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Muhammad A, Shafiq Y, Nisar MI, Baloch B, Pasha A, Yazdani NS, Rizvi A, Muhammad S, Jehan F. Effect of maternal postnatal balanced energy protein supplementation and infant azithromycin on infant growth outcomes: an open-label randomized controlled trial. Am J Clin Nutr 2024; 120:550-559. [PMID: 38925354 PMCID: PMC11393397 DOI: 10.1016/j.ajcnut.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/31/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Maternal undernutrition is a direct risk factor for infant growth faltering. OBJECTIVES We evaluated the effect of postnatal balanced energy protein (BEP) supplementation in lactating women and azithromycin (AZ) in infants on infant growth outcomes. METHODS A randomized controlled superiority trial of lactating mother-newborn dyads was conducted in Karachi, Pakistan. Mothers intending to breastfeed their newborns with mid-upper arm circumference of <23 cm and live infants between 0 and 6 d of life were randomly assigned to 1 of 3 arms in a 1:1:1 ratio. Lactating mothers in the control arm received standard-of-care counseling on exclusive breastfeeding, nutrition, infant immunization, and health promotion plus iron-folate supplementation until the infant was 6 mo old. In intervention arm 1, mothers additionally received two 75-g sachets of BEP per day. In intervention arm 2, along with the standard-of-care and BEP to the mother, the infant also received 1 dose of azithromycin (20 mg/kg) at the age of 42 d . The primary outcome was infant length velocity at 6 mo. The total sample size was 957 (319 in each arm). RESULTS From 1 August, 2018 to 19 May, 2020, 319 lactating mother-newborn dyads were randomly assigned in each arm, and the last follow-up was completed on 20 November, 2020. The mean difference in length velocity (cm/mo) between BEP alone and control was 0.01 (95% confidence interval [CI]: -0.03, 0.06), BEP plus AZ and control was 0.08 (95% CI: 0.03, 0.13), and between BEP + AZ and BEP alone was 0.06 (95% CI: 0.01, 0.11). There were 1.46% (14/957) infant deaths in the trial, and 17.9% (171/957) nonfatal events (injectable treatment and/or hospitalizations) were recorded. CONCLUSIONS Postnatal maternal BEP supplementation and infant AZ administration could modestly improve infant growth outcomes at 6 mo, suggesting potential benefits in simultaneously addressing maternal and infant undernutrition. This trial was registered at clinicaltrials.gov as NCT03564652.
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Affiliation(s)
- Ameer Muhammad
- Vaccines and Other Initiatives to Advance Lives (VITAL) Pakistan Trust, Karachi, Pakistan
| | - Yasir Shafiq
- Center of Excellence for Trauma and Emergencies and Community Health Sciences, The Aga Khan University, Karachi, Pakistan; Global Advancement of Infants and Mothers (AIM), Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard T. H. Chan School of Public Health, Boston, MA, United States; Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health (CRIMEDIM), Università degli Studi del Piemonte Orientale "Amedeo Avogadro," Vercelli, Italy
| | - Muhammad Imran Nisar
- Department of Pediatrics and Child Health Medical College, The Aga Khan University, Karachi, Pakistan
| | - Benazir Baloch
- Department of Pediatrics and Child Health Medical College, The Aga Khan University, Karachi, Pakistan
| | - Aneela Pasha
- Department of Pediatrics and Child Health Medical College, The Aga Khan University, Karachi, Pakistan
| | - Nida Salman Yazdani
- Vaccines and Other Initiatives to Advance Lives (VITAL) Pakistan Trust, Karachi, Pakistan
| | - Arjumand Rizvi
- Centre of Excellence in Maternal and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sajid Muhammad
- Centre of Excellence in Maternal and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Fyezah Jehan
- Department of Pediatrics and Child Health Medical College, The Aga Khan University, Karachi, Pakistan.
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North K, Mathias S, Schmeck N, Kim Y, Kehoe T, Folger LV, Hoey A, Wade C, Driker S, Chou R, Edmond KM, Lee AC. Efficacy of Antibiotic Regimens for Sepsis or Possible Serious Bacterial Infection in Young Infants Aged 0 to 59 Days: A Systematic Review and Meta-analysis. Pediatrics 2024; 154:e2024066588F. [PMID: 39087801 DOI: 10.1542/peds.2024-066588f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 08/02/2024] Open
Abstract
CONTEXT Sepsis is a leading cause of young infant mortality. OBJECTIVE To evaluate the efficacy of different antibiotic regimens to treat young infant sepsis or possible serious bacterial infection (PSBI) on clinical outcomes. DATA SOURCES MEDLINE, Embase, CINAHL, World Health Organization Global Index Medicus, Cochrane Central Registry of Trials. STUDY SELECTION We included randomized controlled trials (RCTs) of young infants 0 to 59 days with sepsis or PBSI (population) comparing the efficacy of antibiotic regimens (intervention) with alternate regimens or management (control) on clinical outcomes. DATA EXTRACTION We extracted data and assessed risk of bias in duplicate. We performed random-effects meta-analysis, and used Grading of Recommendations, Assessment, Development, and Evaluation to assess certainty of evidence. RESULTS Of 2390 publications, we included 41 RCTs (n = 18 054). Thirty-five trials were hospital-based and 6 were nonhospital-based. Meta-analysis of 4 trials demonstrated similar rates of treatment success with intramuscular/intravenous third generation cephalosporins versus intramuscular/intravenous penicillin or ampicillin + gentamicin (RR 1.03, 95% CI 0.93-1.13]; n = 1083; moderate certainty of evidence). Meta-analysis of 3 trials demonstrated similar rates of treatment failure with oral amoxicillin + intramuscular gentamicin versus intramuscular penicillin + gentamicin for nonhospital treatment of clinical severe illness (RR 0.86, 95% CI 0.72-1.02]; n = 5054; low certainty of evidence). Other studies were heterogeneous. LIMITATIONS RCTs evaluated heterogeneous regimens, limiting our ability to pool data. CONCLUSIONS We found limited evidence to support any single antibiotic regimen as superior to alternate regimens to treat young infant sepsis or PSBI.
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Affiliation(s)
- Krysten North
- Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sitarah Mathias
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Naomi Schmeck
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yumin Kim
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Tessa Kehoe
- Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lian V Folger
- Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amber Hoey
- Bryn Mawr College, Bryn Mawr, Pennsylvania
| | - Carrie Wade
- Countway Library, Harvard Medical School, Boston, Massachusetts
| | - Sophie Driker
- Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Roger Chou
- Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | | | - Anne Cc Lee
- Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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Lokangaka A, Ramani M, Bauserman M, Patterson J, Engmann C, Tshefu A, Cousens S, Qazi SA, Ayede AI, Adejuyigbe EA, Esamai F, Wammanda RD, Nisar YB, Coppieters Y. 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. J Glob Health 2024; 14:04009. [PMID: 38299777 PMCID: PMC10832543 DOI: 10.7189/jogh.14.04009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
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.
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Affiliation(s)
- Adrien Lokangaka
- Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Manimaran Ramani
- University of Alabama at Birmingham, Birmingham, Alabama, USA
- University of South Alabama, Birmingham, Alabama, USA
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jackie Patterson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cyril Engmann
- University of Washington, Seattle, Washington, USA
- PATH Organization, Seattle, Washington, USA
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Simons Cousens
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | | | - Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | - Ebunoluwa A Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Robinson D Wammanda
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yves Coppieters
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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5
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Malchau Carlsen EL, Dungu KHS, Lewis A, Vissing NH, Aunsholt L, Trautner S, Stanchev H, Dayani GK, Pedersen AJL, Bjerager M, De Salas M, Vestergaard K, Pedersen P, Frimodt-Møller N, Greisen G, Hansen BM, Nygaard U. Switch from intravenous-to-oral antibiotics in neonatal probable and proven early-onset infection: a prospective population-based real-life multicentre cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 109:34-40. [PMID: 37369601 DOI: 10.1136/archdischild-2023-325386] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE To evaluate the implementation of switch from intravenous-to-oral antibiotic therapy with amoxicillin in neonates with early-onset infection (EOI). DESIGN, SETTING AND PATIENTS A population-based multicentre cohort study. All term-born neonates with EOI were prospectively included between 1 December 2018 to 30 November 2020. INTERVENTION Intravenous-to-oral switch antibiotic therapy in clinically stable neonates. MAIN OUTCOME MEASURES The primary outcome was readmission due to infection. Secondary outcomes were days of hospitalisation and antibiotic use in the pre-implementation versus post implementation period. RESULTS During 2 years, 835 neonates commenced antibiotics for EOI (1.5% (95% CI 1.4% to 1.6%)) of all term live births). Of those, 554 (66%) underwent a full course of treatment. There were 23 episodes of culture-proven infection (0.42 per 1000 term live births (95% CI 0.27 to 0.63)). A total of 478 of 531 (90%) neonates with probable infection underwent switch therapy. None was readmitted due to infection. The median duration of hospitalisation was 3.0 days (IQR 2.5-3.5) and 7.4 days (IQR 7.0-7.5) in the switch and intravenous therapy groups, respectively. According to antibiotic surveillance data, 1.2% underwent a full course of treatment following implementation of oral switch therapy (2019-2020), compared with 1.2% before (2017-2018). CONCLUSION In clinical practice, switch therapy was safe and used in 9 of 10 neonates with probable EOI. Knowledge of the safety of antibiotic de-escalation is important as home-based oral therapy ameliorates the treatment burden for neonates, caregivers and healthcare systems. Despite the ease of oral administration, implementation of switch therapy did not increase the overall use of antibiotics.
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Affiliation(s)
- Emma Louise Malchau Carlsen
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Department of Pediatrics, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Kia Hee Schultz Dungu
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Anna Lewis
- Department of Pediatrics, Hillerød Hospital, University of Copenhagen, Hillerod, Denmark
| | - Nadja Hawwa Vissing
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Lise Aunsholt
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhagen, Denmark
| | - Simon Trautner
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Hristo Stanchev
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | | | | | - Mia Bjerager
- Department of Pediatrics, Hillerød Hospital, University of Copenhagen, Hillerod, Denmark
| | - Maria De Salas
- Department of Pediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Pernille Pedersen
- Department of Pediatrics, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Niels Frimodt-Møller
- Department of Microbiology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Bo Mølholm Hansen
- Department of Pediatrics, Hillerød Hospital, University of Copenhagen, Hillerod, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Ulrikka Nygaard
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
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6
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Keij FM, Schouwenburg S, Kornelisse RF, Preijers T, Mir F, Degraeuwe P, Stolk LM, van Driel A, Kenter S, van der Sluijs J, Heidema J, den Butter PCP, Reiss IKM, Allegaert K, Tramper-Stranders GA, Koch BCP, Flint RB. Oral and Intravenous Amoxicillin Dosing Recommendations in Neonates: A Pooled Population Pharmacokinetic Study. Clin Infect Dis 2023; 77:1595-1603. [PMID: 37757471 PMCID: PMC10686957 DOI: 10.1093/cid/ciad432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND There is a lack of evidence on oral amoxicillin pharmacokinetics and exposure in neonates with possible serious bacterial infection (pSBI). We aimed to describe amoxicillin disposition following oral and intravenous administration and to provide dosing recommendations for preterm and term neonates treated for pSBI. METHODS In this pooled-population pharmacokinetic study, 3 datasets were combined for nonlinear mixed-effects modeling. In order to evaluate amoxicillin exposure following oral and intravenous administration, pharmacokinetic profiles for different dosing regimens were simulated with the developed population pharmacokinetic model. A target of 50% time of the free fraction above the minimal inhibitory concentration (MIC) with an MICECOFF of 8 mg/L (to cover gram-negative bacteria such as Escherichia coli) was used. RESULTS The cohort consisted of 261 (79 oral, 182 intravenous) neonates with a median (range) gestational age of 35.8 weeks (range, 24.9-42.4) and bodyweight of 2.6 kg (range, 0.5-5). A 1-compartment model with first-order absorption best described amoxicillin pharmacokinetics. Clearance (L/h/kg) in neonates born after 30 weeks' gestation increased with increasing postnatal age (PNA day 10, 1.25-fold; PNA day 20, 1.43-fold vs PNA day 3). Oral bioavailability was 87%. We found that a twice-daily regimen of 50 mg/kg/day is superior to a 3- or 4-times daily schedule in the first week of life for both oral and intravenous administration. CONCLUSIONS This pooled population pharmacokinetic description of intravenous and oral amoxicillin in neonates provides age-specific dosing recommendations. We conclude that neonates treated with oral amoxicillin in the first weeks of life reach adequate amoxicillin levels following a twice-daily dosing regimen. Oral amoxicillin therapy could therefore be an adequate, cost-effective, and more patient-friendly alternative for neonates worldwide.
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Affiliation(s)
- Fleur M Keij
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Stef Schouwenburg
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - René F Kornelisse
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tim Preijers
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Fatima Mir
- Section of Paediatric Infectious Disease, Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Pieter Degraeuwe
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Leo M Stolk
- Department of Clinical Pharmacy, Maastricht University Medical Centre, The Netherlands
| | - Arianne van Driel
- Department of Paediatrics, IJsselland Hospital, Capelle a/d IJssel, The Netherlands
| | - Sandra Kenter
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Jacqueline van der Sluijs
- Department of Paediatrics, Division of Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Jojanneke Heidema
- Department of Paediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Gerdien A Tramper-Stranders
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robert B Flint
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
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7
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Hasan BS, Hoodbhoy Z, Khan A, Nogueira M, Bijnens B, Chowdhury D. Can machine learning methods be used for identification of at-risk neonates in low-resource settings? A prospective cohort study. BMJ Paediatr Open 2023; 7:e002134. [PMID: 37918940 PMCID: PMC10626794 DOI: 10.1136/bmjpo-2023-002134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/07/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION Timely identification of at-risk neonates (ARNs) in the community is essential to reduce mortality in low-resource settings. Tools such as American Academy of Pediatrics pulse oximetry (POx) and WHO Young Infants Clinical Signs (WHOS) have high specificity but low sensitivity to identify ARNs. Our aim was assessing the value of POx and WHOS independently, in combination and with machine learning (ML) from clinical features, to detect ARNs in a low/middle-income country. METHODS This prospective cohort study was conducted in a periurban community in Pakistan. Eligible live births were screened using WHOS and POx along with clinical information regarding pregnancy and delivery. The enrolled neonates were followed for 4 weeks of life to assess the vital status. The predictive value to identify ARNs, of POx, WHOS and an ML model using maternal and neonatal clinical features, was assessed. RESULTS Of 1336 neonates, 68 (5%) had adverse outcomes, that is, sepsis (n=40, 59%), critical congenital heart disease (n=2, 3%), severe persistent pulmonary hypertension (n=1), hospitalisation (n=8, 12%) and death (n=17, 25%) assessed at 4 weeks of life. Specificity of POx and WHOS to independently identify ARNs was 99%, with sensitivity of 19% and 63%,respectively. Combining both improved sensitivity to 70%, keeping specificity at 98%. An ML model using clinical variables had 44% specificity and 76% sensitivity. A staged assessment, where WHOS, POx and ML are sequentially used for triage, increased sensitivity to 85%, keeping specificity 75%. Using ML (when WHOS and POx negative) for community follow-up detected the majority of ARNs. CONCLUSION Classic screening, combined with ML, can help maximise identifying ARNs and could be embedded in low-resource clinical settings, thereby improving outcome. Sequential use of classic assessment and clinical ML identifies the most ARNs in the community, still optimising follow-up clinical care.
