Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis

Machine Learning: A Potential Therapeutic Tool to Facilitate Neonatal Therapeutic Decision Making

Bacterial infection is one of the major causes of neonatal morbidity and mortality worldwide. Finding rapid and reliable methods for early recognition and diagnosis of bacterial infections and early individualization of antibacterial drug administration are essential to eradicate these infections and prevent serious complications. However, this is often difficult to perform due to non-specific clinical presentations, low accuracy of current diagnostic methods, and limited knowledge of neonatal pharmacokinetics. Although neonatal medicine has been relatively late to embrace the benefits of machine learning (ML), there have been some initial applications of ML for the early prediction of neonatal sepsis and individualization of antibiotics. This article provides a brief introduction to ML and discusses the current state of the art in diagnosing and treating neonatal bacterial infections, gaps, potential uses of ML, and future directions to address the limitations of current studies. Neonatal bacterial infections involve a combination of physiologic development, disease expression, and treatment response outcomes. To address this complex relationship, future models could consider appropriate ML algorithms to capture time series features while integrating influences from the host, microbes, and drugs to optimize antimicrobial drug use in neonates. All models require prospective clinical trials to validate their clinical utility before clinical use.

Magnitude of neonatal sepsis and its associated factors among neonates admitted to the neonatal intensive care unit in Hawassa Comprehensive Specialized Hospital, Sidama Regional State, Ethiopia, 2020

BACKGROUND

Neonatal sepsis is one of the most common causes of disease and death among neonates globally. And it made a great contribution to neonatal admission to intensive care units. To mitigate the ongoing neonatal crisis and accomplish the goal of sustainable development through a decrease in neonatal mortality, information from various regions is needed. Despite the considerable burden of neonatal sepsis in our setting, no prior studies were conducted in the study area. So, this study aimed to assess the magnitude and associated factors of neonatal sepsis among neonates admitted to the neonatal intensive care unit at Hawassa University Comprehensive Specialized Hospital, Sidama Regional State, Ethiopia.

METHODS

A hospital-based cross-sectional study was carried out among 287 neonates from March 1, 2020, to April 25, 2020. An interviewer-administered structured questionnaire was used to collect the data. The data were cleaned, coded, and entered into Epi Data 3.1 software and exported to Statistical Package for Social Science (SPSS) software version 23.0 for analysis. Binary logistic regression analyses were performed to identify variables having a significant association with neonatal sepsis. A p-value of ≤ 0.05 was considered statistically significant during multivariable logistic regression.

RESULTS

The study found that the magnitude of neonatal sepsis was 56%. The mean age of neonates was 3.2(SD±2.2) days. Around two-fifths (39%) of neonates were in the gestational age of <37 completed weeks. A quarter of mothers(25.8%) were delivered through cesarean section. During labor, 251 (87.5%) mothers had ≤4 digital vaginal examinations. Moreover, the finding revealed that mothers who delivered by cesarean section [AOR = 2.13, 95% CI (1.090-4.163)]. neonates who had been resuscitated at birth [AOR = 4.5, 95% CI (2.083-9.707)], and neonates who had NG tube inserted [AOR = 4.29, 95% CI (2.302-8.004)] were found to be significantly associated with neonatal sepsis.

CONCLUSIONS

The current study shows that neonatal sepsis was prevalent among more than half of the neonates admitted to the NICU. Therefore, designing strategies to enhance the aseptic techniques of professionals in the provision of care and actively and collaboratively working with cluster health facilities is highly recommended.

Financial and economic costs of healthcare-associated infections in Africa

BACKGROUND

Healthcare-associated infections (HAIs) remain a global health challenge, and have elevated rates in Sub-Saharan Africa. HAIs impact patients and their families by causing illness, prolonged hospital stay, potential disability, excess costs and, sometimes, death. The costs of HAIs are increasing due to spreading antimicrobial resistance. A major risk factor for HAIs is lack of water, sanitation and hygiene (WASH); environmental cleaning and healthcare waste management. In Sub-Saharan Africa, these services are lacking in at least 50% of healthcare facilities.

AIM

To estimate the costs associated with HAIs at national level in 14 countries in Sub-Saharan Africa.

METHODS

Economic methodologies were employed to estimate the medical costs, productivity losses and value of premature death from HAIs, drawing on national statistics and published studies to populate the economic model.

RESULTS

In 2022, the number of HAIs was estimated at 4.8 million, resulting in 500,000 deaths. Health-related economic losses amounted to US$13 billion per year, equivalent to 1.14% of combined gross domestic product and US$15.7 per capita. Healthcare costs were US$500 per HAI, and represented 5.6% of total health expenditure. The costs of providing basic WASH were US$0.91 per capita, which, if they reduced HAIs by 50%, would result in benefit-cost ratios of 1.6 (financial healthcare savings alone) and 8.6 (all economic benefits).

CONCLUSION

HAIs have a major health and economic burden on African societies, and a significant proportion can be prevented. It is critical that health policy makers and practitioners dedicate policy space, resources and training to address HAIs.

Reintroduction of Legacy Antibiotics in Neonatal Sepsis: The Special Role of Fosfomycin and Colistin

Neonatal sepsis is a leading cause of morbidity and mortality in neonates, particularly in low- and middle-income countries. The emergence of antimicrobial resistance is a rapidly growing global problem. A significant proportion of the pathogens that commonly cause neonatal sepsis are resistant to multiple antibiotics. Therefore, for the empirical treatment of neonatal sepsis, the repurposing of older antibiotics that are effective against multidrug-resistant pathogens is being investigated. This review aims to provide an overview of current research and experience using the repurposed antibiotics colistin and fosfomycin for the empirical treatment of neonatal sepsis. Based on current knowledge, colistin and fosfomycin may be potentially helpful for the empirical treatment of sepsis in neonates due to their efficacy against a wide range of pathogens and acceptable safety profile.

Determinants and Magnitude of Neonatal Sepsis at Hiwot Fana Comprehensive Specialized University Hospital, in Eastern Ethiopia: A Cross-Sectional Study

Background

Neonatal sepsis is a serious blood bacterial infection in neonates at the age of equal to or less than 28 days of life, and it's still the major significant cause of death and long-term morbidity in developing countries.

Objective

This study aimed to assess the prevalence and related factors with neonatal sepsis among newborns admitted to the neonatal intensive care unit at Hiwot Fana Comprehensive Specialized University Hospital, Harar, Ethiopia.

Methods

An institutional-based retrospective cross-sectional study design was conducted among 386 neonates admitted to Neonatal Intensive Care Unit from September 2017 to August 2019. A systematic random sampling method was used. Data were analyzed using SPSS V.26. Descriptive summary statistics were done. Bivariate regression and multivariate analysis were computed. Variables with P-value <.05 were declared as having a statistically significant association.

Result

The prevalence of neonatal sepsis was 53.1%. Among the total neonates who had sepsis, 67.8% had early neonatal sepsis. Among neonatal factors, preterm neonates (AOR: 8.1, 95%CI: 2.1, 31.2), birth asphyxia (AOR: 4.7, 95%CI: 1.6, 13.6); and among maternal factors, urban residence (AOR: 0.26, 95%CI: 0.1, 0.5), antenatal care attendance (AOR: 0.32, 95%CI: 0.2, 0.6), spontaneous vaginal delivery (AOR: 0.047, 95%CI: 0.01, 0.2), and maternal antibiotic use (AOR: 0.39; 95%CI: 0.2, 0.8) were found to have significant association with neonatal sepsis.

Conclusion

Overall, the magnitude of neonatal sepsis was high. Provision of neonatal and obstetrics care as per standard during prenatal, intranatal, and postnatal periods is needed. Training of health professionals on infection prevention and safe delivery practice should be provided.

Effect of community-based newborn care implementation strategies on access to and effective coverage of possible serious bacterial infection (PSBI) treatment for sick young infants during COVID-19 pandemic

BACKGROUND

In Ethiopia, neonatal mortality is persistently high. The country has been implementing community-based treatment of possible serious bacterial infection (PSBI) in young infants when referral to a hospital is not feasible since 2012. However, access to and quality of PSBI services remained low and were worsened by COVID-19. From November 2020 to June 2022, we conducted implementation research to mitigate the impact of COVID-19 and improve PSBI management implementation uptake and delivery in two woredas in Ethiopia.

METHODS

In April-May 2021, guided by implementation research frameworks, we conducted formative research to understand the PSBI management implementation challenges, including those due to the COVID-19 pandemic. Through a participatory process engaging stakeholders, we designed adaptive implementation strategies to bridge identified gaps using mechanism mapping to achieve implementation outcomes. Strategies included training and coaching, supportive supervision and mentorship, technical support units, improved supply of essential commodities, and community awareness creation about PSBI and COVID-19. We conducted cross-sectional household surveys in the two woredas before (April 2021) and after the implementation of strategies (June 2022) to measure changes in targeted outcomes.

RESULTS

We interviewed 4,262 and 4,082 women who gave live birth 2-14 months before data collection and identified 374 and 264 PSBI cases in April 2021 and June 2022, respectively. The prevalence of PSBI significantly decreased (p-value = 0.018) from 8.7% in April 2021 to 6.4% while the mothers' care-seeking behavior from medical care for their sick newborns increased significantly from 56% to 91% (p-value <0.01). Effective coverage of severely ill young infants that took appropriate antibiotics significantly improved from 33% [95% CI: 25.5-40.7] to 62% [95% CI: 51.0-71.6]. Despite improvements in the uptake of PSBI treatment, persisting challenges at the facility and systems levels impeded optimal PSBI service delivery and uptake, including perceived low quality of service, lack of community trust, and shortage of supplies.

CONCLUSION

The participatory design and implementation of adaptive COVID-19 strategies effectively improved the uptake and delivery of PSBI treatment. Support systems were critical for frontline health workers to deliver PSBI services and create a resilient community health system to provide quality PSBI care during the pandemic. Additional strategies are needed to address persistent gaps, including improvement in client-provider interactions, supply of essential drugs, and increased social mobilization strategies targeting families and communities to further increase uptake.

Safety and efficacy of whole-body chlorhexidine gluconate cleansing with or without emollient in hospitalised neonates (NeoCHG): a multicentre, randomised, open-label, factorial pilot trial

Background

Healthcare-associated infections account for substantial neonatal in-hospital mortality. Chlorhexidine gluconate (CHG) whole body skin application could reduce sepsis by lowering bacterial colonisation density, although safety and optimal application regimen is unclear. Emollients, including sunflower oil, may independently improve skin condition, thereby reducing sepsis. We aimed to inform which concentration and frequency of CHG, with or without emollient, would best balance safety and the surrogate marker of efficacy of reduction in bacterial colonisation, to be taken forward in a future pragmatic trial evaluating clinical outcomes of sepsis and mortality.

Methods

In this multicentre, randomised, open-label, factorial pilot trial, neonates in two hospital sites (South Africa, Bangladesh) aged 1-6 days with gestational age ≥ 28 weeks and birthweight 1000-1999 g were randomly assigned in a factorial design stratified by site to three different concentrations of CHG (0.5%, 1%, and 2%), with or without emollient (sunflower oil) applied on working days vs alternate working days. A control arm received neither product. Caregivers were unblinded although laboratory staff were blinded to randomisation Co-primary outcomes were safety (change in neonatal skin condition score incorporating dryness, erythema, and skin breakdown) and efficacy in reducing bacterial colonisation density (change in total skin bacterial log10 CFU from randomisation to day-3 and day-8). The trial is registered at the ISRCTN registry, ISRCTN 69836999.

