Rational development of guidelines for management of neonatal sepsis in developing countries

Arginine-Rich Peptidomimetic Ampicillin/Gentamicin Conjugate To Tackle Nosocomial Biofilms: A Promising Strategy To Repurpose First-Line Antibiotics

Combined therapy with penicillins and aminoglycosides has been proved beneficial to address many persistent bacterial infections with possible synergistic effects. However, the different pharmacokinetic profiles of these two antibiotic classes may not guarantee a concerted spatio-temporal delivery at the site of action, decreasing the efficacy of this combination and promoting resistance. Herein, we propose a multifunctional antibiotic-polymer conjugate, designed to colocalize ampicillin and gentamicin to tackle persistent biofilm infections. The two antibacterial molecules were grafted along with the amino acid l-arginine to a biocompatible polymer backbone with peptidomimetic hydrophilic structure, obtaining the antimicrobial poly(argilylaspartamide-co-aspartic) acid-ampicillin, gentamicin (PAA-AG) conjugate. The PAA-AG conjugate displayed excellent biocompatibility on human cell lines if compared with free drugs, potentially enlarging their therapeutic window and safety, and suitable mucoadhesive characteristics which may help local treatments of mucosal infections. Studies on planktonic cultures of clinical and reference strains of S. aureus, P. aeruginosa, and E. coli revealed that PAA-AG holds a broad-spectrum antibacterial efficacy, revealing high potency in inhibiting the growth of the tested strains. More interestingly, PAA-AG exhibited excellent antibiofilm activity on both Gram+ and Gram- communities, showing inhibition of their formation at subMIC concentrations as well as inducing the regression of mature biofilms. Given the high biocompatibility and broad antibiofilm efficacy, combined with the opportunity for synchronous co-delivery, the PAA-AG conjugate could be a valuable tool to increase the success of ampicillin/gentamicin-based antibiotic multitherapy.

Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital

Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.

Metagenomic profiles of the early life microbiome of Indonesian inpatient neonates and their influence on clinical characteristics

Determining the initial normal neonatal gut microbiome is challenging. The debate regarding the sterile fetal environment is still ongoing. Therefore, studying and comparing normal and dysbiotic microbiomes requires the elucidation of both the fetal and infant microbiomes. Factors influencing the normal microbiome also include regional and genetic factors specific to different countries. Determining the normal microbiome population in our center and their association with the clinical conditions of infants is helpful as a tool for both the prevention and treatment of related diseases during neonatal care. Here, we employed metagenomic sequencing to characterize meconium and the subsequent early-life gut microbiome of preterm neonates in Jakarta, Indonesia. Microbiome diversity and complexity was higher in the meconium and on day 4 than on day 7. At the genus level, the most abundant genus overall was unidentified Enterobacteriaceae, with meconium samples dominated by Ureaplasma, day 4 fecal samples dominated by Staphylococcus, and day 7 samples dominated by Clostridiales, while at the phylum level the most abundant was Proteobacteria and Firmicutes. Perinatal factors of PROM and mother’s diet influenced the meconium microbiome, while day 4 and day 7 microbiome was associated with bacteremia and early administration of antibiotics. One of our sample sets was derived from triplets, and they had varying diversity despite being triplets. These data are valuable for understanding the formation of a healthy microbiome specific to neonates and devising a strategy to improve both the gut health and related clinical outcomes of the neonate.

Study of Plasmid-Mediated Quinolone Resistance in Klebsiella pneumoniae: Relation to Extended-Spectrum Beta-Lactamases