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Affiliation(s)
- Babar S Hasan
- Department of Pediatrics and Child Health, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Zahra Hoodbhoy
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Amna Khan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Bart Bijnens
- IDIBAPS, Barcelona, Spain
- ICREA, Barcelona, Spain
| | - Devyani Chowdhury
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Hemingway-Foday J, Tita A, Chomba E, Mwenechanya M, Mweemba T, Nolen T, Lokangaka A, Tshefu Kitoto A, Lomendje G, Hibberd PL, Patel A, Das PK, Kurhe K, Goudar SS, Kavi A, Metgud M, Saleem S, Tikmani SS, Esamai F, Nyongesa P, Sagwe A, Figueroa L, Mazariegos M, Billah SM, Haque R, Shahjahan Siraj M, Goldenberg RL, Bauserman M, Bose C, Liechty EA, Ekhaguere OA, Krebs NF, Derman R, Petri WA, Koso-Thomas M, McClure E, Carlo WA. Prevention of maternal and neonatal death/infections with a single oral dose of azithromycin in women in labour in low-income and middle-income countries (A-PLUS): a study protocol for a multinational, randomised placebo-controlled clinical trial. BMJ Open 2023; 13:e068487. [PMID: 37648383 PMCID: PMC10471878 DOI: 10.1136/bmjopen-2022-068487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/15/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Maternal and neonatal infections are among the most frequent causes of maternal and neonatal mortality, and current antibiotic strategies have been ineffective in preventing many of these deaths. A randomised clinical trial conducted in a single site in The Gambia showed that treatment with an oral dose of 2 g azithromycin versus placebo for all women in labour reduced certain maternal and neonatal infections. However, it is unknown if this therapy reduces maternal and neonatal sepsis and mortality. In a large, multinational randomised trial, we will evaluate the impact of azithromycin given in labour to improve maternal and newborn outcomes. METHODS AND ANALYSIS This randomised, placebo-controlled, multicentre clinical trial includes two primary hypotheses, one maternal and one neonatal. The maternal hypothesis is to test whether a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in labour will reduce maternal death or sepsis. The neonatal hypothesis will test whether this intervention will reduce intrapartum/neonatal death or sepsis. The intervention is a single, prophylactic intrapartum oral dose of 2 g azithromycin, compared with a single intrapartum oral dose of an identical appearing placebo. A total of 34 000 labouring women from 8 research sites in sub-Saharan Africa, South Asia and Latin America will be randomised with a one-to-one ratio to intervention/placebo. In addition, we will assess antimicrobial resistance in a sample of women and their newborns. ETHICS AND DISSEMINATION The study protocol has been reviewed and ethics approval obtained from all the relevant ethical review boards at each research site. The results will be disseminated via peer-reviewed journals and national and international scientific forums. TRIAL REGISTRATION NUMBER NCT03871491 (https://clinicaltrials.gov/ct2/show/NCT03871491?term=NCT03871491&draw=2&rank=1).
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Affiliation(s)
| | - Alan Tita
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Elwyn Chomba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | | | - Trecious Mweemba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Tracy Nolen
- RTI International, Research Triangle Park, North Carolina, USA
| | - Adrien Lokangaka
- University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Antoinette Tshefu Kitoto
- University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Gustave Lomendje
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
- Datta Meghe Institute of Higher Education & Research (Deemed to be University), Wardha, Maharashtra, India
| | | | - Kunal Kurhe
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Avinash Kavi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Mrityunjay Metgud
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Sarah Saleem
- Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | - Shiyam S Tikmani
- Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | | | | | - Amos Sagwe
- Moi University School of Medicine, Eldoret, Kenya
| | - Lester Figueroa
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Manolo Mazariegos
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Sk Masum Billah
- The University of Sydney, Sydney, New South Wales, Australia
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Md Shahjahan Siraj
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | | | - Melissa Bauserman
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carl Bose
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Edward A Liechty
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Richard Derman
- Office of Global Affairs, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | | | - Waldemar A Carlo
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Garg CC, Mukopadhyay R, Arora NK, Awasthi S, Verma RK, Poluru R, Limbu P, Qazi SA, Bahl R, Nisar YB. Cost of treating sick young infants (0-59 days) with Possible Serious Bacterial Infection in resource-constrained outpatient primary care facilities: An insight from implementation research in two districts of Haryana and Uttar Pradesh (India). J Glob Health 2023; 13:04062. [PMID: 37594179 PMCID: PMC10436679 DOI: 10.7189/jogh.13.04062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Background Information on the average and incremental costs of implementing alternative strategies for treating young infants 0-59 days old in primary health facilities with signs of possible serious bacterial infection (PSBI) when a referral is not feasible is limited but valuable for policymakers. Methods Direct activity costs were calculated for outpatient treatment of PSBI and pneumonia in two districts of India: Palwal, Haryana and Lucknow, Uttar Pradesh. These included costs of staff time and consumables for initial assessment, classification, and referrals; recommended treatment of fast breathing (oral amoxicillin for seven days) and PSBI (injection gentamicin and oral amoxicillin for seven days); and daily assessments. Indirect operational costs included staff training; staff time cost for general management, supervision, and coordination; referral transport; and communication. Results The average cost per young infant treated for recommended and acceptable treatment for PSBI was 16 US dollars (US$) (95% CI = US$15.4-16.3) in 2018-19 and US$18.5 in 2022 (adjusted for inflation) when all direct and indirect operational costs were considered. The average cost of recommended treatment for pneumonia was US$10.1 (95% CI = US$9.7-10.6) or US$11.7 in 2022, per treated young infant. The incremental cost 2018-2019 for supplies, medicines, and operations (excluding staff time costs) per infant treated for PSBI was US$6.1 and US$4.3 and for pneumonia was US$3.5 and US$2.2 in Palwal and Lucknow, respectively. Operation and administrative costs were 25% in Palwal and 12% in Lucknow of the total PSBI treatment costs. The average cost per live birth for treating PSBI in each population was US$5 in Palwal and US$3 in Lucknow. Higher operation costs for social mobilisation activities in Palwal led to the empowerment of families and timely care-seeking. Conclusions Costs of treatment of PSBI with the recommended regimen in an outpatient setting, when a referral is not feasible, are under US$20 per treated child and must be budgeted to reduce deaths from neonatal sepsis. The investment must be made in activities that lead to successful identification, prompt care seeking, timely initiation of treatment and follow-up.
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Affiliation(s)
- Charu C Garg
- Health Financing Advisor and Executive Director, Syzygy Consulting, California, USA
| | - Rupak Mukopadhyay
- Centre for Anthropology, Amity University, Uttar Pradesh, Noida Campus, India
| | | | - Shally Awasthi
- Department of Paediatrics, King George's Medical University (KGMU), Lucknow, India
| | - Raj Kumar Verma
- Department of Paediatrics, King George's Medical University (KGMU), Lucknow, India
| | | | - Priya Limbu
- The George Institute of Global Health, New Delhi, India
| | | | - Rajiv Bahl
- Indian Council of Medical Research, New Delhi, India
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Aging (MCH), World Health Organization, Geneva, Switzerland
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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. J Glob Health 2023; 13:04056. [PMID: 37448340 DOI: 10.7189/jogh.13.04056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
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.
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11
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Optimal place of treatment for young infants aged less than two months with any low-mortality-risk sign of possible serious bacterial infection: Study Protocol for a randomised controlled trial from low- and middle-income countries. J Glob Health 2023; 13:04055. [PMID: 37449353 PMCID: PMC10346131 DOI: 10.7189/jogh.13.04055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Background World Health Organization (WHO) recommends hospitalisation and injectable antibiotics for clinical sepsis / possible serious bacterial infection (PSBI) in young infants up to two months of age. However, some young infants with low-mortality risk signs of PSBI may not require hospitalisation, for which evidence needs to be generated. Methods This is a protocol for a multicentre, individually randomised, open-label trial that will be conducted in seven sites in six countries Bangladesh, Ethiopia, India (two sites), Nigeria, Pakistan and Tanzania. All sites will use this common protocol with the same study design, inclusion of participants, intervention, comparison, and outcomes, as well as quality control and analysis procedures to contribute to the overall sample size. All young infants (age <60 days) presenting at study hospitals with any single low-mortality risk sign (high body temperature ≥38°C, severe chest indrawing, or fast breathing of ≥60 breaths per minute in <7 days old infants) will be randomised to either outpatient care with injectable gentamicin for two days and oral amoxicillin for seven days (intervention) or inpatient care with injection gentamicin plus injection ampicillin along with supportive treatment, where needed, for seven days (control). We plan to enrol 7000 eligible young infants, 3500 infants in each of the two study arms. A trained and standardised independent outcome assessor will visit all enrolled cases on days two, four, eight and 15 post-randomisation to assess the study outcomes in both intervention and control groups. The primary outcome of poor clinical outcome, defined as death within two weeks of initiation of treatment, deterioration during the 7-day treatment period, or persistence of the presenting sign at the end of the 7-day treatment period, will be compared to assess if the outpatient treatment leads to superior or at least non-inferior clinical outcome than inpatient treatment. The selected sites have extensive research experience. The methods and all study procedures will be harmonised through central training of research staff by WHO, standardisation exercises for clinical signs, central data coordination centre and internal and external monitoring. Continuous evaluation of the enrolment by the sites will be carried out through regular calls, databased monitoring, and site visits by WHO monitors. This trial has received ethical approvals from the WHO and local site institutional ethics committees. Discussion If the results show that young infants with any single low-mortality risk PSBI sign can be effectively and safely treated on an outpatient basis, it may substantially increase access to treatment for infants and families with poor access to health facilities. It may also reduce the human, financial and material costs to the health system and allow the currently overloaded health facilities to focus on more critically ill infants. This evidence will contribute toward making a case for reviewing the current WHO PSBI management guideline. Registration International Standard Randomised Controlled Trial Number ISRCTN44033252.
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12
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Russell NJ, Stöhr W, Plakkal N, Cook A, Berkley JA, Adhisivam B, Agarwal R, Ahmed NU, Balasegaram M, Ballot D, Bekker A, Berezin EN, Bilardi D, Boonkasidecha S, Carvalheiro CG, Chami N, Chaurasia S, Chiurchiu S, Colas VRF, Cousens S, Cressey TR, de Assis ACD, Dien TM, Ding Y, Dung NT, Dong H, Dramowski A, DS M, Dudeja A, Feng J, Glupczynski Y, Goel S, Goossens H, Hao DTH, Khan MI, Huertas TM, Islam MS, Jarovsky D, Khavessian N, Khorana M, Kontou A, Kostyanev T, Laoyookhon P, Lochindarat S, Larsson M, Luca MD, Malhotra-Kumar S, Mondal N, Mundhra N, Musoke P, Mussi-Pinhata MM, Nanavati R, Nakwa F, Nangia S, Nankunda J, Nardone A, Nyaoke B, Obiero CW, Owor M, Ping W, Preedisripipat K, Qazi S, Qi L, Ramdin T, Riddell A, Romani L, Roysuwan P, Saggers R, Roilides E, Saha SK, Sarafidis K, Tusubira V, Thomas R, Velaphi S, Vilken T, Wang X, Wang Y, Yang Y, Zunjie L, Ellis S, Bielicki JA, Walker AS, Heath PT, Sharland M. 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). PLoS Med 2023; 20:e1004179. [PMID: 37289666 PMCID: PMC10249878 DOI: 10.1371/journal.pmed.1004179] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/19/2023] [Indexed: 06/10/2023] Open
Abstract
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).
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Affiliation(s)
- Neal J. Russell
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Wolfgang Stöhr
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Aislinn Cook
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - James A. Berkley
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Ramesh Agarwal
- Newborn Division and WHO-CC, All India Institute of Medical Sciences, New Delhi, India
| | - Nawshad Uddin Ahmed
- Child Health Research Foundation (CHRF), Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Manica Balasegaram
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Daynia Ballot
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | | | | | | | - Cristina G. Carvalheiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Neema Chami
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suman Chaurasia
- All India Institute of Medical Sciences, Department of Paediatrics, New Delhi, India
| | - Sara Chiurchiu
- Academic Hospital Paediatric Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | | | - Simon Cousens
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tim R. Cressey
- PHPT/IRD-MIVEGEC, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Tran Minh Dien
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Yijun Ding
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Nguyen Trong Dung
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Han Dong
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Madhusudhan DS
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Ajay Dudeja
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India
| | - Jinxing Feng
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Youri Glupczynski
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Srishti Goel
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India
| | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Doan Thi Huong Hao
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Mahmudul Islam Khan
- Child Health Research Foundation (CHRF), Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Tatiana Munera Huertas
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | | | - Daniel Jarovsky
- Pediatric Infectious Diseases Unit, Santa Casa de São Paulo, São Paulo, Brazil
| | - Nathalie Khavessian
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Meera Khorana
- Neonatal Unit, Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Angeliki Kontou
- Neonatology Dept, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | | | | | - Mattias Larsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maia De Luca
- Academic Hospital Paediatric Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | | | - Nivedita Mondal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Nitu Mundhra
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Philippa Musoke
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University and MUJHU Care, Kampala, Uganda
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ruchi Nanavati
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Firdose Nakwa
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India
| | - Jolly Nankunda
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Borna Nyaoke
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Christina W. Obiero
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Department of Global Health, Amsterdam, the Netherlands
| | - Maxensia Owor
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Wang Ping
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | | | - Shamim Qazi
- World Health Organization, Maternal, Newborn, Child and Adolescent Health Department, Geneva, Switzerland
| | - Lifeng Qi
- Department of Infectious Diseases, Shenzhen Children’s Hospital, Shenzhen, China
| | - Tanusha Ramdin
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Amy Riddell
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Lorenza Romani
- Academic Hospital Paediatric Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Praewpan Roysuwan
- PHPT/IRD-MIVEGEC, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Robin Saggers
- Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Dept Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Samir K. Saha
- Child Health Research Foundation (CHRF), Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Kosmas Sarafidis
- Neonatology Dept, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Valerie Tusubira
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University and MUJHU Care, Kampala, Uganda
| | - Reenu Thomas
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tuba Vilken
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Xiaojiao Wang
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Centre for Children’s Health, Beijing, China
| | - Yajuan Wang
- Department of Neonatology, Children’s Hospital, Capital Institute of Pediatrics, Yabao Road, Chaoyang District, Beijing, China
| | - Yonghong Yang
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Liu Zunjie
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Julia A. Bielicki
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Paul T. Heath
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Mike Sharland
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
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Abdalhady M, Harrison CM. Early switch of intravenous to oral antibiotic therapy in clinically well neonates with a probable bacterial infection is as effective as a full course of intravenous antibiotics therapy. Arch Dis Child Educ Pract Ed 2023:archdischild-2023-325599. [PMID: 37197897 DOI: 10.1136/archdischild-2023-325599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
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14
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Ariff S, Soofi SB, Suhag Z, Chanar S, Bhura M, Dahar Z, Ahmed I, Turab A, Habib A, Nisar YB, Aboubaker S, Wall S, Soomro AW, Qazi SA, Bahl R, Bhutta ZA. Implementation research to increase treatment coverage of possible serious bacterial infections in young infants when a referral is not feasible: lessons learnt. J Public Health (Oxf) 2023; 45:176-188. [PMID: 35138390 PMCID: PMC10017086 DOI: 10.1093/pubmed/fdab409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/03/2021] [Accepted: 04/18/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Bashir Soofi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zamir Suhag
- People's Primary Healthcare Initiative, Sindh, Pakistan
| | - Suhail Chanar
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Maria Bhura
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zaib Dahar
- People's Primary Healthcare Initiative, Sindh, Pakistan
| | - Imran Ahmed
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Ali Turab
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Atif Habib
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Yasir Bin Nisar
- Department of Maternal Newborn Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal Newborn Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Steve Wall
- Saving Newborn Lives, Save the Children, Washington DC, USA
| | | | | | - Rajiv Bahl
- Department of Maternal Newborn Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
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15
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Muhammad Zeb MI, Shahid S, Naeem K, Fatima U, Kazi AM, Jehan F, Shafiq Y, Mehmood U, Ali R, Ali M, Ahmed I, Zaidi AK, Nisar MI. Profile: Maternal and Child Health Surveillance System in peri-urban areas of Karachi, Pakistan. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.12788.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A Maternal and Child Health Surveillance System (MCHSS) was set up by the department of pediatrics and child health, Aga Khan University, Pakistan in peri-urban areas of Karachi to provide a platform for various research projects. It was established in five low-socioeconomic communities in a stepwise manner between 2003 and 2014. The total area currently under surveillance is 18.6 km2 covering a population of 302,944. We maintain a record of all births, deaths, pregnancies, and migration events by two monthly household visits. Verbal autopsies for stillbirths, deaths of children under the age of five years and adult female deaths are also conducted. For over a decade, the MCHSS has been a platform for a variety of studies describing the burden of various infectious diseases like typhoid, pneumonia and diarrhea, evaluation of effectiveness of various treatment regimens for neonatal sepsis, assessment of the acceptance of hospitalized care, determination of the etiology of moderate to severe diarrhea, assessment of burden and etiology of neonatal sepsis and a multi-center cohort study measuring the burden of stillbirths, neonatal and maternal deaths. More recently we have also established a bio-repository of the well-characterized maternal and newborn cohort. Through a well-established MCHSS, we aim to provide concrete evidence base to guide policy makers to make informed decisions at local, national, and international levels.
