation is not feasible. However, implementation research is recommended to study the effectiveness and scale-up of simplified, community-based antibiotics in resource-limited settings.

Development of Rectodispersible Tablets and Granulate Capsules for the Treatment of Serious Neonatal Sepsis in Developing Countries

Current pediatric antibiotic therapies often use oral and parenteral routes of administration. Neither are suitable for treating very sick neonates who cannot take oral medication and may be several hours away from hospital in developing countries. Here, we report on the development of rectal forms of ceftriaxone, a third-generation cephalosporin. Rectodispersible tablets and capsules were developed and successfully passed 6-month accelerated stability tests. Rabbit bioavailability showed plasma concentrations above the minimal inhibitory concentrations for 3 formulations of rectodispersible tablets and 2 formulations of hard capsules. Clinical batches are currently being prepared for human evaluation with the prospect of offering therapeutic alternatives for treating critically ill neonates. This proof of concept for efficient rectal delivery of antibiotics could help the development of other rectal antibiotic treatments and increase options for noninvasive drug development for pediatric patients.

Simplified Treatment of Possible Severe Bacterial Infection in Young Infants When Referral Is Not Feasible. What Happened There? What Are the Implications Here?

Severe bacterial infections remain one of the 3 leading causes of newborn death worldwide. Most such deaths could be prevented with timely and appropriate antibiotic treatment. However, in low-income countries, there are many such cases for which, practically speaking, it is not currently feasible to offer gold-standard, inpatient treatment with 7 days of parenteral antibiotics. Recent trial results, however, provide evidence for efficacy using simpler outpatient antibiotic regimens, equivalent to treatment with 7 days of procaine penicillin and gentamicin, given on an outpatient basis. Based on these findings, the World Health Organization has recently released guidelines endorsing such an approach for cases for which referral for inpatient treatment is not feasible. This brief report looks beyond the measured effect sizes in the published trials to other details on how they were implemented and what outcomes were observed for different groups of study participants. The report considers, further, the circumstances in country settings where such a strategy may be appropriate and offers issues for consideration by policy makers.

Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study

BACKGROUND

More than 500 000 neonatal deaths per year result from possible serious bacterial infections (pSBIs), but the causes are largely unknown. We investigated the incidence of community-acquired infections caused by specific organisms among neonates in south Asia.

METHODS

From 2011 to 2014, we identified babies through population-based pregnancy surveillance at five sites in Bangladesh, India, and Pakistan. Babies were visited at home by community health workers up to ten times from age 0 to 59 days. Illness meeting the WHO definition of pSBI and randomly selected healthy babies were referred to study physicians. The primary objective was to estimate proportions of specific infectious causes by blood culture and Custom TaqMan Array Cards molecular assay (Thermo Fisher, Bartlesville, OK, USA) of blood and respiratory samples.

FINDINGS

6022 pSBI episodes were identified among 63 114 babies (95·4 per 1000 livebirths). Causes were attributed in 28% of episodes (16% bacterial and 12% viral). Mean incidence of bacterial infections was 13·2 (95% credible interval [CrI] 11·2-15·6) per 1000 livebirths and of viral infections was 10·1 (9·4-11·6) per 1000 livebirths. The leading pathogen was respiratory syncytial virus (5·4, 95% CrI 4·8-6·3 episodes per 1000 livebirths), followed by Ureaplasma spp (2·4, 1·6-3·2 episodes per 1000 livebirths). Among babies who died, causes were attributed to 46% of pSBI episodes, among which 92% were bacterial. 85 (83%) of 102 blood culture isolates were susceptible to penicillin, ampicillin, gentamicin, or a combination of these drugs.

INTERPRETATION

Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed. Given the burden of disease, prevention of respiratory syncytial virus would have a notable effect on the overall health system and achievement of Sustainable Development Goal.

FUNDING

Bill & Melinda Gates Foundation.