Klebsiella pneumoniae (K. pneumoniae) is an important pathogen associated with various infections. The emergence of antibiotic resistances, such as quinolone resistance and those due to extended-spectrum beta-lactamases (ESBL), reduces the available choices for treatment. The objectives of the current study include the evaluation of the prevalence of the plasmid-mediated quinolone resistance genes qepA, acrA, acrB, and aac(6’)-Ib-cr by polymerase chain reaction (PCR) in K. pneumoniae and the determination of the mechanism relating these genes to the ESBL phenotype and resistance to other groups of antibiotics. In total, 300 clinical isolates of K. pneumoniae were included in the study. Isolates were subjected to antibiotic sensitivity tests using the disc diffusion method. Quinolone resistance by the minimum inhibitory concentration method and detection of ESBL resistance by the double disc diffusion method were also determined. PCR analyses revealed the prevalence of acrA, aac(6’)-Ib-cr, acrB, and qepA in 74.3%, 73.7%, 71%, and 6.7% of the isolates, respectively. Quinolone-resistant isolates positive for plasmid-encoded genes represented 82.7% of K. pneumoniae isolates positive for ESBL activity. The results also showed that the isolates of K. pneumoniae carrying plasmid-encoded quinolone resistance genes had significantly increased resistance to amikacin, amoxicillin/clavulanate, gentamicin, and cefoxitin than those isolates without quinolone resistance genes. Therefore, there was a high prevalence of acrA, acrB, and aac(6’)-Ib-cr among K. pneumoniae and the prevalence of quinolone resistance was significantly associated with the ESBL resistance phenotype. Moreover, the presence of quinolone resistance genes was associated with resistance to aminoglycosides, namely amikacin and gentamicin.

Early-onset neonatal sepsis and antibiotic use in Indonesia: a descriptive, cross-sectional study

BACKGROUND

Early diagnosis and prompt antibiotic treatment are crucial to reducing morbidity and mortality of early-onset sepsis (EOS) in neonates. However, this strategy remains challenging due to non-specific clinical findings and limited facilities. Inappropriate antibiotics use is associated with ineffective therapy and adverse outcomes. This study aims to determine the characteristics of EOS and use of antibiotics in the neonatal-intensive care units (NICUs) in Indonesia, informing efforts to drive improvements in the prevention, diagnosis, and treatment of EOS.

METHODS

A descriptive study was conducted based on pre-intervention data of the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Our study population consisted of neonates admitted within 72 h of life to the three participating NICUs. Neonates who presented with three or more clinical signs or laboratory results consistent with sepsis and who received antibiotics for 5 consecutive days were considered to have EOS. Culture-proven EOS was defined as positive blood or cerebrospinal fluid culture. Type and duration of antibiotics used were also documented.

RESULTS

Of 2,509 neonates, 242 cases were suspected of having EOS (9.6%) with culture-proven sepsis in 83 cases (5.0% of neonatal admissions in hospitals with culture facilities). The causative organisms were mostly gram-negative bacteria (85/94; 90.4%). Ampicillin / amoxicillin and amikacin were the most frequently prescribed antibiotics in hospitals with culture facilities, while a third-generation cephalosporin was mostly administered in hospital without culture facilities. The median durations of antibiotic therapy were 19 and 9 days in culture-proven and culture-negative EOS groups, respectively.

CONCLUSIONS

The overall incidence of EOS and culture-proven EOS was high in Indonesia, with diverse and prolonged use of antibiotics. Prospective antibiotic surveillance and stewardship interventions are required.

Risk factors and clinical analysis of peripherally inserted central catheter-related fungal colonization in premature infants

We aimed to analyze the risk factors of positive peripherally inserted central catheter (PICC)-related fungal colonization in preterm infants. This retrospective study collected data from 2018 to 2020. The enrolled infants who underwent PICC insertion were born at < 32 weeks’ gestation or birth weight < 1500 g. The demographics, PICC-related characteristics, and treatment information were collected. Univariate and multivariate analyses were performed to investigate risk factors for PICC-related fungal colonization. The receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the duration of antibiotics and parenteral nutrition. In total, 124 premature infants underwent PICC insertion. Among them, 19 patients had positive results of fungi on the PICC tips. The duration of antibiotics (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.02–1.31), parenteral nutrition infusion (OR 1.27, 95% CI 1.05–1.54), and postnatal glucocorticoid exposure (OR 9.48, 95% CI 1.06–84.98) were independent risk factors for fungal colonization in PICCs. The ROC curves showed that the risk increased after 15 days of antibiotic use and 28 days of parenteral nutrition infusion. Appropriate clinical management should be used to prevent fungal colonization and fungemia.