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16
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Longombe AL, Ayede AI, Marete I, Mir F, Ejembi CL, Shahidullah M, Adejuyigbe EA, Wammanda RD, Tshefu A, Esamai F, Zaidi AK, Baqui AH, Cousens S. 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. J Glob Health 2022; 12:04084. [PMID: 36403158 PMCID: PMC9676044 DOI: 10.7189/jogh.12.04084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
| | - Adejumoke Idowu Ayede
- College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | - Irene Marete
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Fatima Mir
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Clara Ladi Ejembi
- Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | | | - Ebunoluwa A Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Robinson D Wammanda
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Antoinette Tshefu
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, DR Congo
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Anita K Zaidi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan,Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Simon Cousens
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
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Keij FM, Kornelisse RF, Hartwig NG, van der Sluijs-Bens J, van Beek RHT, van Driel A, van Rooij LGM, van Dalen-Vink I, Driessen GJA, Kenter S, von Lindern JS, Eijkemans M, Stam-Stigter GM, Qi H, van den Berg MM, Baartmans MGA, van der Meer-Kappelle LH, Meijssen CB, Norbruis OF, Heidema J, van Rossem MC, den Butter PCP, Allegaert K, Reiss IKM, Tramper-Stranders GA. Efficacy and safety of switching from intravenous to oral antibiotics (amoxicillin-clavulanic acid) versus a full course of intravenous antibiotics in neonates with probable bacterial infection (RAIN): a multicentre, randomised, open-label, non-inferiority trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:799-809. [PMID: 36088952 DOI: 10.1016/s2352-4642(22)00245-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/25/2022] [Accepted: 08/09/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Switching from intravenous antibiotic therapy to oral antibiotic therapy among neonates is not yet practised in high-income settings due to uncertainties about exposure and safety. We aimed to assess the efficacy and safety of early intravenous-to-oral antibiotic switch therapy compared with a full course of intravenous antibiotics among neonates with probable bacterial infection. METHODS In this multicentre, randomised, open-label, non-inferiority trial, patients were recruited at 17 hospitals in the Netherlands. Neonates (postmenstrual age ≥35 weeks, postnatal age 0-28 days, bodyweight ≥2 kg) in whom prolonged antibiotic treatment was indicated because of a probable bacterial infection, were randomly assigned (1:1) to switch to an oral suspension of amoxicillin 75 mg/kg plus clavulanic acid 18·75 mg/kg (in a 4:1 dosing ratio, given daily in three doses) or continue on intravenous antibiotics (according to the local protocol). Both groups were treated for 7 days. The primary outcome was cumulative bacterial reinfection rate 28 days after treatment completion. A margin of 3% was deemed to indicate non-inferiority, thus if the reinfection rate in the oral amoxicillin-clavulanic acid group was less than 3% higher than that in the intravenous antibiotic group the null hypothesis would be rejected. The primary outcome was assessed in the intention-to-treat population (ie, all patients who were randomly assigned and completed the final follow-up visit on day 35) and the per protocol population. Safety was analysed in all patients who received at least one administration of the allocated treatment and who completed at least one follow-up visit. Secondary outcomes included clinical deterioration and duration of hospitalisation. This trial was registered with ClinicalTrials.gov, NCT03247920, and EudraCT, 2016-004447-36. FINDINGS Between Feb 8, 2018 and May 12, 2021, 510 neonates were randomly assigned (n=255 oral amoxicillin-clavulanic group; n=255 intravenous antibiotic group). After excluding those who withdrew consent (n=4), did not fulfil inclusion criteria (n=1), and lost to follow-up (n=1), 252 neonates in each group were included in the intention-to-treat population. The cumulative reinfection rate at day 28 was similar between groups (one [<1%] of 252 neonates in the amoxicillin-clavulanic acid group vs one [<1%] of 252 neonates in the intravenous antibiotics group; between-group difference 0 [95% CI -1·9 to 1·9]; pnon-inferiority<0·0001). No statistically significant differences were observed in reported adverse events (127 [50%] vs 113 [45%]; p=0·247). In the intention-to-treat population, median duration of hospitalisation was significantly shorter in the amoxicillin-clavulanic acid group than the intravenous antibiotics group (3·4 days [95% CI 3·0-4·1] vs 6·8 days [6·5-7·0]; p<0·0001). INTERPRETATION An early intravenous-to-oral antibiotic switch with amoxicillin-clavulanic acid is non-inferior to a full course of intravenous antibiotics in neonates with probable bacterial infection and is not associated with an increased incidence of adverse events. FUNDING The Netherlands Organization for Health Research and Development, Innovatiefonds Zorgverzekeraars, and the Sophia Foundation for Scientific Research.
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Affiliation(s)
- Fleur M Keij
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands.
| | - René F Kornelisse
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Nico G Hartwig
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | | | | | - Arianne van Driel
- Department of Paediatrics, IJsselland Hospital, Capelle aan den IJssel, Netherlands
| | | | - Ilka van Dalen-Vink
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | - Gertjan J A Driessen
- Department of Paediatrics, Juliana Children's Hospital, Haga Teaching Hospital, the Hague, Netherlands
| | - Sandra Kenter
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | | | | | | | - Hongchao Qi
- Department of Biostatistics, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | | | | | - Clemens B Meijssen
- Department of Paediatrics, Meander Medical Centre, Amersfoort, Netherlands
| | - Obbe F Norbruis
- Department of Paediatrics, Isala Hospital, Zwolle, Netherlands
| | - Jojanneke Heidema
- Department of Paediatrics, St Antonius Hospital, Nieuwegein, Netherlands
| | | | | | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, Netherlands; Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Gerdien A Tramper-Stranders
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands.
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Connor NE, Islam MS, Mullany LC, Shang N, Bhutta ZA, Zaidi AKM, Soofi S, Nisar I, Panigrahi P, Panigrahi K, Satpathy R, Bose A, Isaac R, Baqui AH, Mitra DK, Sadeq-ur Rahman Q, Hossain T, Schrag SJ, Winchell JM, Arvay ML, Diaz MH, Waller JL, Weber MW, Hamer DH, Hibberd P, Nawshad Uddin Ahmed ASM, Islam M, Hossain MB, Qazi SA, El Arifeen S, Darmstadt GL, Saha SK. Risk factors for community-acquired bacterial infection among young infants in South Asia: a longitudinal cohort study with nested case-control analysis. BMJ Glob Health 2022; 7:bmjgh-2022-009706. [PMID: 36319031 PMCID: PMC9628539 DOI: 10.1136/bmjgh-2022-009706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/24/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Risk factors predisposing infants to community-acquired bacterial infections during the first 2 months of life are poorly understood in South Asia. Identifying risk factors for infection could lead to improved preventive measures and antibiotic stewardship. METHODS Five sites in Bangladesh, India and Pakistan enrolled mother-child pairs via population-based pregnancy surveillance by community health workers. Medical, sociodemographic and epidemiological risk factor data were collected. Young infants aged 0-59 days with signs of possible serious bacterial infection (pSBI) and age-matched controls provided blood and respiratory specimens that were analysed by blood culture and real-time PCR. These tests were used to build a Bayesian partial latent class model (PLCM) capable of attributing the probable cause of each infant's infection in the ANISA study. The collected risk factors from all mother-child pairs were classified and analysed against the PLCM using bivariate and stepwise logistic multivariable regression modelling to determine risk factors of probable bacterial infection. RESULTS Among 63 114 infants born, 14 655 were assessed and 6022 had signs of pSBI; of these, 81% (4859) provided blood samples for culture, 71% (4216) provided blood samples for quantitative PCR (qPCR) and 86% (5209) provided respiratory qPCR samples. Risk factors associated with bacterial-attributed infections included: low (relative risk (RR) 1.73, 95% credible interval (CrI) 1.42 to 2.11) and very low birth weight (RR 5.77, 95% CrI 3.73 to 8.94), male sex (RR 1.27, 95% CrI 1.07 to 1.52), breathing problems at birth (RR 2.50, 95% CrI 1.96 to 3.18), premature rupture of membranes (PROMs) (RR 1.27, 95% CrI 1.03 to 1.58) and being in the lowest three socioeconomic status quintiles (first RR 1.52, 95% CrI 1.07 to 2.16; second RR 1.41, 95% CrI 1.00 to 1.97; third RR 1.42, 95% CrI 1.01 to 1.99). CONCLUSION Distinct risk factors: birth weight, male sex, breathing problems at birth and PROM were significantly associated with the development of bacterial sepsis across South Asian community settings, supporting refined clinical discernment and targeted use of antimicrobials.
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Affiliation(s)
- Nicholas E Connor
- Department of Microbiology, Child Health Research Foundation, Dhaka, Bangladesh,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nong Shang
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan
| | - Anita K M Zaidi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sajid Soofi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Imran Nisar
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Pinaki Panigrahi
- Department of Pediatrics, Georgetown University Medical Center, Washington, DC, USA
| | | | | | | | - Rita Isaac
- Christian Medical College, Vellore, India
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dipak K Mitra
- Department of Public Health, North South University, Dhaka, Bangladesh
| | - Qazi Sadeq-ur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tanvir Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Stephanie J Schrag
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas M Winchell
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa L Arvay
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maureen H Diaz
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica L Waller
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Martin W Weber
- Child and Adolescent Health and Development Division, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Patricia Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Maksuda Islam
- Department of Microbiology, Child Health Research Foundation, Dhaka, Bangladesh
| | | | - Shamim A Qazi
- Consultant and Researcher, (Retired WHO staff), Geneva, Switzerland
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Samir K Saha
- Department of Microbiology, Child Health Research Foundation, Dhaka, Bangladesh
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Gupta S, PN Rao S, Yoshida S, Bahl R. Global newborn health research priorities identified in 2014: A review to evaluate the uptake. EClinicalMedicine 2022; 52:101599. [PMID: 35958522 PMCID: PMC9358417 DOI: 10.1016/j.eclinm.2022.101599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/14/2022] [Accepted: 07/14/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In 2014, World Health Organization published global research priorities for newborn health till 2025. We conducted this review to summarize completed or ongoing research on the twenty priorities. METHODS We conducted searches for twenty questions on MEDLINE via PubMed, Cochrane CENTRAL, Web of Science, clinical trial registries, and funder websites between July 2014 and May 2022. Studies addressing research questions using adequate design were included. Adequacy of uptake of a priority was assessed based on predefined criteria. FINDINGS The uptake of research priorities was high for 8 (40%), moderate for 11 (55%), and one priority, effectiveness of training community health workers (CHWs) to treat neonatal sepsis at home remains unaddressed. Priorities with moderate uptake include effectiveness of simplified neonatal resuscitation programme, simple clinical algorithms for CHWs to neonatal infection, CHWs training in basic neonatal resuscitation, community-initiated kangaroo mother care, perinatal audits, and novel tocolytic agents, scaling-up chlorhexidine cord application, stable surfactant with simpler administration, accurate, affordable methods to diagnose fetal distress, strategies for prevention and treatment of intrauterine growth retardation, and causal pathways for antenatal stillbirths. INTERPRETATION Adequate research was undertaken on pressing global concerns in newborn health. Funders and researchers should reflect on and address less researched areas. FUNDING None.
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Affiliation(s)
| | | | | | - Rajiv Bahl
- Corresponding author at: Newborn Unit Head, Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, 20 Avenue Appia, CH-1211, Geneva, Switzerland.
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Barriers to optimal care and strategies to promote safe and optimal management of sick young infants during the COVID-19 pandemic: A multi-country formative research study. J Glob Health 2022; 12:05023. [PMID: 36056769 PMCID: PMC9440476 DOI: 10.7189/jogh.12.05023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Essential health and nutrition services for pregnant women, newborns, and children, particularly in low- and middle-income countries (LMICs), are disrupted by the COVID-19 pandemic. This formative research was conducted at five LMICs to understand the pandemic's impact on barriers to and mitigation for strategies of care-seeking and managing possible serious bacterial infection (PSBI) in young infants. Methods We used a convergent parallel mixed-method design to explore the possible factors influencing PSBI management, barriers, and facilitators at three levels: 1) national and local policy, 2) the health systems, public and private facilities, and 3) community and caregivers. We ascertained trends in service provision and utilisation across pre-lockdown, lockdown, and post-lockdown periods by examining facility records and community health worker registers. Results The pandemic aggravated pre-existing challenges in the identification of young infants with PSBI; care-seeking, referral, and treatment due to several factors at the policy level (limited staff and resource reallocation), health facility level (staff quarantine, sub-optimal treatment in facilities, limited duration of service availability, lack of clear guidelines on the management of sick young infants, and inadequate supplies of protective kits and essential medicines) and at the community level (travel restrictions, lack of transportation, and fear of contracting the infection in hospitals). Care-seeking shifted to faith healers, traditional and informal private sources, or home remedies. However, caregivers were willing to admit their sick young infants to the hospital if advised by doctors. A review of facility records showed low attendance (<50%) of sick young infants in the OPD/emergencies during lockdowns in Bangladesh, India (both sites) and Pakistan, but it gradually increased as lockdowns eased. Stakeholders suggested aspirational and pragmatic mitigation strategies. Conclusions We obtained useful insights on health system preparedness during catastrophes and strategies to strengthen services and improve utilisation regarding PSBI management. The current pandemic provides an opportunity for implementing various mitigation strategies at the policy, health system, and community levels to improve preparedness.