Findings

Between Apr 12 2021 and Jan 18 2022, 208 infants were randomised and 198 were included in the final analysis. Skin condition scores were low with mean 0.1 (sd = 0.3; N = 208) at baseline, 0.1 (sd = 0.3; N = 199) at day 3 and 0.1 (sd = 0.3; N = 189) at day 8, with no evidence of differences between concentration (1% CHG vs 0.5% estimate = -0.3, 95% CI = (-1.2, 0.6), p = 0.55. 2% CHG vs 0.5% CHG estimate = 0.5 (-0.4, 1.4), p = 0.30), increasing frequency (estimate = -0.4; 95% CI = (-1.1, 0.4), p = 0.33), emollient (estimate = -0.5, (-1.2, 0.3), p = 0.23) or with control (estimate = -0.9, (-2.3, 0.4), p = 0.18). Mean log10 CFU was 4.9 (sd = 3.0; N = 208) at baseline, 6.3 (sd = 3.1; N = 198) at day 3 and 8.4 (sd = 2.6; N = 183) with no evidence of differences between concentration (1% CHG vs 0.5% estimate = -0.4; 95% CI = (-1.1, 0.23); p = 0.23. 2% CHG vs 0.5% CHG estimate = 0.0 (-0.6, 0.6), p = 0.96), with increasing frequency (estimate = -0.4; 95% CI = (-0.9, 0.2); p = 0.17), with emollient (estimate = 0.4, 95% CI = (-0.2, 0.9); p = 0.18) or with control (estimate = -0.2, 95% CI = (-1.3, 0.9); p = 0.73). By day-8, overall 158/183 (86%) of neonates were colonised with Enterobacterales, and 72/183 (39%) and 69/183 (9%) with Klebsiella spp resistant to third-generation cephalosporin and carbapenems, respectively. There were no CHG-related SAEs, emollient-related SAEs, grade 3 or 4 skin scores or grade 3 or 4 hypothermias.

Interpretation

In this pilot trial of CHG with or without sunflower oil, no safety issues were identified, and further trials examining clinical outcomes are warranted. The relatively late start application of emollient, at a mean of 3.8 days of life, may have reduced the impact of the intervention although no subgroup effects were detected. There was no clear evidence in favour of a specific concentration of chlorhexidine, and there was rapid colonisation with Enterobacterales with frequent antimicrobial resistance, regardless of skin application regimen.

Funding

The MRC Joint Applied Global Health award, the Global Antibiotic Research and Development Partnership (GARDP), MRC Clinical Trials Unit core funding (UKRI) and St. George's, University of London.

Development and application of neonatal physiology-based pharmacokinetic models of amikacin and fosfomycin to assess pharmacodynamic target attainment

Antimicrobial resistance increasingly complicates neonatal sepsis in a global context. Fosfomycin and amikacin are two agents being tested in an ongoing multicenter neonatal sepsis trial. Although neonatal pharmacokinetics (PKs) have been described for these drugs, the physiological variability within neonatal populations makes population PKs in this group uncertain. Physiologically-based pharmacokinetic (PBPK) models were developed in Simcyp for fosfomycin and amikacin sequentially for adult, pediatric, and neonatal populations, with visual and quantitative validation compared to observed data at each stage. Simulations were performed using the final validated neonatal models to determine drug exposures for each drug across a demographic range, with probability of target attainment (PTA) assessments. Successfully validated neonatal PBPK models were developed for both fosfomycin and amikacin. PTA analysis demonstrated high probability of target attainment for amikacin 15 mg/kg i.v. q24h and fosfomycin 100 mg/kg (in neonates aged 0-7 days) or 150 mg/kg (in neonates aged 7-28 days) i.v. q12h for Enterobacterales with fosfomycin and amikacin minimum inhibitory concentrations at the adult breakpoints. Repeat analysis in premature populations demonstrated the same result. PTA analysis for a proposed combination fosfomycin-amikacin target was also performed. The simulated regimens, tested in a neonatal sepsis trial, are likely to be adequate for neonates across different postnatal ages and gestational age. This work demonstrates a template for determining target attainment for antimicrobials (alone or in combination) in special populations without sufficient available PK data to otherwise assess with traditional pharmacometric methods.

Incidence of possible serious bacterial infection in young infants in the three high-burden countries of the Democratic Republic of the Congo, Kenya, and Nigeria: A secondary analysis of a large, multi-country, multi-centre clinical trial

Background

Neonatal infections are a major public health concern worldwide, particularly in low- and middle-income countries, where most of the infection-related deaths in under-five children occur. Sub-Saharan Africa has the highest mortality rates, but there is a lack of data on the incidence of sepsis from this region, hindering efforts to improve child survival. We aimed to determine the incidence of possible serious bacterial infection (PSBI) in young infants in three high-burden countries in Africa.

Methods

This is a secondary analysis of data from the African Neonatal Sepsis (AFRINEST) trial, conducted in the Democratic Republic of the Congo (DRC), Kenya, and Nigeria between 15 March 2012 and 15 July 2013. We recorded baseline characteristics, the incidence of PSBI (as defined by the World Health Organization), and the incidence of local infections among infants from 0-59 days after birth. We report descriptive statistics.

Results

The incidence of PSBI among 0-59-day-old infants across all three countries was 11.2% (95% confidence interval (CI) = 11.0-11.4). The DRC had the highest incidence of PSBI (19.0%; 95% CI = 18.2-19.8). Likewise, PSBI rates were higher in low birth weight infants (24.5%; 95% CI = 23.1-26.0) and infants born to mothers aged <20 years (14.1%; 95% CI = 13.4-14.8). The incidence of PSBI was higher among infants delivered at home (11.7%; 95% CI = 11.4-12.0).

Conclusions

The high burden of PSBI among young infants in DRC, Kenya, and Nigeria demonstrates the importance of addressing PSBI in improving child survival in sub-Saharan Africa to reach the Sustainable Development Goals (SDGs). These data can support government authorities, policymakers, programme implementers, non-governmental organisations, and international partners in reducing preventable under-five deaths.

Registration

Australian New Zealand Clinical Trials Registry: ACTRN12610000286044.

Determinants of Neonatal Sepsis among Neonates Admitted in a Neonatal Intensive Care Unit at Injibara General Hospital, Awi Zone, and Amhara Regional State, Ethiopia

Introduction. Neonatal sepsis is the primary cause of increased newborn morbidity and mortality worldwide, particularly in developing countries. In Ethiopia, the factors of neonatal sepsis are not well understood. Therefore, the purpose of this study was to determine the factors associated with neonatal sepsis in the study area. Methods. A case-control study design was conducted among 60 cases and 120 controls. Variables with P ≤ .25 in the bivariate analysis were entered into multivariable logistic regression, and statistical significance was declared at P < .05. Result. Birth weight <2500-g (AOR = 4.05 [1.44, 11.36], number of ANC visits <3 (AOR = 4.49 [1.70, 11.86], duration of rupture of membrane ≥18 hours (AOR = 4.42; [2.02, 9.66], first minute APGAR score <7 (AOR = 3.09 [1.10, 8.70], birth at a health-center (AOR = 0.22 [0.08, 0.60]) and instrumental delivery (AOR = 0.30 [0.10, 0.88]) were factors associated with neonatal sepsis. Conclusion. Neonatal sepsis was associated with different factors like prolonged membrane rupture, birth weight, and antenatal care visits.

Young Infants Clinical Signs Study 8-sign Algorithm for Identification of Sick Infants Adapted for Routine Home Visits: A Systematic Review and Critical Appraisal of its Measurement Properties

Objective. The 8-sign algorithm adapted from the Young Infants Clinical Signs Study (YICSS) is widely used to identify sick infants during home visits (YICSS-home algorithm). We aimed to critically appraise the development and evidence of measurement properties, including sensibility, reliability, and validity, of the YICSS-home algorithm. Methods. Relevant studies were identified through a systematic literature search. Results. The YICSS-home algorithm has good sensibility. The algorithm demonstrated at least moderate inter-rater reliability and sensitivity ranging from 69% to 80%. However, the algorithm was developed among sick infants brought for care to a health facility and not initially developed for use by community health workers (CHWs) during home visits. Some important risk factors were omitted at item generation. Inter-CHW reliability and construct validity have not been estimated. Conclusion. Future research should build on the strengths of the YICSS-home algorithm and address its limitations to develop a new algorithm with improved predictive accuracy.

Factors influencing community-facility linkage for case management of possible serious bacterial infections among young infants in Kenya

Despite evidence showing the feasibility and acceptability of implementing the World Health Organization's guidelines on managing possible serious bacterial infection (PSBI) in Kenya, the initial implementation revealed sub-optimal community-facility referrals and follow-up of PSBI cases. This study explores facilitators and barriers of community-facility linkages in implementing PSBI guidelines in Busia and Migori counties, Kenya. We used an exploratory qualitative study design drawing on endline evaluation data from the 'COVID-19: Mitigating Neonatal Mortality' project collected between June and July 2022. Data include case narratives with caregivers of sick young infants (0-59 days old) (18), focus group discussions with community health volunteers (CHVs) (6), and in-depth interviews with facility-based providers (18). Data were analysed using an inductive thematic analysis framework. Between August 2021 and July 2022, CHVs assessed 10 187 newborns, with 1176 (12%) identified with PSBI danger signs and referred to the nearest facility, of which 820 (70%) accepted referral. Analysis revealed several factors facilitating community-facility linkage for PSBI treatment, including CHVs' relationship with community members and facilities, availability of a CHV desk and tools, use of mobile app, training and supportive supervision. However, challenges such as health system-related factors (inadequate providers, stockout of essential commodities and supplies, and lack of transport/ambulance) and individual-related factors (caregivers' refusal to take referrals) hindered community-facility linkage. Addressing common barriers and fostering positive relationships between community health workers and facilities can enhance acceptance and access to PSBI services at the community level. Combining community health workers' efforts with a mobile digital strategy can improve the efficiency of the identification, referral and tracking of PSBI cases in the community and facilitate linkage with primary healthcare facilities.

The neonatal gut microbiome and global health

The role of gut microbiome in health, a century-old concept, has been on the center stage of medical research recently. While different body sites, disease conditions, and populations have been targeted, neonatal and early infancy appear to be the most suitable period for such interventions. It is intriguing to note that, unlike traditional use in diarrhea and maintenance of gastrointestinal health, microbiome-mediating therapies have now addressed the most serious medical conditions in young infants such as necrotizing enterocolitis and neonatal sepsis. Unfortunately, almost all new endeavors in this space have been carried out in the Western world leaving behind millions of neonates that can benefit from such manipulations while serving as a large resource for further learning. In this review, an attempt has been made to quantify the global burden of neonatal morbidity and mortality, examples presented on interventions that have failed as a result of drawing from studies conducted in the West, and a case made for manipulating the neonatal gut microbiome to address the biggest killers in early life. A brief comparative analysis has been made to demonstrate the differences in the gut microbiota of North and South and a large clinical trial of synbiotics conducted by our group in a South Asian setting has been presented. Although challenging, the value of conducting such global health research is introduced with an intent to invite medical scientists to engage in well-planned, scientifically robust research endeavors. This can bring about innovation while saving and serving the most vulnerable citizens now and protecting them from the negative health consequences in the later part of their lives, ultimately shaping a resilient and equitable world as pledged by 193 United Nations member countries in 2015.