Reviewing the WHO guidelines for antibiotic use for sepsis in neonates and children

Background Guidelines from 2005 for treating suspected sepsis in low- and middle-income countries (LMIC) recommended hospitalisation and prophylactic intramuscular (IM) or intravenous (IV) ampicillin and gentamicin. In 2015, recommendations when referral to hospital is not possible suggest the administration of IM gentamicin and oral amoxicillin. In an era of increasing antimicrobial resistance, an updated review of the appropriate empirical therapy for treating sepsis (taking into account susceptibility patterns, cost and risk of adverse events) in neonates and children is necessary. Methods Systematic literature review and international guidelines were used to identify published evidence regarding the treatment of (suspected) sepsis. Results Five adequately designed and powered studies comparing antibiotic treatments in a low-risk community in neonates and young infants in LMIC were identified. These addressed potential simplifications of the current WHO treatment of reference, for infants for whom admission to inpatient care was not possible. Research is lacking regarding the treatment of suspected sepsis in neonates and children with hospital-acquired sepsis, despite rising antimicrobial resistance rates worldwide. Conclusions Current WHO guidelines supporting the use of gentamicin and penicillin for hospital-based patients or gentamicin (IM) and amoxicillin (oral) when referral to a hospital is not possible are in accordance with currently available evidence and other international guidelines, and there is no strong evidence to change this. The benefit of a cephalosporin alone or in combination as a second-line therapy in regions with known high rates of non-susceptibility is not well established. Further research into hospital-acquired sepsis in neonates and children is required.

Profile: Health and Demographic Surveillance System in peri-urban areas of Karachi, Pakistan

The Aga Khan University’s Health and Demographic Surveillance System (HDSS) in peri urban areas of Karachi was set up in the year 2003 in four low socioeconomic communities and covers an area of 17.6 square kilometres. Its main purpose has been to provide a platform for research projects with the focus on maternal and child health improvement, as well as educational opportunities for trainees. The total population currently under surveillance is 249,128, for which a record of births, deaths, pregnancies and migration events is maintained by two monthly household visits. Verbal autopsies for stillbirths, deaths of children under the age of five years and adult female deaths are conducted. For over a decade, the HDSS has been a platform for a variety of studies  including, calculation of the incidence of various infectious diseases like typhoid bacteremia, pneumonia and diarrhea, evaluation of effectiveness of various treatment regimens for neonatal sepsis, assessment of the acceptance of hospitalized care, determination of the etiology of moderate to severe diarrhea, assessment of burden and etiology of neonatal sepsis and a multi-centre cohort study measuring the burden of stillbirths, neonatal and maternal deaths. We have also established a bio-repository of a well-defined maternal and newborn cohort. Through a well-established HDSS rooted in maternal and child health we aim to provide concrete evidence base to guide policy makers to make informed decisions at local, national and international levels.

Global Emergency Medicine: A Review of the Literature From 2016

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.

METHODS

This year 13,890 articles written in four languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles.

RESULTS

A total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as EM development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score of 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's kappa of 0.441.

CONCLUSIONS

In 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.

Respiratory distress in term neonates in low-resource settings

Most neonatal deaths worldwide occur in low- and middle-income countries (LMICs). Respiratory distress is an important cause of neonatal morbidity and mortality. The epidemiology of respiratory distress among term neonates who constitute the vast majority of births is under reported. The scarcely available data from LMICs suggest an incidence of 1.2% to 7.2% among term live births and greater morbidity compared to that in high-income countries. Pneumonia and meconium aspiration syndrome are the predominant causes among outborn neonates, but next only to transient tachypnea among inborn neonates. Community management of neonatal sepsis/pneumonia using simplified antibiotic regimens when referral is not feasible, implementation of non-invasive ventilation, and innovative low-cost technologies to deliver respiratory therapy are important advances that have taken place in these settings. There is an urgent need to generate data on respiratory morbidities among term neonates so that the limited resources in these settings can be allocated judiciously.

Reducing Sepsis Deaths in Newborns Through Home Visitation and Active Case Detection: Is it Realistic?

Severe bacterial infection remains one of the major causes of newborn deaths in low-income countries. A key challenge for reducing this burden is making definitive treatment more easily available. Active case detection through early postnatal home visits can work under trial conditions but is difficult to implement at scale under routine conditions. In many settings, making treatment available at peripheral-level primary health care facilities may be more feasible.