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Arvay ML, Shang N, Qazi SA, Darmstadt GL, Islam MS, Roth DE, Liu A, Connor NE, Hossain B, Sadeq-ur Rahman Q, El Arifeen S, Mullany LC, Zaidi AKM, Bhutta ZA, Soofi SB, Shafiq Y, Baqui AH, Mitra DK, Panigrahi P, Panigrahi K, Bose A, Isaac R, Westreich D, Meshnick SR, Saha SK, Schrag SJ. Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA study. THE LANCET GLOBAL HEALTH 2022; 10:e1289-e1297. [PMID: 35961352 PMCID: PMC9380253 DOI: 10.1016/s2214-109x(22)00244-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background Globally, neonatal mortality accounts for almost half of all deaths in children younger than 5 years. Aetiological agents of neonatal infection are difficult to identify because the clinical signs are non-specific. Using data from the Aetiology of Neonatal Infections in south Asia (ANISA) cohort, we aimed to describe the spectrum of infectious aetiologies of acute neonatal illness categorised post-hoc using the 2015 WHO case definitions of critical illness, clinical severe infection, and fast breathing only. Methods Eligible infants were aged 0–59 days with possible serious bacterial infection and healthy infants enrolled in the ANISA study in Bangladesh, India, and Pakistan. We applied a partial latent class Bayesian model to estimate the prevalence of 27 pathogens detectable on PCR, pathogens detected by blood culture only, and illness not attributed to any infectious aetiology. Infants with at least one clinical specimen available were included in the analysis. We assessed the prevalence of these aetiologies according to WHO's case definitions of critically ill, clinical severe infection, and infants with late onset, isolated fast breathing. For the clinical severe definition, we compared the prevalence of signs by bacterial versus viral aetiology. Findings There were 934 infants (992 episodes) in the critically ill category, 3769 (4000 episodes) in the clinical severe infection category, and 738 (771 episodes) in the late-onset isolated fast breathing category. We estimated the proportion of illness attributable to bacterial infection was 32·7% in infants in the critically ill group, 15·6% in the clinical severe infection group, and 8·8% among infants with late-onset isolated fast breathing group. An infectious aetiology was not identified in 58–82% of infants in these categories. Among 4000 episodes of clinical severe infection, those with bacterial versus viral attribution had higher proportions of hypothermia, movement only when stimulated, convulsions, and poor feeding. Interpretation Our modelled results generally support the revised WHO case definitions, although a revision of the most severe case definition could be considered. Clinical criteria do not clearly differentiate between young infants with and without infectious aetiologies. Our results highlight the need for improved point-of-care diagnostics, and further study into neonatal deaths and episodes with no identified aetiology, to ensure antibiotic stewardship and targeted interventions. Funding The Bill and Melinda Gates Foundation.
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Bang A, Baitule S, Deshmukh M, Bang A, Duby J. Home-based management of neonatal sepsis: 23 years of sustained implementation and effectiveness in rural Gadchiroli, India, 1996-2019. BMJ Glob Health 2022; 7:bmjgh-2022-008469. [PMID: 36162868 PMCID: PMC9516090 DOI: 10.1136/bmjgh-2022-008469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 09/01/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Although hospitalisation remains the preferred management for neonatal sepsis, it is often not possible in resource-limited settings. The Home-Based Newborn Care (HBNC) study in Gadchiroli, India (1995–1998) was the first trial to demonstrate that neonatal sepsis can be managed in the community. HBNC continues to operate in Gadchiroli. In 2015, WHO recommended community-based management of neonatal sepsis when hospitalisation is not feasible but called for implementation research. We studied the implementation and effectiveness of home-based management of neonatal sepsis over 23 years in Gadchiroli. Methods In this cohort study (1996–2019), community health workers (CHWs) visited neonates at home in 39 villages in Gadchiroli, India. CHWs screened, diagnosed sepsis and offered home-based antibiotic treatment if hospitalisation was refused. We evaluated the implementation outcomes of coverage, diagnostic fidelity and adoption. We assessed the association between treatment type and odds of neonatal death using mixed effects logistic regression. Time trends were analysed using the Mann-Kendall test. Results CHWs screened 93.8% (17 700/18 874) of neonates (coverage) and correctly diagnosed 89% (1051/1177) of sepsis episodes (diagnostic fidelity). Home-based management was preferred by 88.4% (929/1051) of parents (adoption), with 5.6 percent of total neonates receiving antibioties at home. Compared with neonates treated at home, the adjusted odds of death was 5.27 (95% CI 1.91 to 14.58) times higher when parents refused all treatment, 2.17 (95% CI 1.07 to 4.41) times higher when CHWs missed the diagnosis and 5.45 (95% CI 2.74 to 10.87) times higher when parents accepted hospital referral. Implementation outcomes remained consistent over 23 years (coverage p=0.57; fidelity p=0.57; adoption p=0.26; mortality p=0.71). The rate of facility births increased (p<0.01) and the sepsis incidence decreased (p<0.05) over 23 years. Conclusion Implementation of home-based management of neonatal sepsis was sustainable and effective over 23 years. During this period, the need for home-based management in Gadchiroli is declining. Home-based management is advised where sepsis remains a major cause of neonatal mortality and hospital access is limited.
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Affiliation(s)
- Abhay Bang
- Society for Education Action and Research in Community Health, Gadchiroli, Maharashtra, India
| | - Sanjay Baitule
- Society for Education Action and Research in Community Health, Gadchiroli, Maharashtra, India
| | - Mahesh Deshmukh
- Society for Education Action and Research in Community Health, Gadchiroli, Maharashtra, India
| | - Anand Bang
- Society for Education Action and Research in Community Health, Gadchiroli, Maharashtra, India
| | - Jessica Duby
- McGill University Health Centre, Montreal, Québec, Canada
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Lokangaka A, Ishoso D, Tshefu A, Kalonji M, Takoy P, Kokolomami J, Otomba J, Aboubaker S, Qazi SA, Nisar YB, Bahl R, Bose C, Coppieters Y. Simplified antibiotic regimens for young infants with possible serious bacterial infection when the referral is not feasible in the Democratic Republic of the Congo. PLoS One 2022; 17:e0268277. [PMID: 35771738 PMCID: PMC9246187 DOI: 10.1371/journal.pone.0268277] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Neonates with serious bacterial infections should be treated with injectable antibiotics after hospitalization, which may not be feasible in many low resource settings. In 2015, the World Health Organization (WHO) launched a guideline for the management of young infants (0-59 days old) with possible serious bacterial infection (PSBI) when referral for hospital treatment is not feasible. We evaluated the feasibility of the WHO guideline implementation in the Democratic Republic of the Congo (DRC) to achieve high coverage of PSBI treatment. METHODS From April 2016 to March 2017, in a longitudinal, descriptive, mixed methods implementation research study, we implemented WHO PSBI guideline for sick young infants (0-59 dyas of age) in the public health programme setting in five health areas of North and South Ubangi Provinces with an overall population of about 60,000. We conducted policy dialogue with national and sub-national level government planners, decision-makers, academics and other stakeholders. We established a Technical Support Unit to provide implementation support. We built the capacity of health workers and managers and ensured the availability of necessary medicines and commodities. We followed infants with PSBI signs up to 14 days. The research team systematically collected data on adherence to treatment and outcomes. RESULTS We identified 3050 live births and 285 (9.3%) young infants with signs of PSBI in the study area, of whom 256 were treated. Published data have reported 10% PSBI incidence rate in young infants. Therefore, the estimated coverage of treatment was 83.9% (256/305). Another 426 from outside the study catchment area were also identified with PSBI signs by the nurses of a health centre within the study area. Thus, a total of 711 young infants with PSBI were identified, 285 (40%) 7-59 days old infants had fast breathing (pneumonia), 141 (20%) 0-6 days old had fast breathing (severe pneumonia), 233 (33%) had signs of clinical severe infection (CSI), and 52 (7%) had signs of critical illness. Referral to a hospital was advised to 426 (60%) infants with CSI, critical illness or severe pneumonia. The referral was refused by 282 families who accepted simplified antibiotic treatment on an outpatient basis at the health centres. Treatment failure among those who received outpatient treatment occurred in 10/128 (8%) with severe pneumonia, 25/147 (17%) with CSI, including one death, and 2/7 (29%) young infants with a critical illness. Among 285 infants with pneumonia, 257 (90%) received oral amoxicillin treatment, and 8 (3%) failed treatment. Adherence to outpatient treatment was 98% to 100% for various PSBI sub-categories. Among 144 infants treated in a hospital, 8% (1/13) with severe pneumonia, 23% (20/86) with CSI and 40% (18/45) with critical illness died. CONCLUSION Implementation of the WHO PSBI guideline when a referral was not possible was feasible in our context with high coverage. Without financial and technical input to strengthen the health system at all levels, including the community and the referral level, it may not be possible to achieve and sustain the same high treatment coverage.
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Affiliation(s)
- Adrien Lokangaka
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Daniel Ishoso
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Michel Kalonji
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Paulin Takoy
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jack Kokolomami
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - John Otomba
- Faculté de Médecine, Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- World Health Organization, Kinshasa, Democratic Republic of the Congo
| | | | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Carl Bose
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Yves Coppieters
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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Nisar YB, Aboubaker S, Arifeen SE, Ariff S, Arora N, Awasthi S, Ayede AI, Baqui AH, Bavdekar A, Berhane M, Chandola TR, Leul A, Sadruddin S, Tshefu A, Wammanda R, Nigussie A, Pyne-Mercier L, Pearson L, Brandes N, Wall S, Qazi SA, Bahl R. 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. PLoS One 2022; 17:e0269524. [PMID: 35696401 PMCID: PMC9191694 DOI: 10.1371/journal.pone.0269524] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization (WHO), Geneva, Switzerland
| | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shabina Ariff
- Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Shally Awasthi
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Abdullah H. Baqui
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ashish Bavdekar
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, Maharashtra, India
| | - Melkamu Berhane
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
| | | | - Abadi Leul
- Department of Paediatrics and Child Health, School of Medicine, Mekelle University, Mekelle, Ethiopia
| | | | - Antoinette Tshefu
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, DR Congo
| | - Robinson Wammanda
- Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Assaye Nigussie
- Health science college, Bahir Dar University, Bahir Dar, Ethiopia and Harvard, T.H. CHAN School of Public Health; Boston, Massachusetts, United States of America
| | - Lee Pyne-Mercier
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Luwei Pearson
- UNICEF, HQ, New York, New York, United States of America
| | | | - Steve Wall
- Save the Children, Saving Newborn Lives, Washington, DC, United States of America
| | | | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization (WHO), Geneva, Switzerland
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Shahrin L, Chisti MJ, Sarmin M, Rahman ASMMH, Shahid ASMSB, Islam MZ, Afroze F, Huq S, Ahmed T. Intravenous Amoxicillin Plus Intravenous Gentamicin for Children with Severe Pneumonia in Bangladesh: An Open-Label, Randomized, Non-Inferiority Controlled Trial. Life (Basel) 2021; 11:1299. [PMID: 34947830 PMCID: PMC8707665 DOI: 10.3390/life11121299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022] Open
Abstract
The World Health Organization (WHO) recommends intravenous (IV) ampicillin and gentamicin as first-line therapy to treat severe pneumonia in children under five years of age. Ampicillin needs to be administered at a six-hourly interval, which requires frequent nursing intervention and bed occupancy for 5-7 days, limiting its utility in resource-poor settings. We compared the efficacy of IV amoxicillin over IV ampicillin, which is a potential alternative drug in treating severe pneumonia in children between 2-59 months. We conducted an unblinded, randomized, controlled, non-inferiority trial in the Dhaka hospital of icddr,b from 1 January 2018 to 31 October 2019. Children from 2-59 months of age presenting with WHO defined severe pneumonia with respiratory danger signs were randomly assigned 1:1 to either 50 mg/kg ampicillin or 40 mg/kg amoxicillin per day with 7.5 mg/kg gentamicin. The primary outcome was treatment failure as per the standard definition of persistence of danger sign(s) of severe pneumonia beyond 48 h or deterioration within 24 h of therapy initiation. The secondary outcomes were: (i) time required for resolution of danger signs since enrolment, (ii) length of hospital stay, (iii) death during hospitalization, and (iv) rate of nosocomial infections. Among 308 enrolled participants, baseline characteristics were similar among the two groups. Sixty-two (20%) children ended up with treatment failure, 21 (14%) in amoxicillin, and 41 (27%) in ampicillin arm, which is statistically significant (relative risk [RR] 0.51, 95% CI 0.32-0.82; p = 0.004). We reported 14 deaths for serious adverse events, 4 (3%) and 10 (6%) among amoxicillin and ampicillin arm, respectively. IV amoxicillin and IV gentamicin combination is not inferior to combined IV ampicillin and IV gentamicin in treating severe pneumonia in under-five children in Bangladesh. Considering the less frequent dosing and more compliance, IV amoxicillin is a better choice for treating children with severe pneumonia in resource-limited settings.
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Affiliation(s)
- Lubaba Shahrin
- Head Acute Respiratory Infection Unit, Dhaka Hospital, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | - Mohammod Jobayer Chisti
- Head Clinical Research Unit, Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | - Monira Sarmin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | - Abu Sayem Mirza Md Hasibur Rahman
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | | | - Md Zahidul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | - Farzana Afroze
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | - Sayeeda Huq
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1000, Bangladesh
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Wen SCH, Ezure Y, Rolley L, Spurling G, Lau CL, Riaz S, Paterson DL, Irwin AD. Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003787. [PMID: 34582466 PMCID: PMC8478175 DOI: 10.1371/journal.pmed.1003787] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 09/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms, which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries. We therefore completed a systematic review and meta-analysis of available data from all low- and lower-middle-income countries (LLMICs) since 2010, with a focus on regional differences in Gram-negative infections and AMR. METHODS AND FINDINGS All studies published from 1 January 2010 to 21 April 2021 about microbiologically confirmed bloodstream infections or meningitis in neonates and AMR in LLMICs were assessed for eligibility. Small case series, studies with a small number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. We included 88 studies (4 cohort studies, 3 randomised controlled studies, and 81 cross-sectional studies) comprising 10,458 Gram-negative isolates from 19 LLMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 55% to 65%). Klebsiella spp. was the most common, with a pooled proportion of 38% of Gram-negative sepsis (95% CI 33% to 43%). Regional differences were observed, with higher proportions of Acinetobacter spp. in Asia and Klebsiella spp. in Africa. Resistance to aminoglycosides and third-generation cephalosporins ranged from 42% to 69% and from 59% to 84%, respectively. Study limitations include significant heterogeneity among included studies, exclusion of upper-middle-income countries, and potential sampling bias, with the majority of studies from tertiary hospital settings, which may overestimate the burden caused by Gram-negative bacteria. CONCLUSIONS Gram-negative bacteria are an important cause of neonatal sepsis in LLMICs and are associated with significant rates of resistance to WHO-recommended first- and second-line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required.