Clinical Utility of Procalcitonin and C-Reactive Protein in the Management of Neonatal Sepsis in a Resource-Limited Nigerian Hospital

BACKGROUND

Neonatal sepsis is an invasive infection of the bloodstream in neonates and a leading cause of morbidity and mortality among them.

AIM

To investigate the role of procalcitonin (PCT) and C-reactive protein (CRP) in the management of neonatal sepsis.

MATERIALS AND METHODS

This was a prospective case-control study over one-year period using convenience sampling. Blood samples for PCT and CRP were taken from all neonates, while blood culture and white blood cell count samples were additionally taken from babies with neonatal sepsis. PCT and CRP were repeated at 24 and 48 hours. The continuous variables were found to have a nonparametric distribution. They were presented as median and interquartile range, and compared using Wilcoxon signed rank and Friedman test as appropriate.

RESULTS

The blood culture analysis yielded a prevalence of 12.7% with Staphylococcus aureus being the commonest organism. Baseline concentrations of PCT (1.28 ng/ml) and CRP (17.31 mg/L) in neonates with sepsis were higher than that of controls (PCT-0.63 ng/ml, CRP-5.40 mg/L). PCT concentrations decreased after two days of antibiotic treatment, while CRP concentrations decreased after a day. The concentration of both decreased to normal levels after two days of treatment.

CONCLUSION

This study showed that CRP was more reliable in monitoring antibiotic therapy, unlike other studies which suggested PCT. In cases where the management of neonatal sepsis may be limited by a low blood culture yield, therapeutic monitoring may be aided by CRP and/or PCT.

Multidrug-resistant and carbapenemase-producing critical gram-negative bacteria isolated from the intensive care unit environment in Amhara region, Ethiopia

BACKGROUND

Intensive care units are units where healthcare-associated infections (HAIs) are common and antimicrobial resistance rates are increasing. Microbial contamination in hospital environment plays an important role in the development of HAIs. Intervention-based improvements in infection prevention and control at national and facility level are critical for the containment of antimicrobial resistance and prevention of HAIs.

OBJECTIVES

This study aimed to determine the distribution of multidrug-resistant and carbapenemase-producing critical gram negative bacteria (Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Acinetobacter species) and their antibiotic resistance in intensive care unit environmental surfaces at the University of Gondar and Felege Hiwot Comprehensive Specialized Hospitals.

METHODS

This was multicenter hospital-based cross sectional study. Environmental samples were swabbed from all intensive care units using a normal saline moistened-sterile cotton tip stick. Bacteria culturing and antibiotic susceptibility testing were performed following standard microbiological techniques. Selected meropenem-resistant isolates were phenotypically assessed for carbapenemase production using modified and simplified carbapenem inactivation methods.

RESULTS

From a total of 384 environmental samples analyzed, 126 (32.8%) showed growth and 162 isolates were identified. K. pneumoniae (79/162, 48.8%) was the commonest isolate followed by Acinetobacter species (51/162, 31.5%), E. coli (19/162, 11.7%) and P. aeruginosa (13/162, 8.0%). Multidrug-resistant and carbapenemase-producing isolates were detected on most hospital environment surface types, especially from the baby bed sets and incubators. The most common multidrug-resistant and principal carbapenemase producer was K. pneumoniae, with rates of 71(89.9%) and 24(85.7%), respectively.

CONCLUSION

This study revealed the distribution of multidrug-resistant and carbapenemase-producing critical gram negative bacteria in the environment of intensive care unit. Higher detection rate of multidrug-resistant and carbapenemase-producing K. pneumoniae on most environmental surfaces calls for urgent control action and further attention.

Prevalence and antibiotic resistance pattern of bacteria from sepsis suspected neonates at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

BACKGROUND

Neonatal sepsis is the major cause of neonatal mortality and morbidity, especially in low and middle-income countries. Continuous monitoring of pathogens and their antibiotic resistance pattern is crucial for managing neonatal sepsis. This study aimed to determine neonatal sepsis due to bacteria, antibiotic resistance patterns, associated risk factors and patient outcomes at St. Paul's Hospital Millennium Medical College.

METHOD

An institutional-based cross-sectional study was conducted on 400 neonates suspected of sepsis at St. Paul's Hospital Millennium Medical College from March 2020 to July 2020. A questionnaire was used to collect socio-demographic information, clinical parameters and potential risk factors from study participants. About 2ml of blood was drawn aseptically and inoculated into Tryptone Soya Broth at the patient's bedside. Bacterial identification was performed by using standard microbiological techniques. The disk diffusion method was used to determine the antibiotic susceptibility patterns of each isolated bacteria. Data entry and analysis were done using Statistical Package for Social Sciences (SPSS) version 20 software. Bivariate and multivariable logistic regressions were used to assess associated risk factors of neonatal sepsis. A p-value less than 0.05 was considered statically significant with a 95% confidence interval.

RESULTS

The overall prevalence of neonatal septicemia was 21% (84/400). Of these, 67 (79.8%) and 17 (20.2%) were gram-negative and gram-positive bacteria, respectively. Klebsiella spp, 37 (44%), E. coli 19 (21.6%) and Coagulase negative Staphylococci 13 (15.47%) were the leading cause of neonatal sepsis. Ciprofloxacin and amikacin were the most effective antibiotics for gram-negative and gram-positive bacteria. Multidrug resistance was observed in 84% of the bacterial isolates. Low birth weight and preterm were associated with neonatal septicemia (AOR = 49.90, 95% CI = 15.14-123.081, P = 0.002) and (AOR = 18.20, 95% CI = 6.835-27.541, P = 0.004) respectively.

CONCLUSION

Klebsiella spp and E. coli were frequently isolated bacteria in our study. The proportion of multidrug-resistance was significantly high. Most isolated bacteria were resistant to ampicillin, ceftazidime, cefotaxime and gentamycin, which indicates the necessity of continuous evaluation of antibiotic resistance rate.

Sepsis Risk Factors in Neonatal Intensive Care Units of Public Hospitals in Southeast Ethiopia, 2020: A Retrospective Unmatched Case-Control Study

Background

Neonatal sepsis is a significant contributor to neonatal morbidity and mortality worldwide. It is more prevalent in developing countries. Thus, understanding the risk factors for neonatal sepsis is critical to minimizing the incidence of infection, particularly in Ethiopia. The purpose of this study was to identify the risk factors for neonatal sepsis in neonates admitted to neonatal intensive care units of public hospitals in Southeast Ethiopia in 2020.

Method

An institution-based, retrospective unmatched case-control study was conducted on 97 cases and 194 controls in neonatal intensive care units of public hospitals in Southeast Ethiopia. A pretested, structured questionnaire was used to collect the data. Data was entered using EpiData 3.1 and analyzed using SPSS version 23. Bivariable and multivariable logistic regression analyses were performed to identify associated factors. An adjusted odds ratio with a 95% confidence interval was used to determine the degree of association, and statistical significance was declared at a p value of < 0.05.

Results

In this study, 97 cases and 194 controls were included. About two-thirds (63.9%) of cases were with early onset neonatal sepsis (<7 days). Mode of delivery with spontaneous vaginal delivery (AOR:5.032; 95% CI (1.887-13.418)), type of birth attendant (traditional birth attendant) (AOR: 4.407 95% CI (1.213,16.004)), history of STI/UTI (AOR:2.543; 95% CI (1.313,4.925)), intrapartum fever (AOR:4.379; 95% CI (2.170,8.835)), APGAR score at the 5thminute < 7 (AOR:4.832; 95% CI (1.862,12.537)), neonate received resuscitation (AOR:3.830; 95% CI (1.753,8.369)), low birth weight (AOR:6.101; 95% CI (2.124,17.525)) were the identified risk factors for neonatal sepsis.

Conclusion

Both maternal and neonatal factors contribute to the risk of neonatal sepsis. Spontaneous vaginal delivery, birth attended by the traditional birth attendant, history of STI/UTI, presence of intrapartum fever, low APGAR score at the 5th minute, neonate receiving resuscitation, and low birth weight were identified as independent risk factors for neonatal sepsis. Prompt identification of the aforementioned factors and management should be sought for all newborns.

Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review

Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70-90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo-arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m-2) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m-2) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers.

Incidence and risk factors of neonatal bacterial infections: a community-based cohort from Madagascar (2018-2021)

BACKGROUND

Few studies on neonatal severe bacterial infection are available in LMICs. Data are needed in these countries to prioritize interventions and decrease neonatal infections which are a primary cause of neonatal mortality. The BIRDY project (Bacterial Infections and Antimicrobial Drug Resistant among Young Children) was initially conducted in Madagascar, Senegal and Cambodia (BIRDY 1, 2012-2018), and continued in Madagascar only (BIRDY 2, 2018-2021). We present here the BIRDY 2 project whose objectives were (1) to estimate the incidence of neonatal severe bacterial infections and compare these findings with those obtained in BIRDY 1, (2) to identify determinants associated with severe bacterial infection and (3) to specify the antibiotic resistance pattern of bacteria in newborns.

METHODS

The BIRDY 2 study was a prospective community-based mother and child cohort, both in urban and semi-rural areas. All pregnant women in the study areas were identified and enrolled. Their newborns were actively and passively followed-up from birth to 3 months. Data on clinical symptoms developed by the children and laboratory results of all clinical samples investigated were collected. A Cox proportional hazards model was performed to identify risk factors associated with possible severe bacterial infection.

FINDINGS

A total of 53 possible severe bacterial infection and 6 confirmed severe bacterial infection episodes were identified among the 511 neonates followed-up, with more than half occurring in the first 3 days. For the first month period, the incidence of confirmed severe bacterial infection was 11.7 per 1,000 live births indicating a 1.3 -fold decrease compared to BIRDY 1 in Madagascar (p = 0.50) and the incidence of possible severe bacterial infection was 76.3, indicating a 2.6-fold decrease compared to BIRDY 1 in Madagascar (p < 0.001). The 6 severe bacterial infection confirmed by blood culture included 5 Enterobacterales and one Enterococcus faecium. The 5 Enterobacterales were extended-spectrum β-lactamases (ESBL) producers and were resistant to quinolones and gentamicin. Enterococcus faecium was sensitive to vancomycin but resistant to amoxicillin and to gentamicin. These pathogns were classified as multidrug-resistant bacteria and were resistant to antibiotics recommended in WHO guidelines for neonatal sepsis. However, they remained susceptible to carbapenem. Fetid amniotic fluid, need for resuscitation at birth and low birth weight were associated with early onset possible severe bacterial infection.