Assessing the impact of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) on hospital antimicrobial stewardship programmes: results of a worldwide survey

BACKGROUND

The Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) provides a methodology to support hospitals worldwide in collecting antimicrobial use data. We aim to evaluate the impact of the Global-PPS on local antimicrobial stewardship (AMS) programmes and assess health care professionals' educational needs and barriers for implementing AMS.

METHODS

A cross-sectional survey was disseminated within the Global-PPS network. The target audience consisted of hospital healthcare workers, involved in local surveillance of antimicrobial consumption and resistance. This included contacts from hospitals that already participated in the Global-PPS or were planning to do so. The survey contained 24 questions that addressed the hospital's AMS activities, experiences conducting the PPS, as well as the learning needs and barriers for implementing AMS.

RESULTS

A total of 248 hospitals from 74 countries participated in the survey, of which 192 had already conducted the PPS at least once. The survey response rate was estimated at 25%. In 96.9% of these 192 hospitals, Global-PPS participation had led to the identification of problems related to antimicrobial prescribing. In 69.3% at least one of the hospital's AMS components was initiated as a result of Global-PPS findings. The level of AMS implementation varied across regions. Up to 43.1% of all hospitals had a formal antimicrobial stewardship strategy, ranging from 10.8% in Africa to 60.9% in Northern America. Learning needs of hospitals in high-income countries and in low-and middle-income countries were largely similar and included general topics (e.g. 'optimising antibiotic treatment'), but also PPS-related topics (e.g. 'translating PPS results into meaningful interventions'). The main barriers to implementing AMS programmes were a lack of time (52.7%), knowledge on good prescribing practices (42.0%), and dedicated funding (39.9%). Hospitals in LMIC more often reported unavailability of prescribing guidelines, insufficient laboratory capacity and suboptimal use of the available laboratory services.

CONCLUSIONS

Although we observed substantial variation in the level of AMS implementation across regions, the Global-PPS has been very useful in informing stewardship activities in many participating hospitals. More is still to be gained in guiding hospitals to integrate the PPS throughout AMS activities, building on existing structures and processes.

Clinical Profile of Neonates Admitted with Sepsis to Neonatal Intensive Care Unit of Jimma Medical Center, A Tertiary Hospital in Ethiopia

Background

Globally, over 3 million newborn die each year, one million of these attributed to infections. The objective of this study was to determine the etiologies and clinical characteristics of sepsis in neonates admitted to intensive care unit of a tertiary hospital in Ethiopia.

Methods

A longitudinal hospital based cohort study was conducted from April 1 to October 31, 2018 at the neonatal intensive care unit of Jimma Medical Center, southwest Ethiopia. Diagnosis of sepsis was established using the World Health Organization's case definition. Structured questionnaires and case specific recording formats were used to capture the relevant data. Venous blood and cerebrospinal fluid from neonates suspected to have sepsis were collected.

Results

Out of 304 neonates enrolled in the study, 195 (64.1%) had clinical evidence for sepsis, majority (84.1%; 164/195) of them having early onset neonatal sepsis. The three most frequent presenting signs and symptoms were fast breathing (64.6%; 122/195), fever (48.1%; 91/195) and altered feeding (39.0%; 76/195). Etiologic agents were detected from the blood culture of 61.2% (115/195) neonates. Bacterial pathogens contributed for 94.8% (109/115); the rest being fungal etiologies. Coagulase negative staphylococci (25.7%; 28/109), Staphylococcus aureus (22.1%; 24/109) and Klebsiella species (16.5%; 18/109) were the most commonly isolated bacteria.

Conclusion

Majority of the neonates had early onset neonatal sepsis. The major etiologies isolated in our study markedly deviate from the usual organisms causing neonatal sepsis. Multicentre study and continuous surveillance are essential to tackle the current challenge to reduce neonatal mortality due to sepsis in Ethiopia.