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Affiliation(s)
- Sophie C. H. Wen
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- * E-mail:
| | - Yukiko Ezure
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Lauren Rolley
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
| | - Geoff Spurling
- Primary Care Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Colleen L. Lau
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Saba Riaz
- Institute of Microbiology and Molecular Genetics, University of the Punjab, Lahore, Pakistan
| | - David L. Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Adam D. Irwin
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
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Shahid S, Tikmani SS, Brown N, Zaidi AK, Jehan F, Nisar MI. Young infant clinical signs study--, Pakistan: a data note. Gates Open Res 2021; 5:122. [PMID: 38510846 PMCID: PMC10950895 DOI: 10.12688/gatesopenres.13317.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 03/22/2024] Open
Abstract
Neonatal sepsis is the leading cause of child death globally with most of these deaths occurring in the first week of life. It is of utmost public health importance that clinical signs predictive of severe illness and need for referral are identified early in the course of illness. From 2002-2005, a multi country trial called the Young Infant Clinical Signs Study (YICSS) was conducted in seven sites across three South-Asian (Bangladesh, India, and Pakistan), two African (Ghana, and South Africa), and one South American (Bolivia) country. The study aimed to develop a simplified algorithm to be used by primary healthcare workers for the identification of sick young infants needing prompt referral and treatment. The main study enrolled 8,889 young infants between the ages of 0-59 days old. This dataset contains observations on 2950 young infants aged 0-59 days from the Pakistan site. The data was collected between 2003-2004 with information on the most prevalent signs and symptoms. The data from this study was used to update the Integrated Management of Childhood Illness guidelines. The World Health Organisation (WHO) seven-sign algorithm has been used in other major community-based trials to study possible serious bacterial infection and its treatment regimens.
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Affiliation(s)
- Shahira Shahid
- Department of Pediatrics and Child Health, Aga khan University, Karachi, Pakistan
| | | | - Nick Brown
- Uppsala University Hospital, Sweden, Sweden
| | - Anita K.M. Zaidi
- Department of Pediatrics and Child Health, Aga khan University, Karachi, Pakistan
| | - Fyezah Jehan
- Department of Pediatrics and Child Health, Aga khan University, Karachi, Pakistan
| | - Muhammad Imran Nisar
- Department of Pediatrics and Child Health, Aga khan University, Karachi, Pakistan
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Berhane M, Girma T, Tesfaye W, Jibat N, Abera M, Abrahim S, Aboubaker S, Nisar YB, Ahmad Qazi S, Bahl R, Abdissa A. Implementation research on management of sick young infants with possible serious bacterial infection when referral is not possible in Jimma Zone, Ethiopia: Challenges and solutions. PLoS One 2021; 16:e0255210. [PMID: 34370744 PMCID: PMC8351942 DOI: 10.1371/journal.pone.0255210] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 07/09/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Of 2.5 million newborn deaths each year, serious neonatal infections are a leading cause of neonatal death for which inpatient treatment is recommended. However, manysick newborns in sub-Saharan Africa and south Asia do not have access to inpatientcare. A World Health Organization (WHO) guideline recommends simplified antibiotic treatment atan outpatient level for young infants up to two months of age with possible serious bacterial infection (PSBI), when referral is not feasible.We implemented this guidelinein Ethiopia to increase coverage of treatment and to learn about potential facilitating factors and barriers for implementation. Methods We conducted implementation research in two districts (Tiro Afata and Gera) in Jimma Zone, Ethiopia, to learn about the feasibility of implementing the WHO PSBI guideline within a programme setting using the existing health care structure. We conducted orientation meetings and policy dialogue with key stakeholders and trained health extension workers and health centre staff to identify and manage sick young infants with PSBI signs at a primary health care unit. We established a Technical Support Unit (TSU) to facilitate programme learning, built health workers’ capacity and provided support for quality control, monitoring and data collection.We sensitized the community to appropriate care-seeking and supported the health care system in implementation. The research team collected data using structured case recording forms. Results From September 2016 to August 2017, 6185 live births and 601 sick young infants 0–59 days of age with signs of PSBI were identified. Assuming that 25% of births were missed (total births 7731) and 10% of births had an episode of PSBI in the first two months of life, the coverage of appropriate treatment for PSBI was 77.7% (601/773). Of 601 infants with PSBI, fast breathing only (pneumonia) was recorded in 432 (71.9%) infants 7–59 days of age; signs of clinical severe infection (CSI) in 155 (25.8%) and critical illnessin 14 (2.3%). Of the 432 pneumonia cases who received oral amoxicillin treatment without referral, 419 (97.0%) were successfully treated without any deaths. Of 169 sick young infants with either CSI or critical illness, only 110 were referred to a hospital; 83 did not accept referral advice and received outpatient injectable gentamicin plus oral amoxicillin treatment either at a health post or health centre. Additionally, 59 infants who should have been referred, but were not received injectable gentamicin plus oral amoxicillin outpatient treatment. Of infants with CSI, 129 (82.2%) were successfully treated as outpatients, while two died (1.3%). Of 14 infants with critical illness, the caregivers of five accepted referral to a hospital, and nine were treated with simplified antibiotics on an outpatient basis. Two of 14 (14.3%) infants with critical illness died within 14 days of initial presentation. Conclusion In settings where referral to a hospital is not feasible, young infants with PSBI can be treated on an outpatient basis at either a health post or health centre, which can contribute to saving many lives. Scaling-up will require health system strengthening including community mobilization. Registration Trial is registered on Australian New Zealand Clinical Trials registry (ANZCTR) ACTRN12617001373369.
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Affiliation(s)
- Melkamu Berhane
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
- * E-mail:
| | - Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
| | - Workneh Tesfaye
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
| | - Nega Jibat
- College of Social Sciences and Humanities, Jimma University, Jimma, Ethiopia
| | - Mulumebet Abera
- Department of Population and Family Health, Jimma University, Jimma, Ethiopia
| | | | - Samira Aboubaker
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization (Retired) Currently WHO consultants, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization (Retired) Currently WHO consultants, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
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Mukhopadhyay R, Arora NK, Sharma PK, Dalpath S, Limbu P, Kataria G, Singh RK, Poluru R, Malik Y, Khera A, Prabhakar PK, Kumar S, Gupta R, Chellani H, Aggarwal KC, Gupta R, Arya S, Aboubaker S, Bahl R, Nisar YB, Qazi SA. Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India. PLoS One 2021; 16:e0252700. [PMID: 34234352 PMCID: PMC8279773 DOI: 10.1371/journal.pone.0252700] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 05/07/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. METHODOLOGY The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0-59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). FINDINGS A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0-6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7-59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. CONCLUSION The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7-59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7-59 days old fast breathers and recommend a review of the current national policy.
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Affiliation(s)
| | | | | | - Suresh Dalpath
- Department of Health, Government of Haryana, Palwal/Chandigarh, India
| | - Priya Limbu
- The INCLEN Trust International, New Delhi, India
| | | | | | | | - Yogesh Malik
- Department of Health, Government of Haryana, Palwal/Chandigarh, India
| | - Ajay Khera
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - P. K. Prabhakar
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Saket Kumar
- Department of Health, Government of Haryana, Palwal/Chandigarh, India
| | - Rakesh Gupta
- Department of Health, Government of Haryana, Palwal/Chandigarh, India
| | - Harish Chellani
- Department of Pediatrics, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Kailash Chander Aggarwal
- Department of Pediatrics, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Ratan Gupta
- Department of Pediatrics, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Sugandha Arya
- Department of Pediatrics, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Nisar YB, Tshefu A, Longombe AL, Esamai F, Marete I, Ayede AI, Adejuyigbe EA, Wammanda RD, Qazi SA, Bahl R. Clinical signs of possible serious infection and associated mortality among young infants presenting at first-level health facilities. PLoS One 2021; 16:e0253110. [PMID: 34191832 PMCID: PMC8244884 DOI: 10.1371/journal.pone.0253110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 05/30/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization recommends inpatient hospital treatment of young infants up to two months old with any sign of possible serious infection. However, each sign may have a different risk of death. The current study aims to calculate the case fatality ratio for infants with individual or combined signs of possible serious infection, stratified by inpatient or outpatient treatment. METHODS We analysed data from the African Neonatal Sepsis Trial conducted in five sites in the Democratic Republic of the Congo, Kenya and Nigeria. Trained study nurses classified sick infants as pneumonia (fast breathing in 7-59 days old), severe pneumonia (fast breathing in 0-6 days old), clinical severe infection [severe chest indrawing, high (> = 38°C) or low body temperature (<35.5°C), stopped feeding well, or movement only when stimulated] or critical illness (convulsions, not able to feed at all, or no movement at all), and referred them to a hospital for inpatient treatment. Infants whose caregivers refused referral received outpatient treatment. The case fatality ratio by day 15 was calculated for individual and combined clinical signs and stratified by place of treatment. An infant with signs of clinical severe infection or severe pneumonia was recategorised as having low- (case fatality ratio ≤2%) or moderate- (case fatality ratio >2%) mortality risk. RESULTS Of 7129 young infants with a possible serious infection, fast breathing (in 7-59 days old) was the most prevalent sign (26%), followed by high body temperature (20%) and severe chest indrawing (19%). Infants with pneumonia had the lowest case fatality ratio (0.2%), followed by severe pneumonia (2.0%), clinical severe infection (2.3%) and critical illness (16.9%). Infants with clinical severe infection had a wide range of case fatality ratios for individual signs (from 0.8% to 11.0%). Infants with pneumonia had similar case fatality ratio for outpatient and inpatient treatment (0.2% vs. 0.3%, p = 0.74). Infants with clinical severe infection or severe pneumonia had a lower case fatality ratio among those who received outpatient treatment compared to inpatient treatment (1.9% vs. 6.5%, p<0.0001). We recategorised infants into low-mortality risk signs (case fatality ratio ≤2%) of clinical severe infection (high body temperature, or severe chest indrawing) or severe pneumonia and moderate-mortality risk signs (case fatality ratio >2%) (stopped feeding well, movement only when stimulated, low body temperature or multiple signs of clinical severe infection). We found that both categories had four times lower case fatality ratio when treated as outpatient than inpatient treatment, i.e., 1.0% vs. 4.0% (p<0.0001) and 5.3% vs. 22.4% (p<0.0001), respectively. In contrast, infants with signs of critical illness had nearly two times higher case fatality ratio when treated as outpatient versus inpatient treatment (21.7% vs. 12.1%, p = 0.097). CONCLUSIONS The mortality risk differs with clinical signs. Young infants with a possible serious infection can be grouped into those with low-mortality risk signs (high body temperature, or severe chest indrawing or severe pneumonia); moderate-mortality risk signs (stopped feeding well, movement only when stimulated, low body temperature or multiple signs of clinical severe infection), or high-mortality risk signs (signs of critical illness). New treatment strategies that consider differential mortality risks for the place of treatment and duration of inpatient treatment could be developed and evaluated based on these findings. CLINICAL TRIAL REGISTRATION This trial was registered with the Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.
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Affiliation(s)
- Yasir Bin Nisar
- Department of Maternal, Neonatal, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Antoinette Tshefu
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, DR Congo
| | | | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Irene Marete
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Adejumoke Idowu Ayede
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Ebunoluwa A Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Robinson D Wammanda
- Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | | | - Rajiv Bahl
- Department of Maternal, Neonatal, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Korang SK, Safi S, Nava C, Gordon A, Gupta M, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for early-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013837. [PMID: 33998666 PMCID: PMC8127574 DOI: 10.1002/14651858.cd013837.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Possibly due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units. The last Cochrane Review was updated in 2004. Given the clinical importance, an updated systematic review assessing the effects of different antibiotic regimens for early-onset neonatal sepsis is needed. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for early-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2020, Issue 8); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for early-onset neonatal sepsis. We included participants from birth to 72 hours of life at randomisation. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (865 participants). All trials were at high risk of bias. The certainty of the evidence according to GRADE was very low. The included trials assessed five different comparisons of antibiotics. We did not conduct any meta-analyses due to lack of relevant data. Of the five included trials one trial compared ampicillin plus gentamicin with benzylpenicillin plus gentamicin; one trial compared piperacillin plus tazobactam with amikacin; one trial compared ticarcillin plus clavulanic acid with piperacillin plus gentamicin; one trial compared piperacillin with ampicillin plus amikacin; and one trial compared ceftazidime with benzylpenicillin plus gentamicin. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. Large RCTs assessing different antibiotic regimens in early-onset neonatal sepsis with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Adrienne Gordon
- Neonatology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Korang SK, Safi S, Nava C, Greisen G, Gupta M, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for late-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013836. [PMID: 33998665 PMCID: PMC8127057 DOI: 10.1002/14651858.cd013836.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units, and observational studies in high-income countries suggest that 83% to 94% of newborns treated with antibiotics for suspected sepsis have negative blood cultures. The last Cochrane Review was updated in 2005. There is a need for an updated systematic review assessing the effects of different antibiotic regimens for late-onset neonatal sepsis. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for late-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2021, Issue 3); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for late-onset neonatal sepsis. We included participants older than 72 hours of life at randomisation, suspected or diagnosed with neonatal sepsis, meningitis, osteomyelitis, endocarditis, or necrotising enterocolitis. We excluded trials that assessed treatment of fungal infections. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (580 participants). All trials were at high risk of bias, and had very low-certainty evidence. The five included trials assessed five different comparisons of antibiotics. We did not conduct a meta-analysis due to lack of relevant data. Of the five included trials one trial compared cefazolin plus amikacin with vancomycin plus amikacin; one trial compared ticarcillin plus clavulanic acid with flucloxacillin plus gentamicin; one trial compared cloxacillin plus amikacin with cefotaxime plus gentamicin; one trial compared meropenem with standard care (ampicillin plus gentamicin or cefotaxime plus gentamicin); and one trial compared vancomycin plus gentamicin with vancomycin plus aztreonam. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. RCTs assessing different antibiotic regimens in late-onset neonatal sepsis with low risks of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Ayede AI, Ashubu OO, Fowobaje KR, Aboubaker S, Nisar YB, Qazi SA, Bahl R, Falade AG. Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria. PLoS One 2021; 16:e0248720. [PMID: 33784321 PMCID: PMC8009401 DOI: 10.1371/journal.pone.0248720] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/03/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Neonatal infections contribute substantially to infant mortality in Nigeria and globally. Management requires hospitalization, which is not accessible to many in low resource settings. World Health Organization developed a guideline to manage possible serious bacterial infection (PSBI) in young infants up to two months of age when a referral is not feasible. We evaluated the feasibility of implementing this guideline to achieve high coverage of treatment. Methods This implementation research was conducted in out-patient settings of eight primary health care centres (PHC) in Lagelu Local Government Area (LGA) of Ibadan, Oyo State, Nigeria. We conducted policy dialogue with the Federal and State officials to adopt the WHO guideline within the existing programme setting and held orientation and sensitization meetings with communities. We established a Technical Support Unit (TSU), built the capacity of health care providers, supervised and mentored them, monitored the quality of services and collected data for management and outcomes of sick young infants with PSBI signs. The Primary Health Care Directorate of the state ministry and the local government led the implementation and provided technical support. The enablers and barriers to implementation were documented. Results From 1 April 2016 to 31 July 2017 we identified 5278 live births and of these, 1214 had a sign of PSBI. Assuming 30% of births were missed due to temporary migration to maternal homes for delivery care and approximately 45% cases came from outside the catchment area due to free availability of medicines, the treatment coverage was 97.3% (668 cases/6861 expected births) with an expected 10% PSBI prevalence within the first 2 months of life. Of 1214 infants with PSBI, 392 (32%) infants 7–59 days had only fast breathing (pneumonia), 338 (27.8%) infants 0–6 days had only fast breathing (severe pneumonia), 462 (38%) presented with signs of clinical severe infection (CSI) and 22 (1.8%) with signs of critical illness. All but two, 7–59 days old infants with pneumonia were treated with oral amoxicillin without a referral; 80% (312/390) adhered to full treatment; 97.7% (381/390) were cured, and no deaths were reported. Referral to the hospital was not accepted by 87.7% (721/822) families of infants presenting with signs of PSBI needing hospitalization (critical illness 5/22; clinical severe infection; 399/462 and severe pneumonia 317/338). They were treated on an outpatient basis with two days of injectable gentamicin and seven days of oral amoxicillin. Among these 81% (584/721) completed treatment; 97% (700/721) were cured, and three deaths were reported (two with critical illness and one with clinical severe infection). We identified health system gaps including lack of staff motivation and work strikes, medicines stockouts, sub-optimal home visits that affected implementation. Conclusions When a referral is not feasible, outpatient treatment for young infants with signs of PSBI is possible within existing programme structures in Nigeria with high coverage and low case fatality. To scale up this intervention successfully, government commitment is needed to strengthen the health system, motivate and train health workers, provide necessary commodities, establish technical support for implementation and strengthen linkages with communities. Registration Trial is registered on Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001373369.