CONCLUSION

Our results suggest that the incidence of severe bacterial infection is still high in the community of Madagascar, even if it seems lower when compared to BIRDY 1 estimates, and that existing neonatal sepsis treatment guidelines may no longer be appropriate in Madagascar. These results motivate to further strengthen actions for the prevention, early diagnosis and case management during the first 3 days of life.

How long should young infants less than two months of age with moderate-mortality-risk signs of possible serious bacterial infection be hospitalised for? Study protocol for a randomised controlled trial from low- and middle-income countries

Background

Hospitalisation and a seven-day injectable antibiotics course are recommended by the World Health Organization (WHO) to treat suspected clinical neonatal sepsis / possible serious bacterial infection (PSBI). Some infants presenting with PSBI signs associated with a moderate risk of mortality may only need a two-day hospitalisation followed by outpatient care treatment with oral antibiotics to complete seven days of antibiotics.

Methods

A multi-centre, individually randomised, open-label trial will be conducted in seven sites in six countries: Bangladesh, Ethiopia, India (two sites), Nigeria, Pakistan and Tanzania. A common protocol will be used with the same study design, including the participants, intervention, comparison, outcomes, quality control, and analysis procedures. 0-59 days old infants presenting with moderate-mortality risk signs (low body temperature (<35.5°C), movement only when stimulated, stopped feeding well) or two or more signs of clinical severe infection (CSI) will be assessed and pre-enrolled. After 48 hours of hospital stay, clinically stable infants with a negative C-reactive protein test will be randomised either to hospital discharge on oral amoxicillin (intervention) or continued hospitalisation (control) arm. The intervention arm will receive oral amoxicillin for five days, whereas the control arm will receive injection gentamicin plus injection ampicillin for five more days plus supportive therapy if needed. We plan to enrol 5250 eligible young infants, 2625 infants in each of the two study arms. An experienced, well-trained independent outcome assessor will visit all enrolled cases on days 4, 8 and 15 after the initiation of treatment to assess the study outcomes in both intervention and control arms. The primary outcome of poor clinical outcome defined as death between randomisation and day 15 of initiation of treatment, deterioration during the 7-day treatment period, or persistence of the presenting sign of CSI at the end of the 7-day treatment period will be compared to assess if an early discharge and outpatient treatment leads to superior or at least non-inferior clinical outcome than continued inpatient treatment. The harmonisation of activities, including methods and processes, will be carried out diligently. Central training will be conducted by the WHO coordinating team, a central data coordination centre to collate all data, standardisation exercises for all clinical signs and internal and external monitoring. All the selected sites have extensive research experience. Through regular online and physical meetings, data-based monitoring, and physical site visits by WHO monitors, quality assurance and harmonisation will be ensured. This trial has been approved by the WHO and local site institutional ethics committees.

Discussion

If the results show that young infants with moderate-mortality risk PSBI signs can be safely and effectively treated on an outpatient basis after a shorter hospital stay, it will reduce the burden on the hospitals, potentially reduce nosocomial hospital infections and increase access to treatment for families with poor access to health facilities. It may also reduce the health system costs (human and materials) and allow the overburdened hospitals to pay more attention to critically ill young infants. In addition, this evidence will contribute to making a case for reviewing the WHO PSBI guideline.

Registration

International Standard Randomised Controlled Trial Number, ISRCTN16872570.

Neonatal sepsis and its associated factors among neonates admitted to the neonatal intensive care unit in Wachemo University Comprehensive Specialized Hospital, Southern Ethiopia, 2022

Background

Neonatal sepsis is a major public health problem worldwide. It is one of the leading causes of neonatal mortality and morbidity worldwide. The neonatal mortality rate is higher in developing countries, where the extent and causes of neonatal sepsis are not yet known. Neonatal sepsis is a leading cause of neonatal mortality in Ethiopia. As a result, this study aimed to assess the proportion and identify maternal and neonatal risk factors for neonatal sepsis among neonates admitted to the neonatal intensive care unit.

Methods

An institutional-based cross-sectional study was conducted from May 2022 to July 2022 at the Wachemo University Comprehensive Specialized Teaching Hospital, Neonatal Intensive Care Unit, southern Ethiopia. A total of 205 neonates with indexed mothers participated in the study. Using a consecutive sampling technique, a structured, pretested questionnaire was used to collect data from the study subjects. Data were entered into EpiData Manager version 3.1 for Windows and then exported to SPSS version 22 for further data cleaning and analysis. Descriptive analyses were performed by using frequency, percentage, and summary statistics to describe the key variables. A multivariate regression model was used to identify factors associated with neonatal sepsis. Finally, statistical significance was declared at a p-value of less than 0.05, and an adjusted odds ratio (AOR) with a 95% confidence level was used to declare the variable's association with the outcome variable.

Result

The overall prevalence rate of neonatal sepsis was 39.5% (95% CI: 33.7-45.9). Multivariable analysis was performed by taking a variable that is statistically significant in bivariate logistic regression as a candidate variable. Multivariable model analysis showed that unmarried status AOR = 18.37 (95% CI: 1.56-216.14), maternal fever during delivery AOR = 4.74 (95% CI: 1.63-13.8), and premature rupture of membrane AOR = 7.53 (95% CI: 2.19-25.6) were variables that increased the odds of developing neonatal sepsis.

Conclusion

The study's findings indicate that neonatal sepsis is highly prevalent. Unmarried maternal status, maternal fever during delivery, and premature rupture of the membrane were predictors of neonatal sepsis. Therefore, providing training for health workers and close monitoring and evaluation during obstetric and neonatal care are crucial to halt the occurrence of neonatal sepsis.

Measuring implementation outcomes in the context of scaling up possible serious bacterial infection guidelines: Implications for measurement and programs

BACKGROUND

Reducing the burden of neonatal sepsis requires timely identification and initiation of suitable antibiotic treatment in primary health care (PHC) settings. Countries are encouraged to adopt simplified antibiotic regimens at the PHC level for treating sick young infants (SYI) with signs of possible serious bacterial infection (PSBI). As countries implement PSBI guidelines, more lessons on effective implementation strategies and outcome measurements are needed. We document pragmatic approaches used to design, measure and report implementation strategies and outcomes while adopting PSBI guidelines in Kenya.

METHODS

We designed implementation research using longitudinal mixed methods embedded in a continuous regular systematic learning and adoption of evidence in the PHC context. We synthesized formative data to co-create with stakeholders, implementation strategies to incorporate PSBI guidelines into routine service delivery for SYIs. This was followed by quarterly monitoring for learning and feedback on the effect of implementation strategies, documented lessons learned and tracked implementation outcomes. We collected endline data to measure the overall effect on service level outcomes.

RESULTS

Our findings show that characterizing implementation strategies and linking them with implementation outcomes, helps illustrate the pathway between the implementation process and outcomes. Although we have demonstrated that it is feasible to implement PSBI in PHC, effective investment in continuous capacity strengthening of providers through blended approaches, efficient use of available human resources, and improving the efficiency of service areas for managing SYIs optimizes timely identification and management of SYI. Sustained provision of commodities for management of SYI facilitates increased uptake of services. Strengthening facility-community linkages supports adherence to scheduled visits. Enhancing the caregiver's preparedness during postnatal contacts in the community or facility will facilitate the effective completion of treatment.

CONCLUSION

Careful design, and definition of terms related to the measurement of implementation outcomes and strategies enable ease of interpretation of findings. Using the taxonomy of implementation outcomes help frame the measurement process and provides empirical evidence in a structured way to demonstrate causal relationships between implementation strategies and outcomes. Using this approach, we have illustrated that the implementation of simplified antibiotic regimens for treating SYIs with PSBI in PHC settings is feasible in Kenya.

Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS)

BACKGROUND

There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design.

METHODS AND FINDINGS

Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability.

CONCLUSION

Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT03721302).

Global, regional, and national estimates of the impact of a maternal Klebsiella pneumoniae vaccine: A Bayesian modeling analysis

BACKGROUND

Despite significant global progress in reducing neonatal mortality, bacterial sepsis remains a major cause of neonatal deaths. Klebsiella pneumoniae (K. pneumoniae) is the leading pathogen globally underlying cases of neonatal sepsis and is frequently resistant to antibiotic treatment regimens recommended by the World Health Organization (WHO), including first-line therapy with ampicillin and gentamicin, second-line therapy with amikacin and ceftazidime, and meropenem. Maternal vaccination to prevent neonatal infection could reduce the burden of K. pneumoniae neonatal sepsis in low- and middle-income countries (LMICs) but the potential impact of vaccination remains poorly quantified. We estimated the potential impact of such vaccination on cases and deaths of K. pneumoniae neonatal sepsis and project the global effects of routine immunization of pregnant women with the K. pneumoniae vaccine as antimicrobial resistance (AMR) increases.

METHODS AND FINDINGS

We developed a Bayesian mixture-modeling framework to estimate the effects of a hypothetical K. pneumoniae maternal vaccine with 70% efficacy administered with coverage equivalent to that of the maternal tetanus vaccine on neonatal sepsis infections and mortality. To parameterize our model, we used data from 3 global studies of neonatal sepsis and/or mortality-with 2,330 neonates who died with sepsis surveilled from 2016 to 2020 undertaken in 18 mainly LMICs across all WHO regions (Ethiopia, Kenya, Mali, Mozambique, Nigeria, Rwanda, Sierra Leone, South Africa, Uganda, Brazil, Italy, Greece, Pakistan, Bangladesh, India, Thailand, China, and Vietnam). Within these studies, 26.95% of fatal neonatal sepsis cases were culture-positive for K. pneumoniae. We analyzed 9,070 K. pneumoniae genomes from human isolates gathered globally from 2001 to 2020 to quantify the temporal rate of acquisition of AMR genes in K. pneumoniae isolates to predict the future number of drug-resistant cases and deaths that could be averted by vaccination. Resistance rates to carbapenems are increasing most rapidly and 22.43% [95th percentile Bayesian credible interval (CrI): 5.24 to 41.42] of neonatal sepsis deaths are caused by meropenem-resistant K. pneumoniae. Globally, we estimate that maternal vaccination could avert 80,258 [CrI: 18,084 to 189,040] neonatal deaths and 399,015 [CrI: 334,523 to 485,442] neonatal sepsis cases yearly worldwide, accounting for more than 1.49% [CrI: 0.33 to 3.51] of all neonatal deaths. The largest relative benefits are in Africa (Sierra Leone, Mali, Niger) and South-East Asia (Bangladesh) where vaccination could avert over 5% of all neonatal deaths. Nevertheless, our modeling only considers country-level trends in K. pneumoniae neonatal sepsis deaths and is unable to consider within-country variability in bacterial prevalence that may impact the projected burden of sepsis.

CONCLUSIONS

A K. pneumoniae maternal vaccine could have widespread, sustained global benefits as AMR in K. pneumoniae continues to increase.

Late-Onset Group B Streptococcal Sepsis in Preterm Twins

Group B streptococcal (GBS) infection is one of the leading causes of neonatal sepsis worldwide. Despite a significant decline in early-onset (EOS) sepsis due to intrapartum antibiotic prophylaxis, the incidence of late-onset (LOS) infection has remained unchanged. However, LOS GBS sepsis affecting twins is very rare. We report on preterm twins born at 29 weeks of gestation: Twin B was 31 days old when he developed LOS GBS sepsis and meningitis, and Twin A was 35 days old when he developed LOS GBS sepsis. Tests for maternal GBS colonization in breast milk were negative. Both babies were treated with antibiotics and eventually discharged without complications.