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MESH Headings
- Ambulatory Care/methods
- Amoxicillin/therapeutic use
- Anti-Bacterial Agents/therapeutic use
- Delivery of Health Care/methods
- Feasibility Studies
- Follow-Up Studies
- Gentamicins/therapeutic use
- Guideline Adherence
- Health Personnel
- House Calls
- Humans
- Infant
- Infant Mortality
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/microbiology
- Infant, Newborn, Diseases/mortality
- Nigeria/epidemiology
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/microbiology
- Pneumonia, Bacterial/mortality
- Practice Guidelines as Topic
- Referral and Consultation
- Registries
- Treatment Outcome
- World Health Organization
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Affiliation(s)
- Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
- * E-mail:
| | - Oluwakemi Oluwafunmi Ashubu
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
| | - Kayode Raphael Fowobaje
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
| | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | | | - Rajiv Bahl
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Adegoke Gbadegesin Falade
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
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Garg CC, Tshefu A, Longombe AL, Kila JSN, Esamai F, Gisore P, Ayede AI, Falade AG, Adejuyigbe EA, Anyabolu CH, Wammanda RD, Hyellashelni JD, Yoshida S, Gram L, Nisar YB, Qazi SA, Bahl R. Costs and cost-effectiveness of management of possible serious bacterial infections in young infants in outpatient settings when referral to a hospital was not possible: Results from randomized trials in Africa. PLoS One 2021; 16:e0247977. [PMID: 33720960 PMCID: PMC7959374 DOI: 10.1371/journal.pone.0247977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 02/15/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Serious bacterial neonatal infections are a major cause of global neonatal mortality. While hospitalized treatment is recommended, families cannot access inpatient treatment in low resource settings. Two parallel randomized control trials were conducted at five sites in three countries (Democratic Republic of Congo, Kenya, and Nigeria) to compare the effectiveness of treatment with experimental regimens requiring fewer injections with a reference regimen A (injection gentamicin plus injection procaine penicillin both once daily for 7 days) on the outpatient basis provided to young infants (0–59 days) with signs of possible serious bacterial infection (PSBI) when the referral was not feasible. Costs were estimated to quantify the financial implications of scaleup, and cost-effectiveness of these regimens. Methods Direct economic costs (including personnel, drugs and consumable costs) were estimated for identification, prenatal and postnatal visits, assessment, classification, treatment and follow-up. Data on time spent by providers on each activity was collected from 83% of providers. Indirect marginal financial costs were estimated for non-consumables/capital, training, transport, communication, administration and supervision by considering only a share of the total research and health system costs considered important for the program. Total economic costs (direct plus indirect) per young infant treated were estimated based on 39% of young infants enrolled in the trial during 2012 and the number of days each treated during one year. The incremental cost-effectiveness ratio was calculated using treatment failure after one week as the outcome indicator. Experimental regimens were compared to the reference regimen and pairwise comparisons were also made. Results The average costs of treating a young infant with clinical severe infection (a sub-category of PSBI) in 2012 was lowest with regimen D (injection gentamicin once daily for 2 days plus oral amoxicillin twice daily for 7 days) at US$ 20.9 (95% CI US$ 16.4–25.3) or US$ 32.5 (2018 prices). While all experimental regimens B (injection gentamicin once daily plus oral amoxicillin twice daily, both for 7 days), regimen C (once daily of injection gentamicin injection plus injection procaine penicillin for 2 days, thereafter oral amoxicillin twice daily for 5 days) and regimen D were found to be more cost-effective as compared with the reference regimen A; pairwise comparison showed regimen D was more cost-effective than B or C. For fast breathing, the average cost of treatment with regimen E (oral amoxicillin twice daily for 7 days) at US$ 18.3 (95% CI US$ 13.4–23.3) or US$ 29.0 (2018 prices) was more cost-effective than regimen A. Indirect costs were 32% of the total treatment costs. Conclusion Scaling up of outpatient treatment for PSBI when the referral is not feasible with fewer injections and oral antibiotics is cost-effective for young infants and can lead to increased access to treatment resulting in potential reductions in neonatal mortality. Clinical trial registration The trial was registered with Australian New Zealand Clinical
Trials Registry under ID ACTRN 12610000286044.
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Affiliation(s)
- Charu C. Garg
- Consultant, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
- * E-mail:
| | - Antoinette Tshefu
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Adrien Lokangaka Longombe
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Jean-Serge Ngaima Kila
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Peter Gisore
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | - Adegoke Gbadegesin Falade
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | | | - Chineme Henry Anyabolu
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Robinson D. Wammanda
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Joshua Daba Hyellashelni
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Lu Gram
- University College London, London, United Kingdom
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Shamim Ahmad Qazi
- Consultant, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Cassini A, Fleischmann-Struzek C, Naghavi M, Reinhart K, Allegranzi B. Future directions and priorities in sepsis epidemiology research: a call for action. Bull World Health Organ 2021; 99:398-401. [PMID: 33958829 PMCID: PMC8061674 DOI: 10.2471/blt.20.276709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/08/2021] [Accepted: 01/21/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
- Alessandro Cassini
- Department of Integrated Health Services, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | | | - Mohsen Naghavi
- Department of Health Metrics Sciences, University of Washington, Seattle, United States of America
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Benedetta Allegranzi
- Department of Integrated Health Services, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
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Prevalence of clinical signs of possible serious bacterial infection and mortality associated with them from population-based surveillance of young infants from birth to 2 months of age. PLoS One 2021; 16:e0247457. [PMID: 33626090 PMCID: PMC7904202 DOI: 10.1371/journal.pone.0247457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background Community-based data on the prevalence of clinical signs of possible serious bacterial infection (PSBI) and the mortality associated with them are scarce. The aim was to examine the prevalence for each sign of infection and mortality associated with infants in the first two months of life, using community surveillance through community health workers (CHW). Methods We used population-based surveillance data of infants up to two months of age from the African Neonatal Sepsis Trial (AFRINEST). In this study, CHWs visited infants up to 10 times during the first two months of life at five sites in three sub-Saharan African countries. CHW assessed the infant for signs of infection (local or systemic) and referred infants who presented with any sign of infection to a health facility. We used a longitudinal analysis to calculate the risk of death associated with the presence of a sign of infection at the time of the visit until the subsequent visit. Results During the first two months of their life, CHWs visited 84,759 live-born infants at least twice. In 11,089 infants (13.1%), one or more signs of infection were identified, of which 237 (2.1%) died. A sign of infection was detected at 2.1% of total visits. In 52% of visits, infants had one or more sign of systemic infection, while 25% had fast breathing in 7–59 days period and 23% had a local infection. All signs of infection, including multiple signs, were more frequently seen in the first week of life. The risk of mortality was very low (0.2%) for local infections and fast breathing in 7–59 days old, it was low for fast breathing 0–6 days old (0.6%), high body temperature (0.7%) and severe chest indrawing (1.0%), moderate for low body temperature (4.9%) and stopped feeding well/not able to feed at all (5.0%) and high for movement only when stimulated or no movement at all (10%) and multiple signs of systemic infection (15.5%). The risk of death associated with most clinical signs was higher (1.5 to 9 times) in the first week of life than at later age, except for low body temperature (4 times lower) as well as high body temperature (2 times lower). Conclusion Signs of infections are common in the first two months of life. The mortality risk differs with clinical signs and can be grouped as very low (local infections, fast breathing 7–59 days), low (fever, severe chest indrawing and fast breathing 0–6 days), moderate (low body temperature and stopped feeding well/not able to feed at all) and high (for movements only on stimulation or no movements at all and multiple signs of infection). New treatment strategies that consider differential mortality risk could be developed and evaluated based on these findings. Clinical trial registration The trial was registered with Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.
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Innovative approach for potential scale-up to jump-start simplified management of sick young infants with possible serious bacterial infection when a referral is not feasible: Findings from implementation research. PLoS One 2021; 16:e0244192. [PMID: 33544712 PMCID: PMC7864440 DOI: 10.1371/journal.pone.0244192] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neonatal bacterial infections are a common cause of death, which can be managed well with inpatient treatment. Unfortunately, many families in low resource settings do not accept referral to a hospital. The World Health Organization (WHO) developed a guideline for management of young infants up to 2 months of age with possible serious bacterial infection (PSBI) when referral is not feasible. Government of Ethiopia with WHO evaluated the feasibility of implementing this guideline to increase coverage of treatment. OBJECTIVE The objective of this study was to implement a simplified antibiotic regimen (2 days gentamicin injection and 7 days oral amoxicillin) for management of sick young infants with PSBI in a programme setting when referral was not feasible to identify at least 80% of PSBI cases, achieve an overall adequate treatment coverage of at least 80% and document the challenges and opportunities for implementation at the community level in two districts in Tigray, Ethiopia. METHODS Using implementation research, we applied the PSBI guideline in a programme setting from January 2016 to August 2017 in Raya Alamata and Raya Azebo Woredas (districts) in Southern Tigray, Ethiopia with a population of 260884. Policy dialogue was held with decision-makers, programme implementers and stakeholders at federal, regional and district levels, and a Technical Support Unit (TSU) was established. Health Extension Workers (HEWs) working at the health posts and supervisors working at the health centres were trained in WHO guideline to manage sick young infants when referral was not feasible. Communities were sensitized towards appropriate home care. RESULTS We identified 854 young infants with any sign of PSBI in the study population of 7857 live births. The expected live births during the study period were 9821. Assuming 10% of neonates will have any sign of PSBI within the first 2 months of life (n = 982), the coverage of appropriate treatment of PSBI cases in our study area was 87% (854/982). Of the 854 sick young infants, 333 (39%) were taken directly to a hospital and 521 (61%) were identified by HEW at health posts. Of the 521 young infants, 27 (5.2%) had signs of critical illness, 181 (34.7%) had signs of clinical severe infection, whereas 313 (60.1%) young infants 7-59 days of age had only fast breathing pneumonia. All young infants with critical illness accepted referral to a hospital, while 117/181 (64.6%) infants with clinical severe infection accepted referral. Families of 64 (35.3%) infants with clinical severe infection refused referral and were treated at the health post with injectable gentamicin for 2 days plus oral amoxicillin for 7 days. All 64 completed recommended gentamicin doses and 63/64 (98%) completed recommended amoxicillin doses. Of 313 young infants, 7-59 days with pneumonia who were treated by the HEWs without referral with oral amoxicillin for 7 days, 310 (99%) received all 14 doses. No deaths were reported among those treated on an outpatient basis at health posts. But 35/477 (7%) deaths occurred among young infants treated at hospital. CONCLUSIONS When referral is not feasible, young infants with PSBI can be managed appropriately at health posts by HEWs in the existing health system in Ethiopia with high coverage, low treatment failure and a low case fatality rate. Moreover, fast breathing pneumonia in infants 7-59 days of age can be successfully treated at the health post without referral. Relatively higher mortality in sick young infants at the referral level health facilities warrants further investigation.
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Goyal N, Rongsen-Chandola T, Sood M, Sinha B, Kumar A, Qazi SA, Aboubaker S, Nisar YB, Bahl R, Bhan MK, Bhandari N. Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India. PLoS One 2020; 15:e0243724. [PMID: 33351810 PMCID: PMC7755274 DOI: 10.1371/journal.pone.0243724] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 11/28/2020] [Indexed: 11/18/2022] Open
Abstract
Background Government of India and the World Health Organization have guidelines for outpatient management of young infants 0–59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. Methods Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. Findings Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0–6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7–59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. Conclusions Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.
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Affiliation(s)
- Nidhi Goyal
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
| | - Temsunaro Rongsen-Chandola
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
- * E-mail:
| | - Mangla Sood
- Department of Pediatrics, Indira Gandhi Medical College, Shimla and Child Health, National Health Mission, Himachal Pradesh, India
| | - Bireshwar Sinha
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
| | - Amit Kumar
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Maharaj Kishan Bhan
- Indian Institute of Technology-Delhi, New Delhi, India
- Knowledge Integration and Translational Platform (KnIT), Biotechnology Industry Research Assistance Council (BIRAC), New Delhi, India
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
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Mir F, Pearce RE, Baig-Ansari N, Qazi S, Barrett JS, Abdel-Rahman S, Kearns G, Zaidi AK. Serum amoxicillin levels in young infants (0-59 days) with sepsis treated with oral amoxicillin. Arch Dis Child 2020; 105:1208-1214. [PMID: 32404437 DOI: 10.1136/archdischild-2019-317342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/07/2020] [Accepted: 04/17/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND WHO recommends simplified antibiotics for young infants with sepsis in countries where hospitalisation is not feasible. Amoxicillin provides safe, Gram-positive coverage. This study was done to determine pharmacokinetics, drug disposition and interpopulation variability of oral amoxicillin in this demographic. METHODS Young infants with signs of sepsis enrolled in an oral amoxicillin/intramuscular gentamicin treatment arm of a sepsis trial in Karachi, Pakistan, were studied. Limited pharmacokinetic (PK) sampling was performed at 0, 2-3 and 6-8 hours following an index dose of oral amoxicillin. Plasma concentrations were determined by high-performance liquid chromatography/mass spectrometry. Values of ≥2 mg/L were considered as the effect threshold, given the regional minimal inhibitory concentration (MIC) of resistant Streptococcus pneumoniae. RESULTS: Amoxicillin concentrations were determined in 129 samples from 60 young infants. Six of 44 infants had positive blood cultures with predominant Gram-positive organisms. Forty-four infants contributing blood at ≥2 of 3 specified timepoints were included in the analysis. Mean amoxicillin levels at 2-3 hours (11.6±9.5 mg/L, n=44) and 6-8 hours (16.4±9.3 mg/L, n=20) following the index dose exceeded the MIC for amoxicillin (2.0 mg/L) against resistant S. pneumoniae strains. Of 20 infants with three serum levels, 7 showed a classic dose-exposure profile and 13 showed increasing concentrations with time, implying delayed absorption or excretion. CONCLUSION Amoxicillin concentrations in sera of young infants following oral administration at 75-100 mg/kg/day daily divided doses exceeds the susceptibility breakpoint for >50% of a 12-hour dosing interval.Oral amoxicillin may hold potential as a safe replacement of parenteral ampicillin in newborn sepsis regimens, including aminoglycosides, where hospitalisation is not feasible. TRIAL REGISTRATION NUMBER NCT01027429.