Analytical and Non-Analytical Variation May Lead to Inappropriate Antimicrobial Dosing in Neonates: An In Silico Study

BACKGROUND

Therapeutic drug monitoring (TDM) of aminoglycosides and vancomycin is used to prevent oto- and nephrotoxicity in neonates. Analytical and nonanalytical factors potentially influence dosing recommendations. This study aimed to determine the impact of analytical variation (imprecision and bias) and nonanalytical factors (accuracy of drug administration time, use of non-trough concentrations, biological variation, and dosing errors) on neonatal antimicrobial dosing recommendations.

METHODS

Published population pharmacokinetic models and the Australasian Neonatal Medicines Formulary were used to simulate antimicrobial concentration-time profiles in a virtual neonate population. Laboratory quality assurance data were used to quantify analytical variation in antimicrobial measurement methods used in clinical practice. Guideline-informed dosing recommendations based on drug concentrations were applied to compare the impact of analytical variation and nonanalytical factors on antimicrobial dosing.

RESULTS

Analytical variation caused differences in subsequent guideline-informed dosing recommendations in 9.3-12.1% (amikacin), 16.2-19.0% (tobramycin), 12.2-45.8% (gentamicin), and 9.6-19.5% (vancomycin) of neonates. For vancomycin, inaccuracies in drug administration time (45.6%), use of non-trough concentrations (44.7%), within-subject biological variation (38.2%), and dosing errors (27.5%) were predicted to result in more dosing discrepancies than analytical variation (12.5%). Using current analytical performance specifications, tolerated dosing discrepancies would be up to 14.8% (aminoglycosides) and 23.7% (vancomycin).

CONCLUSIONS

Although analytical variation can influence neonatal antimicrobial dosing recommendations, nonanalytical factors are more influential. These result in substantial variation in subsequent dosing of antimicrobials, risking inadvertent under- or overexposure. Harmonization of measurement methods and improved patient management systems may reduce the impact of analytical and nonanalytical factors on neonatal antimicrobial dosing.

Implementation research to increase treatment coverage of possible serious bacterial infections in young infants when a referral is not feasible: lessons learnt

BACKGROUND

The objective was to achieve high coverage of possible serious bacterial infections (PSBI) treatment using the World Health Organization (WHO) guideline for managing it on an outpatient basis when referral to a hospital is not feasible.

METHODS

We implemented this guideline in the programme settings at 10 Basic Health Units (BHU) in two rural districts of Sindh in Pakistan using implementation research. A Technical Support Unit supported the programme to operationalize guidelines, built capacity of health workers through training, monitored their clinical skills, mentored them and assured quality. The community-based health workers visited households to identify sick infants and referred them to the nearest BHU for further management. The research team collected data.

RESULTS

Of 17 600 identified livebirths, 1860 young infants with any sign of PSBI sought care at BHUs and 1113 (59.8%) were brought by families. We achieved treatment coverage of 95%, assuming an estimated 10% incidence of PSBI in the first 2 months of life and that 10% of young infants came from outside the study catchment area. All 923 infants (49%; 923/1860) 7-59 days old with only fast breathing (pneumonia) treated with outpatient oral amoxicillin were cured. Hospital referral was refused by 83.4% (781/937) families who accepted outpatient treatment; 92.2% (720/781) were cured and 0.8% (6/781) died. Twelve (7.6%; 12/156) died among those treated in a hospital.

CONCLUSION

It is feasible to achieve high coverage by implementing WHO PSBI management guidelines in a programmatic setting when a referral is not feasible.

Neutrophil extracellular trap inhibition improves survival in neonatal mouse infectious peritonitis

BACKGROUND

Treatment of neonatal peritonitis and sepsis is challenging. Following infection, neutrophils elaborate neutrophil extracellular traps (NETs)-extracellular lattices of decondensed chromatin decorated with antimicrobial proteins. NETs, however, can augment pathogenic inflammation causing collateral damage. We hypothesized that NET inhibition would improve survival in experimental neonatal infectious peritonitis.

METHODS

We induced peritonitis in 7 to 10-day-old mice by intraperitoneal injection with cecal slurry. We targeted NETs by treating mice with neonatal NET-Inhibitory Factor (nNIF), an endogenous NET-inhibitor; Cl-amidine, a PAD4 inhibitor; DNase I, a NET degrading enzyme, or meropenem (an antibiotic). We determined peritoneal NET and cytokine levels and circulating platelet-neutrophil aggregates. Survival from peritonitis was followed for 6 days.

RESULTS

nNIF, Cl-amidine, and DNase I decreased peritoneal NET formation and inflammatory cytokine levels at 24 h compared to controls. nNIF, Cl-amidine, and DNase I decreased circulating platelet-neutrophil aggregates, and NET-targeting treatments significantly increased survival from infectious peritonitis compared to controls. Finally, nNIF administration significantly improved survival in mice treated with sub-optimal doses of meropenem even when treatment was delayed until 2 h after peritonitis induction.

CONCLUSIONS

NET inhibition improves survival in experimental neonatal infectious peritonitis, suggesting that NETs participate pathogenically in neonatal peritonitis and sepsis.

IMPACT

1. Neutrophil extracellular trap formation participates pathogenically in experimental neonatal infectious peritonitis. 2. NET-targeting strategies improve outcomes in a translational model of neonatal infectious peritonitis. 3. NET inhibition represents a potential target for drug development in neonatal sepsis and infectious peritonitis.

Maternal colonization and early-onset neonatal bacterial sepsis in the Gambia, West Africa: a genomic analysis of vertical transmission

OBJECTIVES

To define bacterial aetiology of neonatal sepsis and estimate the prevalence of neonatal infection from maternal genital tract bacterial carriage among mother-newborn pairs.

METHODS

We carried out a cross-sectional study of newborns with clinical sepsis admitted to three hospitals in the Gambia neonatal wards. Neonatal blood cultures and maternal genital swabs were obtained at recruitment. We used whole-genome sequencing to explore vertical transmission for neonates with microbiologically confirmed bloodstream infection by comparing phenotypically-matched paired neonatal blood cultures and maternal genital tract bacterial isolates.

RESULTS

We enrolled 203 maternal-newborn pairs. Two-thirds (67%; 137/203) of neonates presented with early-onset sepsis (days 0-6 after birth) of which 26% (36/137) were because of a clinically-significant bacterial pathogen. Blood culture isolates from newborns with early-onset sepsis because of Staphylococcus aureus (n = 5), Klebsiella pneumonia (n = 2), and Enterococcus faecalis (n = 1), phenotypically matched their maternal genital tract isolates. Pairwise single-nucleotide variants comparisons showed differences of 12 to 52 single-nucleotide variants only between maternal and newborn S. aureus isolates, presumably representing vertical transmission with a transmission rate of 14% (5/36).

CONCLUSIONS

We found a low prevalence of vertical transmission of maternal genital tract colonization in maternal-newborn pairs for early-onset neonatal sepsis in the West African context. Identifying infection acquisition pathways among newborns is essential to prioritize preventive interventions, which could be targeted at the mother or infection control in the hospital environment, depending on the major pathways of transmission.

Molecular surveillance reveals widespread colonisation by carbapenemase and extended spectrum beta-lactamase producing organisms in neonatal units in Kenya and Nigeria

OBJECTIVES

Neonatal sepsis, a major cause of death amongst infants in sub-Saharan Africa, is often gut derived. Gut colonisation by Enterobacteriaceae producing extended spectrum beta-lactamase (ESBL) or carbapenemase enzymes can lead to antimicrobial-resistant (AMR) or untreatable infections. We sought to explore the rates of colonisation by ESBL or carbapenemase producers in two neonatal units (NNUs) in West and East Africa.

METHODS

Stool and rectal swab samples were taken at multiple timepoints from newborns admitted to the NNUs at the University College Hospital, Ibadan, Nigeria and the Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, western Kenya. Samples were tested for ESBL and carbapenemase genes using a previously validated qPCR assay. Kaplan-Meier survival analysis was used to examine colonisation rates at both sites.

RESULTS

In total 119 stool and rectal swab samples were taken from 42 infants admitted to the two NNUs. Colonisation with ESBL (37 infants, 89%) was more common than with carbapenemase producers (26, 62.4%; P = 0.093). Median survival time before colonisation with ESBL organisms was 7 days and with carbapenemase producers 16 days (P = 0.035). The majority of ESBL genes detected belonged to the CTX-M-1 (36/38; 95%), and CTX-M-9 (2/36; 5%) groups, and the most prevalent carbapenemase was bla_NDM (27/29, 93%).

CONCLUSIONS

Gut colonisation of neonates by AMR organisms was common and occurred rapidly in NNUs in Kenya and Nigeria. Active surveillance of colonisation will improve the understanding of AMR in these settings and guide infection control and antibiotic prescribing practice to improve clinical outcomes.

Metagenomic Next-Generation Sequencing for the Diagnosis of Neonatal Infectious Diseases

Infectious diseases pose a fatal risk to neonates. Timely and accurate pathogen detection is crucial for proper clinical diagnosis and therapeutic strategies. Limited sample volumes from neonatal patients seriously hindered the accurate detection of pathogens. Here, we unravel that metagenomic next-generation sequencing (mNGS) of cell-free DNA (cfDNA) and RNA can achieve unbiased detection of trace pathogens from different kinds of body fluid samples and blood samples. We enrolled 168 neonatal patients with suspected infections from whom blood samples (n = 153), cerebrospinal fluid samples (n = 127), and respiratory tract samples (RTSs) (including bronchoalveolar lavage fluids, sputa, and respiratory secretions) (n = 51) were collected and analyzed using mNGS. High rates of positivity (70.2%; 118/168) of mNGS were observed, and the coincidence rate against the final clinical diagnosis in positive mNGS cases reached 68.6% (81/118). The most common causative pathogens were Klebsiella pneumoniae (n = 12), Escherichia coli (n = 12), and Streptococcus pneumoniae (n = 8). mNGS using cfDNA and RNA can identify microbes that cannot be detected by conventional methods in different body fluid and blood samples, and more than 50% of these microbes were identified as causative pathogens. Further local polynomial regression fitting analysis revealed that the best timing for mNGS detection ranged from 1 to 3 days after the start of continuous antimicrobial therapy. Diagnosed and guided by mNGS results, the therapeutic regimens for 86 out of 117 neonatal patients were changed, most of whom (80/86) completely recovered and were discharged, while 44 out of 86 patients completely or partially stopped unnecessary medication. Our findings highlight the importance of mNGS in detecting causative DNA and RNA pathogens in infected neonatal patients. IMPORTANCE To the best of our knowledge, this is the first report on evaluating the performance of mNGS using cfDNA and RNA from body fluid and blood samples for diagnosing neonatal infections. mNGS of RNA and cfDNA can achieve the unbiased detection and identification of trace pathogens from different kinds of neonatal body fluid and blood samples with a high total coincidence rate (226/331; 68.3%) against final clinical diagnoses by sample. The best timing for mNGS detection in neonatal infections ranged from 1 to 3 days, rather than 0 days, after the start of continuous antimicrobial therapy. Our findings highlight the importance of mNGS in detecting causative DNA and RNA pathogens, and the extensive application of mNGS for the diagnosis of neonatal infections can be expected.

Using the Implementation Research Logic Model to design and implement community-based management of possible serious bacterial infection during COVID-19 pandemic in Ethiopia

BACKGROUND

Community-based treatment of possible serious bacterial infection (PSBI) in young infants, when referral to a hospital is not possible, can result in high treatment coverage and low case fatality. However, in Ethiopia, the coverage of PSBI treatment remains low, worsened by COVID-19. To understand the challenges of delivery of PSBI treatment and design and test adaptative strategies to mitigate the impact of COVID-19 on neonatal mortality, we did implementation research (IR) employing Implementation Research Logic Model (IRLM). In this paper, we describe IRLM application experiences in designing, implementing, and evaluating strategies to improve community-based treatment of PSBI during the COVID-19 pandemic in Ethiopia.

METHODS

This IR was conducted between November 2020-April 2022 at Dembecha and Lume woredas of Amhara and Oromia regions, respectively. We employed narrative reviews, formative assessment and facilitated stakeholder engagement to develop the PSBI treatment IRLM to identify barriers, understand the conceptual linkages among determinants, choose implementation strategies, elicit mechanisms, and link to implementation outcomes. In addition, we used the IRLM to structure the capture of emerging implementation challenges and resulting strategy adaptations throughout implementation.

RESULTS

This IR identified COVID-19 and multiple pre-existing contextual factors. We designed and implemented implementation strategies to address these challenges. These adaptive strategies were implemented with sufficient strength to maintain the delivery of PSBI services and improve mothers' care-seeking behavior for their sick young infants. The IRLM offers us a clear process and path to prioritize implementation challenges, choose strategies informed by mechanisms of action, and where the adaptive implementation of community-based management of PSBI would lead to high-implementation fidelity and change in mother behavior to seek care for their sick young infants. The IRLM was also an effective tool for stakeholder engagement, easily explained and used to structure discussion and decision-making during co-design meetings.

CONCLUSIONS

The use of the IRLM helps us to specify the conceptual links between the implementation challenges, strategies, mechanisms of action, and outcomes to explore the complex community-based management of PSBI during complex contexts to improve high-fidelity implementation and integration of PSBI treatment in the primary healthcare delivery systems through active engagement of stakeholders.

Incidence of Early and Late Onset Neonatal Sepsis in Suriname: A National Tertiary Hospital Birth-cohort Study

BACKGROUND

Early onset neonatal sepsis (EONS) and late onset neonatal sepsis (LONS) are important causes of neonatal mortality and morbidity. A pressing need for reliable and detailed data of low- and middle-income countries exists. This study aimed to describe the incidence and outcome of neonatal sepsis in the only tertiary hospital of Suriname, a middle-income country in South America.

METHODS

Infants born at the Academic Hospital of Paramaribo from May 2017 through December 2018 were prospectively included at birth. Perinatal data, duration of antibiotic treatment, blood culture results and mortality data were gathered. Neonatal sepsis was defined as positive blood culture with a pathogenic microorganism within the first 28 days of life.

RESULTS

Of the 2190 infants included, 483 (22%) were admitted to neonatal (intensive) care. The incidence of EONS was 2.1 (95% CI: 0.9-5) per 1000 live births, with no deaths. Antibiotics for suspected EONS were administrated to 189 (8.6%) infants, of whom 155 (82%) were born prematurely. The incidence of LONS cases was 145 (95% CI: 114-176) per 1000 admissions. Gramnegative bacteria accounted for 70% (48 out of 70) of causative organisms. Seventeen deaths were directly caused by sepsis (35 per 1000 admissions).

CONCLUSIONS

Findings from this tertiary center birth cohort study in a middle-income setting indicate EONS incidence and outcomes comparable to high-income settings, whereas LONS is a more prevalent and significant challenge with a predominance of gram-negative bacteria, and high mortality.

Assessment of flomoxef combined with amikacin in a hollow-fibre infection model for the treatment of neonatal sepsis in low- and middle-income healthcare settings

BACKGROUND

Annual mortality from neonatal sepsis is an estimated 430 000-680 000 infants globally, most of which occur in low- and middle-income countries (LMICs). The WHO currently recommends a narrow-spectrum β-lactam (e.g. ampicillin) and gentamicin as first-line empirical therapy. However, available epidemiological data demonstrate high rates of resistance to both agents. Alternative empirical regimens are needed. Flomoxef and amikacin are two off-patent antibiotics with potential for use in this setting.

OBJECTIVES

To assess the pharmacodynamics of flomoxef and amikacin in combination.

METHODS

The pharmacodynamic interaction of flomoxef and amikacin was assessed in chequerboard assays and a 16-arm dose-ranged hollow-fibre infection model (HFIM) experiment. The combination was further assessed in HFIM experiments mimicking neonatal plasma exposures of clinically relevant doses of both drugs against five Enterobacterales isolates with a range of flomoxef/amikacin MICs.

RESULTS

Flomoxef and amikacin in combination were synergistic in bacterial killing in both assays and prevention of emergence of amikacin resistance in the HFIM. In the HFIM assessing neonatal-like drug exposures, the combination killed 3/5 strains to sterility, (including 2/5 that monotherapy with either drug failed to kill) and failed to kill the 2/5 strains with flomoxef MICs of 32 mg/L.

CONCLUSIONS

We conclude that the combination of flomoxef and amikacin is synergistic and is a potentially clinically effective regimen for the empirical treatment of neonatal sepsis in LMIC settings and is therefore suitable for further assessment in a clinical trial.

Oral amoxicillin plus gentamicin regimens may be superior to the procaine-penicillin plus gentamicin regimens for treatment of young infants with possible serious bacterial infection when referral is not feasible: Pooled analysis from three trials in Africa and Asia

Background

Hospital referral and admission in many- low and middle-income countries are not feasible for many young infants with sepsis/possible serious bacterial infection (PSBI). The effectiveness of simplified antibiotic regimens when referral to a hospital was not feasible has been shown before. We analysed the pooled data from the previous trials to compare the risk of poor clinical outcome for young infants with PSBI with the two regimens containing injectable procaine penicillin and gentamicin with the oral amoxicillin plus gentamicin regimen currently recommended by the World Health Organization (WHO) when referral is not feasible.

Methods

Infant records from three individually randomised trials conducted in Africa and Asia were collated in a standard format. All trials enrolled young infants aged 0-59 days with any sign of PSBI (fever, hypothermia, stopped feeding well, movement only when stimulated, or severe chest indrawing). Eligible young infants whose caretakers refused hospital admission and consented were enrolled and randomised to a trial reference arm (arm A: procaine benzylpenicillin and gentamicin) or two experimental arms (arm B: oral amoxicillin and gentamicin or arm C: procaine benzylpenicillin and gentamicin initially, followed by oral amoxicillin). We compared the rate of poor clinical outcomes by day 15 (deaths till day 15, treatment failure by day 8, and relapse between day 9 and 15) in reference arm A with experimental arms and present risk differences with 95% confidence interval (CI), adjusted for trial.

Results

A total of 7617 young infants, randomised to arm A, arm B, or arm C in the three trials, were included in this analysis. Most were 7-59 days old (71%) and predominately males (56%). Slightly over one-fifth of young infants had more than one sign of PSBI at the time of enrolment. Severe chest indrawing (45%), fever (43%), and feeding problems (25%) were the most common signs. Overall, those who received arm B had a lower risk of poor clinical outcome compared to arm A for both per-protocol (risk difference = -2.1%, 95% CI = -3.8%, -0.4%; P = 0.016) and intention-to-treat (risk difference = -1.8%, 95% CI = -3.5%, -0.2%; P = 0.031) analyses. Those who received arm C did not have an increased risk of poor clinical outcome compared to arm A for both per-protocol (risk difference = -1.1%, 95% CI = -2.8%, 0.6%) and intention-to-treat (risk difference = -0.8%, 95% CI = -2.5%, 0.9%) analyses. Overall, those who received arm B had a lower risk of poor clinical outcome compared to the combined arms A and C for both per-protocol (risk difference = -1.6%, 95% CI = -3.5%, -0.1%; P = 0.035) and intention-to-treat (risk difference = -1.4%, 95% CI = -2.8%, -0.1%; P = 0.049) analyses.

Conclusions

Analysis of pooled individual patient-level data from three large trials in Africa and Asia showed that the WHO-recommended simplified antibiotic regimen B (oral amoxicillin and injection gentamicin) was superior to regimen A (injection procaine penicillin and injection gentamicin) and combined arms A and C (injection procaine penicillin and injection gentamicin, followed by oral amoxicillin) in terms of poor clinical outcome for the outpatient treatment of young infants with PSBI when inpatient treatment was not feasible.

Registration

AFRINEST study [9] is registered with the Australian New Zealand Clinical Trials Registry: ACTRN12610000286044. SATT Bangladesh study [10] is registered with ClinicalTrials.gov: NCT00844337. SATT Pakistan study [11] is registered at ClinicalTrials.gov: NCT01027429.

Cause and risk factors of early neonatal death in Ethiopia

Background

Globally, three fourth of neonatal deaths occur during the early neonatal period, this makes it a critical time to reduce the burden of neonatal death. The survival status of a newborn is determined by the individual (neonatal and maternal), and facility-level factors. Several studies were conducted in Ethiopia to assess early neonatal death; however, most of the studies had limited participants and did not well address the two main determinant factors covered in this study. In response to this gap, this study attempted to examine factors related to early neonatal death based on perinatal death surveillance data in consideration of all the possible determinants of early neonatal death.

Methods

The national perinatal death surveillance data were used for this study. A total of 3814 reviewed perinatal deaths were included in the study. Bayesian multilevel parametric survival analysis was employed to identify factors affecting the survival of newborns during the early neonatal period. Adjusted time ratio (ATR) with 95% Bayesian credible intervals (CrI) was reported and log-likelihood was used for model comparison. Statistical significance was declared based on the non-inclusion of 1.0 in the 95% CrI.

Result

More than half (52.4%) of early neonatal deaths occurred within the first two days of birth. Per the final model, as gestational age increases by a week the risk of dying during the early neonatal period is reduced by 6% [ATR = 0.94,95%CrI:(0.93–0.96)]. There was an increased risk of death during the early neonatal period among neonates deceased due to birth injury as compared to neonates who died due to infection [ATR = 2.05,95%CrI:(1.30–3.32)]; however, perinates who died due to complication of an intrapartum event had a lower risk of death than perinates who died due to infection [ATR = 0.87,95%CrI:(0.83–0.90)]. As the score of delay one and delay three increases by one unit, the newborn’s likelihood of surviving during the early neonatal period is reduced by 4% [ATR = 1.04,95%CrI:(1.01–1.07)] and 21% [ATR = 1.21,95%CrI:(1.15–1.27)] respectively. Neonates born from mothers living in a rural area had a higher risk of dying during the early neonatal period than their counterparts living in an urban area [ATR = 3.53,95%CrI:(3.34–3.69)]. As compared to neonates treated in a primary health facility, being treated in secondary [ATR = 1.14,95%CrI:(1.02–1.27)] and tertiary level of care [ATR = 1.15,95%CrI:(1.04–1.25)] results in a higher risk of death during the early neonatal period.