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Affiliation(s)
- Fatima Mir
- Section of Pediatric Infectious Disease, Pediatrics and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Robin E Pearce
- Pediatric Clinical Pharmacology, The Childrens Mercy Hospital (CMH), University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Naila Baig-Ansari
- Indus Hospital Research Center (IHRC), The Indus Hospital, Karachi, Pakistan
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Jeffrey S Barrett
- Quantitative Sciences, Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA
| | - Susan Abdel-Rahman
- Pediatric Clinical Pharmacology, The Childrens Mercy Hospital (CMH), University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Greg Kearns
- Department of Medical Research, Children's Mercy Hospital, Kansas City, Missouri, USA.,Pediatrics, TCU-UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - Anita Km Zaidi
- Section of Pediatric Infectious Disease, Pediatrics and Child Health, the Aga Khan University, Karachi, Pakistan
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Bhura M, Ariff S, Qazi SA, Qazi Z, Ahmed I, Nisar YB, Suhag Z, Soomro AW, Soofi SB. Evaluating implementation of "management of Possible Serious Bacterial Infection (PSBI) when referral is not feasible" in primary health care facilities in Sindh province, Pakistan. PLoS One 2020; 15:e0240688. [PMID: 33052981 PMCID: PMC7556471 DOI: 10.1371/journal.pone.0240688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Background The World Health Organization (WHO) launched a guideline in 2015 for managing Possible Serious Bacterial Infection (PSBI) when referral is not feasible in young infants aged 0–59 days. This guideline was implemented across 303 Basic Health Unit (BHU) Plus primary health care (PHC) facilities in peri-urban and rural settings of Sindh, Pakistan. We evaluated the implementation of PSBI guideline, and the quality of care provided to sick young infants at these facilities. Methods Thirty (10%) out of 303 BHU Plus facilities were randomly selected for evaluation. A survey team visited each facility for one day, assessed the health system support, observed the management of sick young infants by health care providers (HCP), validated their management, interviewed HCPs and caretakers of sick infants. HCPs who were unable to see a young infant on the day of survey were evaluated using pre-prepared case scenarios. Results Thirty (100%) BHU Plus facilities had oral amoxicillin, injectable gentamicin, thermometers, baby weighing scales and respiratory timers available; 29 (97%) had disposable syringes and needles; 28 (93%) had integrated management of childhood illness (IMCI)/PSBI chart booklets and job aids and 18 (60%) had a functional ambulance. Each facility had at least one HCP trained in PSBI, and 21 (70%) facilities had been visited by a supervisor in the preceding six months. Of 42 HCPs, 19 (45.3%) were trained within the preceding 12 months. During the survey, 26 sick young infants were identified in 18 facilities. HCPs asked about history of breastfeeding in 23 (89%) infants, history of vomiting in 17 (65%), and history of convulsions in 14 (54%); weighed 25 (97%) infants; measured respiratory rate in all (100%) and temperature in 24 (92%); assessed 20 (77%) for movement and 14 (54%) for chest indrawing. HCPs identified two infants with fast breathing pneumonia and managed them correctly per IMCI/PSBI protocol. HCPs identified six (23%) infants with clinical severe infection (CSI), two of them were referred to a higher-level facility, only one accepted the referral advice. Only one CSI patient was managed correctly per IMCI/PSBI protocol at the outpatient level. HCPs described the PSBI danger signs to eight (31%) caretakers. Caretakers of five infants with CSI and two with pneumonia were not counselled for PSBI danger signs. Five of the six CSI cases categorized by HCPs were validated as CSI on re-examination, whereas one had pneumonia. Similarly, one of the two pneumonia patients categorized by HCPs had CSI and one identified as local bacterial infection was classified as CSI upon re-examination. Conclusion Health system support was adequate but clinical management and counselling by HCPs was sub-optimal particularly with CSI cases who are at higher risk of adverse outcomes. Scaling up PSBI management is potentially feasible in PHC facilities in Pakistan, provided that HCPs are trained well and mentored, receive refresher training to appropriately manage sick young infants, and have adequate supplies and counselling skills.
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Affiliation(s)
- Maria Bhura
- Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shamim Ahmad Qazi
- Retired from Department of Maternal, Newborn, Child, and Adolescent Health, WHO, Working as a WHO Consultant, Geneva, Switzerland
| | | | - Imran Ahmed
- Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Yasir bin Nisar
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Zamir Suhag
- People’s Primary Healthcare Initiative, Sindh, Pakistan
| | | | - Sajid Bashir Soofi
- Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- * E-mail:
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D'Agate S, Musuamba FT, Della Pasqua O. Dose Rationale for Amoxicillin in Neonatal Sepsis When Referral Is Not Possible. Front Pharmacol 2020; 11:521933. [PMID: 33117151 PMCID: PMC7549385 DOI: 10.3389/fphar.2020.521933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/24/2020] [Indexed: 01/17/2023] Open
Abstract
Background Despite the widespread use of amoxicillin in young children, efforts to establish the feasibility of simplified dosing regimens in resource-limited settings have relied upon empirical evidence of efficacy. Given the antibacterial profile of beta-lactams, understanding of the determinants of pharmacokinetic variability may provide a more robust guidance for the selection of a suitable regimen. Here we propose a simplified dosing regimen based on pharmacokinetic-pharmacodynamic principles, taking into account the impact of growth, renal maturation and disease processes on the systemic exposure to amoxicillin. Materials and Methods A meta-analytical modeling approach was applied to allow the adaptation of an existing pharmacokinetic model for amoxicillin in critically ill adults. Model parameterization was based on allometric concepts, including a maturation function. Clinical trial simulations were then performed to characterize exposure, as defined by secondary pharmacokinetic parameters (AUC, Cmax, Cmin) and T>MIC. The maximization of the T>MIC was used as criterion for the purpose of this analysis and results compared to current WHO guidelines. Results A two-compartment model with first order absorption and elimination was found to best describe the pharmacokinetics of amoxicillin in the target population. In addition to the changes in clearance and volume distribution associated with demographic covariates, our results show that sepsis alters drug distribution, leading to lower amoxicillin levels and longer half-life as compared to non-systemic disease conditions. In contrast to the current WHO guidelines, our analysis reveals that amoxicillin can be used as a fixed dose regimen including two weight bands: 125 mg b.i.d. for patients with body weight < 4.0 kg and 250 mg b.i.d. for patients with body weight ≥ 4.0 kg. Conclusions In addition to the effect of developmental growth and renal maturation, sepsis also alters drug disposition. The use of a model-based approach enabled the integration of these factors when defining the dose rationale for amoxicillin. A simplified weight-banded dosing regimen should be considered for neonates and young infants with sepsis when referral is not possible.
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Affiliation(s)
- Salvatore D'Agate
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - Flora Tshinanu Musuamba
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
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Feasibility of implementation of simplified management of young infants with possible serious bacterial infection when referral is not feasible in tribal areas of Pune district, Maharashtra, India. PLoS One 2020; 15:e0236355. [PMID: 32833993 PMCID: PMC7446882 DOI: 10.1371/journal.pone.0236355] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/04/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Neonatal infections are a common cause of death in India, but many families cannot access appropriate hospitals for its treatment due to various reasons. We implemented the World Health Organization PSBI management guideline when referral is not feasible within the public health system in Pune, India to evaluate feasibility, barriers and facilitators for its implementation. METHODS A national-level consultative meeting between government officials and study partners resulted in a consensus on adaptation and implementation in four demonstration sites in selected states in India. At the state and district levels, similar meetings to plan the implementation strategy and roles were held between KEM Hospital Research Centre (KEMHRC) Pune and the public health system Pune, Maharashtra. The public health system was responsible for implementation of the intervention at eight tribal primary health centres (PHC) in Pune district, India, including delivering the intervention and ensuring supplies of all commodities while KEMHRC was responsible for technical support including training of health workers, assistance in PSBI identification and management, data collection and documentation of the implementation strategy. RESULTS A total of 175 young infants with PSBI were identified and managed. Of these, 34 had critical illness (CI), 46 had clinical severe infection (CSI) and 10 were infants aged 0-6 days with fast breathing (FB) while 85 infants aged 7-59 days had fast breathing. Assuming a 10% incidence of PSBI among all live births, with 3071 live births recorded, the actual incidence of PSBI found in the study was 5.7%, resulting in an actual coverage was of 57%. Among the 90 infants with CI, CSI and FB in 0-6 days, who were advised referral to government tertiary care centre as per the PSBI guideline algorithm, 81 (90%) accepted referral while 9 (10%) refused and were offered treatment at primary health centres (PHC) with a seven-day course of injectable gentamicin and oral amoxicillin. All infants with FB in 7-59 days were offered treatment at PHCs as per the PSBI guideline algorithm with a seven-day course of oral amoxicillin. All except six infants who died and one with FB in 7-59 days, who was lost to follow-up, were successfully cured. Of the six who died, five had CSI and one had CI. Among the 81 infants with CI, CSI and FB in 0-6 days who accepted referral; 48(53%) were successfully referred to government tertiary facility while 33 (36.6%) preferred to visit a private tertiary health facility. The implementation strategy demonstrated a relatively high fidelity, acceptance and intervention penetration. Lack of training and confidence of the public health staff were major challenges faced, which were resolved to a large extent through supportive supervision and re-trainings. CONCLUSION Management of PSBI is feasible to implement in out-patient facilities in the public health system, but technical support to the health system is required to jump-start the process. Fast breathing in 7-59 days old infants can be managed with oral amoxicillin without referral. A sustainable adoption of this intervention by the health system can lead to decrease in neonatal mortality and morbidity.
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Awasthi S, Kesarwani N, Verma RK, Agarwal GG, Tewari LS, Mishra RK, Shukla L, Raut AK, Qazi SA, Aboubaker S, Nisar YB, Bahl R, Agarwal M. Identification and management of young infants with possible serious bacterial infection where referral was not feasible in rural Lucknow district of Uttar Pradesh, India: An implementation research. PLoS One 2020; 15:e0234212. [PMID: 32497092 PMCID: PMC7272098 DOI: 10.1371/journal.pone.0234212] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Based on World Health Organization guidelines, Government of India recommended management of possible serious bacterial infection (PSBI) in young infants up to two months of age on an outpatient basis where referral is not feasible. We implemented the guideline in program setting to increase access to treatment with high treatment success and low resultant mortality. METHODS Implementation research was conducted in four rural blocks of Lucknow district in Uttar Pradesh, India. It included policy dialogues with the central and state government and district level officials. A Technical Support Unit was established. Thereafter, capacity building across all cadres of health workers in the implementation area was done for strengthening of home based newborn care (HBNC) program, skills enhancement for identification and management of PSBI, logistics management to ensure availability of necessary supplies, monitoring and evaluation as well as providing feedback. Data was collected by the research team. RESULTS From June 2017 to February 2019 there were 24,448 live births in a population of 856106. We identified 1302 infants, aged 0-59 days, with any sign of PSBI leading to a coverage of 53% (1302/2445), assuming an incidence of 10%. However, in the establishment phase the coverage was 33%, while it was 85% in the implementation phase. Accredited social health activists (ASHAs) identified 81.2% (1058/1302) cases while rest were identified by families. ASHAs increased home visits within first 7 days of life in home based newborn care program from 74.3% (2781/3738) to 89.0% (3128/3513) and detection of cases of PSBI from 1.6% (45/2781) to 8.7% (275/3128) in the first and last quarter of the project, respectively. Of these 18.7% (244/1302) refused referral to government health system and 6.7% (88/1302) were treated in a hospital. Among cases of PSBI, there were 13.3% (173/1302) cases of fast breathing in young infant aged 7-59 days in whom referral was not needed. Of these 147 were treated by oral amoxicillin and 95.2% (140/147) were cured. Among those who needed referral, simplified treatment was given when referral was refused. There were 2.9% (37/1302) cases of fast breathing at ages of 0-6 days of which 34 were treated by simplified treatment with100% (34/34) cured;66.5% (866/1302) were cases of clinical severe infection of which 685 treated by simplified treatment with94.2% (645/685)cured and 09 died;17.3% (226/1302) cases of critical illness of which 93 were treated by simplified treatment, as a last resort, 72% (67/93) cured and 16 died. Among 255 cases who either did not seek formal treatment or sought it at private facilities, 96 died. CONCLUSION Simplified treatment for PSBI is feasible in public program settings in northern India with good cure rates. It required system strengthening and supportive supervision.
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Affiliation(s)
- Shally Awasthi
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
- * E-mail:
| | - Naveen Kesarwani
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Raj Kumar Verma
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | | | - Luxmi Shanker Tewari
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Ravi Krishna Mishra
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Lalji Shukla
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Raut
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Shamim Ahmad Qazi
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal Newborn Child and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal Newborn Child and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Monika Agarwal
- Department of Social and Preventive Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
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Rahman AE, Herrera S, Rubayet S, Banik G, Hasan R, Ahsan Z, Siraj W, Ahmed A, Siddique AB, Rahman QSU, Vaz LME, Islam MJ, Hossain MA, Shahidullah M, Osmani MM, E. l. Arifeen S, Wall SN. Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh. PLoS One 2020; 15:e0232675. [PMID: 32392209 PMCID: PMC7213695 DOI: 10.1371/journal.pone.0232675] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/20/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Serious infections account for 25% of global newborn deaths annually, most in low-resource settings where hospital-based treatment is not accessible or feasible. In Bangladesh, one-third of neonatal deaths are attributable to serious infection; in 2014, the government adopted new policy for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral was not possible. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines. METHODS PSBI management was introduced as part of the Comprehensive Newborn Care Package in 2015. The study piloted this package through government health systems with limited partner support to inform scale-up efforts. Data collection included facility register reviews for cases seen at primary level facilities; facility readiness and provider knowledge and skills assessments; household surveys capturing caregiver knowledge of newborn danger signs and care-seeking for newborn illness; and follow-up case tracking, capturing treatment adherence and outcomes. Analysis consisted of descriptive statistics. RESULTS Over the 15-month implementation period, 1432 young infants received care, of which 649 (45%) were classified as PSBI. Estimated coverage of care-seeking increased from 22% to 42% during the implementation period. Although facility readiness and providers' skills increased, providers' adherence to guidelines was not optimal. Among locally managed PSBI cases, 75% completed the oral antibiotic course and 15% received the fourth day follow-up. Care-seeking remained high among private providers (95%), predominantly village health doctors (over 80%). CONCLUSIONS Facility readiness, including health care provider knowledge and skills were strengthened; future efforts should focus on improving provider adherence to guidelines. Social and behavior change strategies targeting families and communities should explore shifting care-seeking from private, possibly less-qualified providers. Strategies to improve private sector management of PSBI cases and improved linkages between private and public sector providers could be explored.