Conclusion

The survival of a newborn during the early neonatal period is determined by both individual (gestational age, cause of death, and delay one) and facility (residence, type of health facility and delay three) level factors. Thus, to have a positive early neonatal outcome, a tailored intervention is needed for the three major causes of death (i.e Infection, birth injury, and complications of the intrapartum period). Furthermore, promoting maternal health, improving the health-seeking behaviour of mothers, strengthening facility readiness, and narrowing down inequalities in service provision are recommended to improve the newborn’s outcomes during the early neonatal period.

Neonatal acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the community of a low-income country (NeoLIC): protocol for a household cohort study in Moramanga, Madagascar

INTRODUCTION

Data regarding the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in neonates at the community level are scarce in low-income and middle-income countries (LMICs), where the burden of neonatal sepsis is high.Our study aims at identifying and quantifying the role of the different routes of ESBL-PE transmission for neonates, which are still undefined in the community in LMICs.

METHODS AND ANALYSIS

In a semirural community in Madagascar, 60 mothers and their neonates will be recruited at delivery, during which a maternal stool sample and meconium of the newborn will be collected. Home visits will be planned the day of the delivery and next at days 3, 7, 14, 21 and 28. Stool samples from the newborn, the mother and every other household member will be collected at each visit, as well as samples from the environment in contact with the newborn (food, surfaces and objects). Sociodemographic data and factors which might drive ESBL-PE acquisition will also be collected.We will analyse the isolated ESBL-PE using DNA sequencing methods to characterise clones, resistance genes and plasmids of ESBL-PE. To analyse these data globally, we will develop novel analytical approaches combining mathematical modelling and statistics. Finally, mathematical simulations will be performed to test different strategies of control of ESBL-PE transmission to neonates.In complement, we will conduct an anthropological investigation to understand local environments and practices that would contribute to neonatal ESBL-PE acquisition. In-depth interviews with members of 16 households will be conducted and 4 mother-newborn pairs will be followed by a participants' observations methodology.

ETHICS AND DISSEMINATION

The study was approved by the ethical committee in Madagascar and by the institutional review board of Institut Pasteur, Paris, France.Findings will be reported to participating families, collaborators and local government; presented at national and international conferences and disseminated by peer-review publications.

Changing Incidence of Invasive Pneumococcal Disease in Infants Less Than 90 Days of Age Before and After Introduction of the 13-Valent Pneumococcal Conjugate Vaccine in Blantyre, Malawi: A 14-Year Hospital Based Surveillance Study

BACKGROUND

Invasive pneumococcal disease (IPD) in young infants is uncommon but associated with high morbidity and mortality. Accurate data on the burden of IPD in young infants in low-income countries are lacking. We examined the burden of IPD in infants <90 days old in Blantyre, Malawi over a 14-year period and evaluated the indirect impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on vaccine-serotype IPD (VT-IPD) in this population.

METHODS

We conducted laboratory-based prospective IPD surveillance in infants <90 days of age admitted to Queen Elizabeth Central Hospital in Blantyre between 2005 and 2018, including 7 years pre-PCV13 and 7 years post-PCV13 introduction. IPD was defined as Streptococcus pneumoniae identified by culture from blood or cerebrospinal fluid. Serotypes were determined by multiplex polymerase chain reaction and latex agglutination testing.

RESULTS

We identified 130 cases of culture-confirmed IPD in infants <90 days old between 2005 and 2018. Total IPD incidence was declining before PCV13 introduction. The mean incidence of IPD was significantly lower in the post-PCV13 era. Serotypes 5 (27.8%) and 1 (15.6%) were most prevalent. Even after PCV13 introduction, VTs remained the primary cause of IPD, with serotype 5 accounting for 17.4% and serotype 1 for 13.0% of cases in young infants.

CONCLUSION

Vaccine serotypes 1 and 5 were the main cause of IPD in neonates and young infants, both before and after PCV13 introduction. This suggests incomplete indirect protection with persisting VT carriage across the population despite vaccination in this setting. Alternative vaccine schedules and other vaccine introduction approaches need to be considered to protect this vulnerable population.

Therapeutic Options and Outcomes for the Treatment of Neonates and Preterms with Gram-Negative Multidrug-Resistant Bacteria: A Systematic Review

(1) Background: Infections caused by multidrug-resistant (MDR) or extensively drug-resistant (XDR) bacteria represent a challenge in the neonatal population due to disease severity and limited therapeutic possibilities compared to adults. The spread of antimicrobial resistance and drug availability differ significantly worldwide. The incidence of MDR bacteria has constantly risen, causing an increase in morbidity, mortality, and healthcare costs in both high-income (HIC) and low- and middle-income countries (LMIC). Therefore, more evidence is needed to define the possible use of newer molecules and to optimize combination regimens for the oldest antimicrobials in neonates. This systematic review aims to identify and critically appraise the current antimicrobial treatment options and the relative outcomes for MDR and XDR Gram-negative bacterial infections in the neonatal population. (2) Methods: A literature search for the treatment of MDR Gram-negative bacterial infections in neonates (term and preterm) was conducted in Embase, MEDLINE, and Cochrane Library. Studies reporting data on single-patient-level outcomes related to a specific antibiotic treatment for MDR Gram-negative bacterial infection in children were included. Studies reporting data from adults and children were included if single-neonate-level information could be identified. We focused our research on four MDROs: Enterobacterales producing extended-spectrum beta-lactamase (ESBL) or carbapenemase (CRE), Pseudomonas aeruginosa, and Acinetobacter baumannii. PROSPERO registration: CRD42022346739 (3) Results: The search identified 11,740 studies (since January 2000), of which 22 fulfilled both the inclusion and exclusion criteria and were included in the analysis. Twenty of these studies were conducted in LMIC. Colistin is the main studied and used molecule to treat Gram-negative MDR bacteria for neonate patients in the last two decades, especially in LMIC, with variable evidence of efficacy. Carbapenems are still the leading antibiotics for ESBL Enterobacterales, while newer molecules (i.e., beta-lactam agents/beta-lactamase inhibitor combination) are promising across all analyzed categories, but data are few and limited to HICs. (4) Conclusions: Data about the treatment of Gram-negative MDR bacteria in the neonatal population are heterogeneous and limited mainly to older antimicrobials. Newer drugs are promising but not affordable yet for many LMICs. Therefore, strategies cannot be generalized but will differ according to the country’s epidemiology and resources. More extensive studies are needed to include new antimicrobials and optimize the combination strategies for the older ones.

Effect of chlorhexidine cleansing on healthcare-associated infections in neonates: a systematic review and meta-analysis

BACKGROUND

Healthcare-associated infections (HAIs) have a significant impact on neonatal morbidity, mortality and long-term prognosis, which have a high incidence in neonates. Many studies have shown that chlorhexidine cleansing is effective in reducing HAIs in adults, but the effect of chlorhexidine cleansing on HAIs in neonates remains controversial.

AIM

The purpose of this study was to conduct a systematic review and meta-analysis of the effect of chlorhexidine cleansing on HAIs in neonates. The protocol of this review has been registered with the PROSPERO international prospective register of systematic reviews.

METHODS

A systematic literature search was performed on five medical literature databases, namely MEDLINE, Web of Science, Embase, Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL), published up until 3 March 2021. In the end, six studies were eligible for inclusion, including four randomised controlled trials and two quasi-experimental studies. Version 2 of the Cochrane tool for assessing risk of bias in randomised trials and the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies were used for quality assessment. Pooled risk ratios (RRs) and their associated 95% CIs were calculated using the fixed effects model (I² <50%) or the random effects model (I² ≥50%).

FINDINGS AND CONCLUSIONS

The results of the meta-analysis revealed that chlorhexidine cleansing had no significant effect on neonatal sepsis (RR: 0.49, 95% CI 0.18 to 1.38, p=0.18, I²=0%), but significantly reduced neonatal skin bacterial colonisation (RR: 0.61, 95% CI 0.42 to 0.90, p=0.01, I²=50%). In addition, this systematic review showed that chlorhexidine cleansing could significantly reduce central line-associated bloodstream infection in neonates based on large-sample studies. However, more studies are needed to determine the optimal concentration and frequency of chlorhexidine cleansing. PROSPERO registration number CRD42021243858.

A multi-country implementation research initiative to jump-start scale-up of outpatient management of possible serious bacterial infections (PSBI) when a referral is not feasible: Summary findings and implications for programs

Introduction

Research on simplified antibiotic regimens for outpatient treatment of ‘Possible Serious Bacterial Infection’ (PSBI) and the subsequent World Health Organization (WHO) guidelines provide an opportunity to increase treatment coverage. This multi-country implementation research initiative aimed to learn how to implement the WHO guideline in diverse contexts. These experiences have been individually published; this overview paper provides a summary of results and lessons learned across sites.

Methods summary

A common mixed qualitative and quantitative methods protocol for implementation research was used in eleven sites in the Democratic Republic of Congo (Equateur province), Ethiopia (Tigray and Oromia regions), India (Haryana, Himachal Pradesh, Maharashtra, and Uttar Pradesh states), Malawi (Central Region), Nigeria (Kaduna and Oyo states), and Pakistan (Sindh province). Key steps in implementation research were: i) policy dialogue with the national government and key stakeholders, ii) the establishment of a ‘Technical Support Unit’ with the research team and district level managers, and iii) development of an implementation strategy and its refinement using an iterative process of implementation, programme learning and evaluation.

Results summary

All sites successfully developed and evaluated an implementation strategy to increase coverage of PSBI treatment. During the study period, a total of 6677 young infants from the study catchment area were identified and treated at health facilities in the study area as inpatients or outpatients among 88179 live births identified. The estimated coverage of PSBI treatment was 75.7% (95% CI 74.8% to 78.6%), assuming a 10% incidence of PSBI among all live births. The treatment coverage was variable, ranging from 53.3% in Lucknow, India to 97.3% in Ibadan, Nigeria. The coverage of inpatient treatment ranged from 1.9% in Zaria, Nigeria, to 33.9% in Tigray, Ethiopia. The outpatient treatment coverage ranged from 30.6% in Pune, India, to 93.6% in Zaria, Nigeria. Overall, the case fatality rate (CFR) was 14.6% (95% CI 11.5% to 18.2%) for 0-59-day old infants with critical illness, 1.9% (95% CI 1.5% to 2.4%) for 0-59-day old infants with clinical severe infection and 0.1% for fast breathing in 7–59 days old. Among infants treated as outpatients, CFR was 13.7% (95% CI 8.7% to 20.2%) for 0-59-day old infants with critical illness, 0.9% (95% CI 0.6% to 1.2%) for 0-59-day old infants with clinical severe infection, and 0.1% for infants 7–59 days old with fast breathing.

Conclusion

Important lessons on how to conduct each step of implementation research, and the challenges and facilitators for implementation of PSBI management guideline in routine health systems are summarised and discussed. These lessons will be used to introduce and scale-up implementation in relevant Low- and middle-income countries.

Group B streptococcus infection during pregnancy and infancy: estimates of regional and global burden

BACKGROUND

Group B streptococcus (GBS) colonisation during pregnancy can lead to invasive GBS disease (iGBS) in infants, including meningitis or sepsis, with a high mortality risk. Other outcomes include stillbirths, maternal infections, and prematurity. There are data gaps, notably regarding neurodevelopmental impairment (NDI), especially after iGBS sepsis, which have limited previous global estimates. In this study, we aimed to address this gap using newly available multicountry datasets.

METHODS

We collated and meta-analysed summary data, primarily identified in a series of systematic reviews published in 2017 but also from recent studies on NDI and stillbirths, using Bayesian hierarchical models, and estimated the burden for 183 countries in 2020 regarding: maternal GBS colonisation, iGBS cases and deaths in infants younger than 3 months, children surviving iGBS affected by NDI, and maternal iGBS cases. We analysed the proportion of stillbirths with GBS and applied this to the UN-estimated stillbirth risk per country. Excess preterm births associated with maternal GBS colonisation were calculated using meta-analysis and national preterm birth rates.

FINDINGS

Data from the seven systematic reviews, published in 2017, that informed the previous burden estimation (a total of 515 data points) were combined with new data (17 data points) from large multicountry studies on neurodevelopmental impairment (two studies) and stillbirths (one study). A posterior median of 19·7 million (95% posterior interval 17·9-21·9) pregnant women were estimated to have rectovaginal colonisation with GBS in 2020. 231 800 (114 100-455 000) early-onset and 162 200 (70 200-394 400) late-onset infant iGBS cases were estimated to have occurred. In an analysis assuming a higher case fatality rate in the absence of a skilled birth attendant, 91 900 (44 800-187 800) iGBS infant deaths were estimated; in an analysis without this assumption, 58 300 (26 500-125 800) infant deaths from iGBS were estimated. 37 100 children who recovered from iGBS (14 600-96 200) were predicted to develop moderate or severe NDI. 40 500 (21 500-66 200) maternal iGBS cases and 46 200 (20 300-111 300) GBS stillbirths were predicted in 2020. GBS colonisation was also estimated to be potentially associated with considerable numbers of preterm births.

INTERPRETATION

Our analysis provides a comprehensive assessment of the pregnancy-related GBS burden. The Bayesian approach enabled coherent propagation of uncertainty, which is considerable, notably regarding GBS-associated preterm births. Our findings on both the acute and long-term consequences of iGBS have public health implications for understanding the value of investment in maternal GBS immunisation and other preventive strategies.

FUNDING

Bill & Melinda Gates Foundation.

Camera fusion for real-time temperature monitoring of neonates using deep learning

Abstract

The continuous monitoring of vital signs is a crucial aspect of medical care in neonatal intensive care units. Since cable-based sensors pose a potential risk for the immature skin of preterm infants, unobtrusive monitoring techniques using camera systems are increasingly investigated. The combination of deep learning–based algorithms and camera modalities such as RGB and infrared thermography can improve the development of cable-free methods for the extraction of vital parameters. In this study, a real-time approach for local extraction of temperatures on the body surface of neonates using a multi-modal clinical dataset was implemented. Therefore, a trained deep learning–based keypoint detector was used for body landmark prediction in RGB. Image registration was conducted to transfer the RGB points to the corresponding thermographic recordings. These landmarks were used to extract the body surface temperature in various regions to determine the central-peripheral temperature difference. A validation of the keypoint detector showed a mean average precision of 0.82. The registration resulted in mean absolute errors of 16.4 px (8.2 mm) for x and 22.4 px (11.2 mm) for y. The evaluation of the temperature extraction revealed a mean absolute error of 0.55 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{\circ }$$\end{document}∘C. A final performance of 31 fps was observed on the NVIDIA Jetson Xavier NX module, which proves real-time capability on an embedded GPU system. As a result, the approach can perform real-time temperature extraction on a low-cost GPU module.

Graphical abstract

Magnitude and associated factors of neonatal sepsis among neonates admitted to neonatal intensive care unit of Northern oromia hospitals, Ethiopia: A multicenter cross-sectional study

Background

Globally sepsis is the most cause of neonatal death. Neonatal sepsis is the major newborn killer in Ethiopia, which accounts for more than one-third of neonatal deaths. Therefore, the study was aimed to assess the prevalence and associated factors of neonatal sepsis.

Methods

An institutional based cross-sectional study was employed on a total of 378 neonates admitted to the NICU of selected four hospitals. It was conducted from January 2021 to March 2021. Multivariate logistic regression analysis was used to determine the prevalence of neonatal sepsis.

Results

Among neonates who enrolled in this study 188(50.1%) of them were females and 283 (75.5%) of them were in the age group of early neonatal period. The overall magnitude of neonatal sepsis in this study was 196(52.27%). From this 159(81.12%) and 37(18.88%) of neonates developed early onset neonatal sepsis and late onset neonatal sepsis, respectively. Factors such as age of neonates[AOR = 2.351, 95% CI (1.131, 4.888)], birth weight of neonate less than 2.5 kg[AOR = 2.546, 95% CI (1.875, 3.643)], multiple per digital vaginal examination[AOR =0.278, 95% CI (0.148,0.522)], history of urinary tract infection[AOR = 3.709, 95% CI (1.828–7.301)], Meconium stained amniotic fluid (MSAF)[AOR = 0.384, 95% CI (0.152, 0.968)] and intrapartum high fever[AOR = 2.203, 95% CI (1.034, 4.692)] were the independent determinants of neonatal sepsis.

Conclusion

This study indicated that the magnitude of neonatal sepsis was found to be high. In general, this study has found that both maternal and neonatal factors had contributed to the risk of neonatal sepsis. Based on these results we recommend the healthcare providers to focus on the prevention of risk factors rather than treating the disease after it occurs.

•

Globally, sepsis is one of the major causes of morbidity and mortality.

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Neonatal sepsis is categorized as early onset neonatal sepsis (EONS) and late onset neonatal sepsis (LONS) .

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In a developing countries accurate diagnosis of neonatal sepsis is not satisfactory.

Introducing pulse oximetry in routine IMCI services in Bangladesh: A context-driven approach to influence policy and programme through stakeholder engagement

Background

An estimated 7 million episodes of severe newborn infections occur annually worldwide, with half a million newborn deaths, most occurring in low- and middle-income countries. Whilst injectable antibiotics are necessary to treat the infection, supportive care is also crucial in ending preventable mortality and morbidity. This study uses multi-country data to assess gaps in coverage, quality, and documentation of supportive care, considering implications for measurement.

Methods

The EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Newborns with an admission diagnosis of clinically-defined infection (sepsis, meningitis, and/or pneumonia) were included. Researchers extracted data from inpatient case notes and interviews with women (usually the mothers) as the primary family caretakers after discharge. The interviews were conducted using a structured survey questionnaire. We used descriptive statistics to report coverage of newborn supportive care components such as oxygen use, phototherapy, and appropriate feeding, and we assessed the validity of measurement through survey-reports using a random-effects model to generate pooled estimates. In this study, key supportive care components were assessment and correction of hypoxaemia, hyperbilirubinemia, and hypoglycaemia.

Results

Among 1015 neonates who met the inclusion criteria, 89% had an admission clinical diagnosis of sepsis. Major gaps in documentation and care practices related to supportive care varied substantially across the participating hospitals. The pooled sensitivity was low for the survey-reported oxygen use (47%; 95% confidence interval (CI) = 30%-64%) and moderate for phototherapy (60%; 95% CI = 44%-75%). The pooled specificity was high for both the survey-reported oxygen use (85%; 95% CI = 80%-89%) and phototherapy (91%; 95% CI = 82%-97%).

Conclusions

The women's reports during the exit survey consistently underestimated the coverage of supportive care components for managing infection. We have observed high variability in the inpatient documents across facilities. A standardised ward register for inpatient small and sick newborn care may capture selected supportive care data. However, tracking the detailed care will require standardised individual-level data sets linked to newborn case notes. We recommend investments in assessing the implementation aspects of a standardised inpatient register in resource-poor settings.

Early-Onset Neonatal Sepsis in Low- and Middle-Income Countries: Current Challenges and Future Opportunities

Neonatal sepsis is defined as a systemic infection within the first 28 days of life, with early-onset sepsis (EOS) occurring within the first 72h, although the definition of EOS varies in literature. Whilst the global incidence has dramatically reduced over the last decade, neonatal sepsis remains an important cause of neonatal mortality, highest in low- and middle-income countries (LMICs). Symptoms at the onset of neonatal sepsis can be subtle, and therefore EOS is often difficult to diagnose from clinical presentation and laboratory testing and blood cultures are not always conclusive or accessible, especially in resource limited countries. Although the World Health Organisation (WHO) currently advocates a ß-lactam, and gentamicin for first line treatment, availability and cost influence the empirical antibiotic therapy administered. Antibiotic treatment of neonatal sepsis in LMICs is highly variable, partially caused by factors such as cost of antibiotics (and who pays for them) and access to certain antibiotics. Antimicrobial resistance (AMR) has increased considerably over the past decade and this review discusses current microbiology data available in the context of the diagnosis, and treatment for EOS. Importantly, this review highlights a large variability in data availability, methodology, availability of diagnostics, and aetiology of sepsis pathogens.

Etiology of severe invasive infections in young infants in rural settings in sub-Saharan Africa

Background

Serious invasive infections in newborns are a major cause of death. Lack of data on etiological causes hampers progress towards reduction of mortality. This study aimed to identify pathogens responsible for such infections in young infants in sub-Saharan Africa and to describe their antibiotics resistance profile.

Methods

Between September 2016 and April 2018 we implemented an observational study in two rural sites in Burkina Faso and Tanzania enrolling young infants aged 0–59 days old with serious invasive infection. Blood samples underwent blood culture and molecular biology.

Results

In total 634 infants with clinical diagnosis of serious invasive infection were enrolled and 4.2% of the infants had a positive blood culture. The most frequent pathogens identified by blood culture were Klebsiella pneumonia and Staphylococcus aureus, followed by Escherichia coli. Gram-negative isolates were only partially susceptible to first line WHO recommended treatment for neonatal sepsis at community level. A total of 18.6% of the infants were PCR positive for at least one pathogen and Escherichia coli and Staphylococcus aureus were the most common bacteria detected. Among infants enrolled, 60/634 (9.5%) died. Positive blood culture but not positive PCR was associated with risk of death. For most deaths, no pathogen was identified either by blood culture or molecular testing, and hence a causal agent remained unclear. Mortality was associated with low body temperature, tachycardia, respiratory symptoms, convulsions, history of difficult feeding, movement only when stimulated or reduced level of consciousness, diarrhea and/or vomiting.

Conclusion

While Klebsiella pneumonia and Staphylococcus aureus, as well as Escherichia coli were pathogens most frequently identified in infants with clinical suspicion of serious invasive infections, most cases remain without definite diagnosis, making more accurate diagnostic tools urgently needed. Antibiotics resistance to first line antibiotics is an increasing challenge even in rural Africa.