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Affiliation(s)
- Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Samantha Herrera
- Save the Children, Saving Newborn Lives, Washington, DC, United States of America
- * E-mail:
| | - Sayed Rubayet
- Ipas (formerly Save the Children International, Saving Newborn Lives), Dhaka, Bangladesh
| | - Goutom Banik
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rezaul Hasan
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ziaul Ahsan
- Ipas (formerly Save the Children International, Saving Newborn Lives), Dhaka, Bangladesh
| | - Wahida Siraj
- Save the Children International (formerly Saving Newborn Lives), Dhaka, Bangladesh
| | - Anisuddin Ahmed
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Bakkar Siddique
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Qazi Sadeq-ur Rahman
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Lara M. E. Vaz
- Population Reference Bureau (formerly Save the Children, Saving Newborn Lives), Washington DC, United States of America
| | - M. Jahurul Islam
- National Newborn Health Program & Integrated Management of Childhood Illness (NNHP & IMCI), DGHS, MoHFW, Dhaka, Bangladesh
| | - M. Altaf Hossain
- Ministry of Health and Family Welfare (MoHFW), Dhaka, Bangladesh
| | - M. Shahidullah
- Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | | | - Shams E. l. Arifeen
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stephen N. Wall
- Save the Children, Saving Newborn Lives, Washington, DC, United States of America
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Applegate JA, Ahmed S, Harrison M, Callaghan-Koru J, Mousumi M, Begum N, Moin MI, Joarder T, Ahmed S, George J, Mitra DK, Ahmed ASMNU, Shahidullah M, Baqui AH. Provider performance and facility readiness for managing infections in young infants in primary care facilities in rural Bangladesh. PLoS One 2020; 15:e0229988. [PMID: 32320993 PMCID: PMC7176463 DOI: 10.1371/journal.pone.0229988] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/18/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016. METHODS This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance. RESULTS At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens. CONCLUSIONS Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.
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Affiliation(s)
- Jennifer A. Applegate
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Meagan Harrison
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jennifer Callaghan-Koru
- Department of Sociology, Anthropology, and Health Administration and Policy, University of Maryland, Baltimore County, Baltimore, Maryland, United States of America
| | | | - Nazma Begum
- Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
| | | | - Taufique Joarder
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sabbir Ahmed
- USAID’s MaMoni Health Systems Strengthening Project, Save the Children, Washington, DC, United States of America
| | - Joby George
- USAID’s MaMoni Health Systems Strengthening Project, Save the Children, Washington, DC, United States of America
| | - Dipak K. Mitra
- Department of Public Health, School of Health and Life Sciences, North South University, Dhaka, Bangladesh
| | | | - Mohammod Shahidullah
- Neonatal Department, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Abdullah H. Baqui
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Wammanda RD, Adamu SA, Joshua HD, Nisar YB, Qazi SA, Aboubaker S, Bahl R. Implementation of the WHO guideline on treatment of young infants with signs of possible serious bacterial infection when hospital referral is not feasible in rural Zaria, Nigeria: Challenges and solutions. PLoS One 2020; 15:e0228718. [PMID: 32155155 PMCID: PMC7064229 DOI: 10.1371/journal.pone.0228718] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/22/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bacterial infection is one of the leading causes of mortality in young infants globally. The standard practice to manage young infants with any sign of possible serious bacterial infection (PSBI) is in a hospital setting with parenteral antibiotics, which may not be feasible for majority of cases in most low resource settings. The World Health Organization developed a guideline on management of PSBI in young infants when referral is not feasible in 2016. METHODS We conducted implementation research in selected communities in Zaria Local Government Areas of Kaduna State with an estimated population of 50,000 with the aim of understanding how to implement the WHO PSBI treatment guideline to achieve high coverage with low case fatality and treatment failure rates. Implementation was within the programmatic settings using existing health structure. We conducted policy dialogue with decision makers to adapt the recommendations to their social, cultural and programmatic context in Nigeria, held orientation meetings with program managers, built capacity of the health workers and supported the implementation within the health system. We supported a non-government organization to conduct community sensitization to promote care seeking and adherence to treatment advice. The research team collected data systematically on all young infants identified to have PSBI, the treatment they received and the clinical outcome. RESULTS Between April 2016 and March 2017, we identified 347 young infants up to 2 months of age with signs of PSBI who received treatment either as an outpatient or in a hospital among 2,154 births in the study population. The coverage of PSBI treatment in the study area was 95.5% assuming that 10% of all births have an episode of PSBI in the first two months of life. Most (89%) sick young infants with PSBI were identified by the community-oriented resource persons and sent to the Primary Health Care Centres (PHCs). Most families (97%) refused referral and were treated at a primary health care centre on outpatient basis. There were 12 deaths (3.5%) and 17 non-death treatment failures (4.9%) in 343 infants in whom an outcome could be ascertained. While non-death treatment failure rate was highest in 0-6-day infants with fast breathing (14.4%), case fatality was highest in those with signs of critical illness (20%). CONCLUSION We have demonstrated that outpatient treatment strategy for young infants with PSBI when referral is not feasible is implementable within the programmatic settings, achieving very high population coverage and relatively low treatment failure and case fatality rates. Implementation at scale will require government's commitment to strengthen the health system with trained, motivated health care providers and necessary commodities.
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Affiliation(s)
- Robinson Daniel Wammanda
- Department of Paediatrics, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
- * E-mail:
| | | | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization (WHO), Geneva, Switzerland
| | | | - Samira Aboubaker
- Retired from WHO, working as a WHO consultant, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization (WHO), Geneva, Switzerland
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Ahmed S, Applegate JA, Mitra DK, Callaghan-Koru JA, Mousumi M, Khan AM, Joarder T, Harrison M, Ahmed S, Begum N, Quaiyum A, George J, Baqui AH. Implementation research to support Bangladesh Ministry of Health and Family Welfare to implement its national guidelines for management of infections in young infants in two rural districts. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2019; 38:41. [PMID: 31810496 PMCID: PMC6898944 DOI: 10.1186/s41043-019-0200-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 10/29/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND World Health Organization revised the global guidelines for management of possible serious bacterial infection (PSBI) in young infants to recommend the use of simplified antibiotic therapy in settings where access to hospital care is not possible. The Bangladesh Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GOB) adopted these guidelines, allowing treatment at first-level facilities. During the first year of implementation, the Projahnmo Study Group and USAID/MaMoni Health Systems Strengthening (HSS) Project supported the MoHFW to operationalize the new guidelines and conducted an implementation research study in selected districts to assess challenges and identify solutions to facilitate scale-up across the country. IMPLEMENTATION SUPPORT Projahnmo and MaMoni HSS teams supported implementation in three areas: building capacity, strengthening service delivery, and mobilizing communities. Capacity building focused on training paramedics to conduct outpatient management of PSBI cases and developing monitoring and supervision systems. The teams also filled gaps in government supply of essential drugs, equipment, and logistics. Community mobilization strategies to promote care-seeking and referrals to facilities varied across districts; in one district community, health workers made home visits while in another district, the promotion was carried out through community volunteers, village doctors, and through existing community structures. METHODS We followed a plan-do-study-act (PDSA) cycle to identify and address implementation challenges. Three cycles-1 every 4 months-were conducted. We collected data utilizing quantitative and qualitative methods in both the community and facilities. The total sample size for this study was 13,590. DISCUSSION This article provides implementation research design details for program managers intending to implement new guidelines on management of young infant infections. Results of this research will be reported in the forthcoming papers. Preliminary findings indicate that the management of PSBI cases at the UH&FWCs is feasible. However, MoHFW, GOB needs to address the implementation challenges before scale-up of this policy to the national level.
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Affiliation(s)
| | - Jennifer A Applegate
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Dipak K Mitra
- Department of Public Health, School of Health and Life Sciences, North South University, Dhaka, 1229, Bangladesh
| | - Jennifer A Callaghan-Koru
- Department of Sociology, Anthropology, and Health Administration and Policy, University of Maryland, Baltimore County, Baltimore, MD, USA
| | | | | | - Taufique Joarder
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Meagan Harrison
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Sabbir Ahmed
- USAID's MaMoni Health Systems Strengthening Project, Save the Children, Washington, DC, USA
| | - Nazma Begum
- Johns Hopkins University-Bangladesh, Dhaka, 1213, Bangladesh
| | - Abdul Quaiyum
- Maternal and Child Health Division, icddr,b, Dhaka, 1212, Bangladesh
| | - Joby George
- USAID's MaMoni Health Systems Strengthening Project, Save the Children, Washington, DC, USA
| | - Abdullah H Baqui
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
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Applegate JA, Ahmed S, Khan MA, Alam S, Kabir N, Islam M, Bhuiyan M, Islam J, Rashid I, Wall S, de Graft-Johnson J, Baqui AH, George J. Early implementation of guidelines for managing young infants with possible serious bacterial infection in Bangladesh. BMJ Glob Health 2019; 4:e001643. [PMID: 31803507 PMCID: PMC6882554 DOI: 10.1136/bmjgh-2019-001643] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 01/29/2023] Open
Abstract
Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) with simpler antibiotic regimens if hospital referral is not feasible. Bangladesh was one of the first countries to adapt WHO guidance into national guidelines for implementation in primary healthcare facilities. Early implementation was led by the Ministry of Health and Family Welfare (MOHFW) in 10 subdistricts of Bangladesh with support from USAID's MaMoni Health System Strengthening project. This mixed methods implementation research case study explores programme feasibility and acceptability through analysis of service delivery data from 4590 sick young infants over a 15-month period, qualitative interviews with providers and MOHFW managers and documentation by project staff. Multistakeholder collaboration was key to ensuring facility readiness and feasibility of programme delivery. For the 514 (11%) infants classified as PSBI, provider adherence to prereferral treatment and follow-up varied across infection subcategories. Many clinical severe infection cases for whom referral was not feasible received the recommended two doses of injectable gentamicin and follow-up, suggesting delivery of simplified antibiotic treatment is feasible. However, prereferral antibiotic treatment was low for infants whose families accepted hospital referral, which highlights the need for additional focus on managing these cases in training and supervision. Systems for tracking sick infants that accept hospital referral are needed, and follow-up of all PSBI cases requires strengthening to ensure sick infants receive the recommended treatment, to monitor outcomes and assess the effectiveness of the programme. Only 11.2% (95% CI 10.3 to 12.1) of the expected PSBI cases sought care from the selected service delivery points in the programme period. However, increasing trends in utilisation suggest improved awareness and acceptability of services among families of young infants as the programme matured. Future programme activities should include interviews with caregivers to explore the complexities around referral feasibility and acceptability of simplified antibiotic treatment.
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Affiliation(s)
- Jennifer A Applegate
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sabbir Ahmed
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Marufa Aziz Khan
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Sanjida Alam
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Nazmul Kabir
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Munia Islam
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Mamun Bhuiyan
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Jahurul Islam
- National Newborn Health Program, Government of Bangladesh Ministry of Health and Family Welfare, Dhaka, Dhaka District, Bangladesh
| | - Iftekhar Rashid
- United States Agency for International Development, Dhaka, Bangladesh
| | - Steve Wall
- Save the Children, Washington, District of Columbia, USA
| | | | - Abdullah H Baqui
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joby George
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
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Keij FM, Kornelisse RF, Hartwig NG, Reiss IKM, Allegaert K, Tramper-Stranders GA. Oral antibiotics for neonatal infections: a systematic review and meta-analysis. J Antimicrob Chemother 2019; 74:3150-3161. [PMID: 31236572 PMCID: PMC6814091 DOI: 10.1093/jac/dkz252] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Worldwide many neonates suffer from bacterial infections. Adequate treatment is important but is associated with prolonged hospitalization for intravenous administration. In older children, oral switch therapy has been proven effective and safe for several indications and is now standard care. OBJECTIVES To evaluate the currently available evidence on pharmacokinetics, safety and efficacy of oral antibiotics and oral switch therapy in neonates (0-28 days old). METHODS We performed systematic searches in Medline, Embase.com, Cochrane, Google Scholar and Web of Science. Studies were eligible if they described the use of oral antibiotics in neonates (0-28 days old), including antibiotic switch studies and pharmacological studies. RESULTS Thirty-one studies met the inclusion criteria. Compared with parenteral administration, oral antibiotics generally reach their maximum concentration later and have a lower bioavailability, but in the majority of cases adequate serum levels for bacterial killing are reached. Furthermore, studies on efficacy of oral antibiotics showed equal relapse rates (OR 0.95; 95% CI 0.79-1.16; I2 0%) or mortality (OR 1.11; 95% CI 0.72-1.72; I2 0%). Moreover, a reduction in hospital stay was observed. CONCLUSIONS Oral antibiotics administered to neonates are absorbed and result in adequate serum levels, judged by MICs of relevant pathogens, over time. Efficacy studies are promising but robust evidence is lacking, most importantly because in many cases clinical efficacy and safety are not properly addressed. Early oral antibiotic switch therapy in neonates could be beneficial for both families and healthcare systems. There is a need for additional well-designed trials in different settings.
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Affiliation(s)
- Fleur M Keij
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - René F Kornelisse
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Nico G Hartwig
- Department of Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Gerdien A Tramper-Stranders
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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Keij FM, Kornelisse RF, Hartwig NG, Mauff K, Poley MJ, Allegaert K, Reiss IKM, Tramper-Stranders GA. RAIN study: a protocol for a randomised controlled trial evaluating efficacy, safety and cost-effectiveness of intravenous-to-oral antibiotic switch therapy in neonates with a probable bacterial infection. BMJ Open 2019; 9:e026688. [PMID: 31289068 PMCID: PMC6615779 DOI: 10.1136/bmjopen-2018-026688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION High morbidity and mortality rates of proven bacterial infection are the main reason for substantial use of intravenous antibiotics in neonates during the first week of life. In older children, intravenous-to-oral switch after 48 hours of intravenous therapy has been shown to have many advantages and is nowadays commonly practised. We, therefore, aim to evaluate the effectiveness, safety and cost-effectiveness of an early intravenous-to-oral switch in neonates with a probable bacterial infection. METHODS AND ANALYSIS We present a protocol for a multicentre randomised controlled trial assessing the non-inferiority of an early intravenous-to-oral antibiotic switch compared with a full course of intravenous antibiotics in neonates (0-28 days of age) with a probable bacterial infection. Five hundred and fifty patients will be recruited in 17 hospitals in the Netherlands. After 48 hours of intravenous treatment, they will be assigned to either continue with intravenous therapy for another 5 days (control) or switch to amoxicillin/clavulanic acid suspension (intervention). Both groups will be treated for a total of 7 days. The primary outcome will be bacterial (re)infection within 28 days after treatment completion. Secondary outcomes are the pharmacokinetic profile of oral amoxicillin/clavulanic acid, the impact on quality of life, cost-effectiveness, impact on microbiome development and additional yield of molecular techniques in diagnosis of probable bacterial infection. ETHICS AND DISSEMINATION This study has been approved by the Medical Ethics Committee of the Erasmus Medical Centre. Results will be presented in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER NCT03247920.
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Affiliation(s)
- Fleur M Keij
- Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - René F Kornelisse
- Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nico G Hartwig
- Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Katya Mauff
- Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Karel Allegaert
- Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Irwin K M Reiss
- Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gerdien A Tramper-Stranders
- Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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