Antibiotic regimens for early-onset neonatal sepsis

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.

Antibiotic regimens for late-onset neonatal sepsis

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.

Simplified Dosing Regimens for Gentamicin in Neonatal Sepsis

Background: The effectiveness of antibiotics for the treatment of severe bacterial infections in newborns in resource-limited settings has been determined by empirical evidence. However, such an approach does not warrant optimal exposure to antibiotic agents, which are known to show different disposition characteristics in this population. Here we evaluate the rationale for a simplified regimen of gentamicin taking into account the effect of body size and organ maturation on pharmacokinetics. The analysis is supported by efficacy data from a series of clinical trials in this population.

Methods: A previously published pharmacokinetic model was used to simulate gentamicin concentration vs. time profiles in a virtual cohort of neonates. Model predictive performance was assessed by supplementary external validation procedures using therapeutic drug monitoring data collected in neonates and young infants with or without sepsis. Subsequently, clinical trial simulations were performed to characterize the exposure to intra-muscular gentamicin after a q.d. regimen. The selection of a simplified regimen was based on peak and trough drug levels during the course of treatment.

Results: In contrast to current World Health Organization guidelines, which recommend gentamicin doses between 5 and 7.5 mg/kg, our analysis shows that gentamicin can be used as a fixed dose regimen according to three weight-bands: 10 mg for patients with body weight <2.5 kg, 16 mg for patients with body weight between 2.5 and 4 kg, and 30 mg for those with body weight >4 kg.

Conclusion: The choice of the dose of an antibiotic must be supported by a strong scientific rationale, taking into account the differences in drug disposition in the target patient population. Our analysis reveals that a simplified regimen is feasible and could be used in resource-limited settings for the treatment of sepsis in neonates and young infants with sepsis aged 0–59 days.

Risk factors for mortality among neonates admitted to a special care unit in a low-resource setting

Background

Although under-5 mortality has decreased in the last two decades, neonatal mortality remains a global health challenge. Despite achieving notable progress, Ethiopia has still one of the highest neonatal mortality rates worldwide. We aimed to assess the risk factors for mortality among neonates admitted to a special care unit in a referral hospital in rural Ethiopia.

Methods

This was a retrospective observational study including all 4182 neonates admitted to the special care unit of the St. Luke Wolisso Hospital (Ethiopia) from January 2014 to December 2017. Data were retrieved from hospital charts and entered in an anonymized dataset. A logistic regression model was applied to identify predictors of mortality and effect sizes were expressed as odds ratios with 95% confidence intervals.

Results

Proportion of deaths was 17% (709/4182 neonates). Neonates referred from other health facilities or home (odds ratio 1.52, 95% confidence interval 1.21 to 1.91), moderate hypothermia at admission (odds ratio 1.53, 95% confidence interval 1.09 to 2.15) and diagnosis of late-onset sepsis (odds ratio 1.63, 95% confidence interval 1.12 to 2.36), low birthweight (odds ratio 2.48, 95% confidence interval 2.00 to 3.09), very low birthweight (odds ratio 11.71, 95% confidence interval 8.63 to 15.94), extremely low birthweight (odds ratio 76.04, 95% confidence interval 28.54 to 263.82), intrapartum-related complications (odds ratio 4.69, 95% confidence interval 3.55 to 6.20), meconium aspiration syndrome (odds ratio 2.34, 95% confidence interval 1.15 to 4.43), respiratory distress (odds ratio 2.25, 95% confidence interval 1.72 to 2.95), other infections (odds ratio 1.92, 95% confidence interval 1.31 to 2.81) or malformations (odds ratio 2.32, 95% confidence interval 1.49 to 3.57) were associated with increased mortality. Being admitted in 2017 vs. 2014 (odds ratio 0.71, 95% confidence interval 0.52 to 0.97), and older age at admission (odds ratio 0.95, 95% confidence interval 0.93 to 0.97) were associated with decreased likelihood of mortality.

Conclusions

The majority of neonatal deaths was associated with preventable and treatable conditions. Education on neonatal resuscitation and postnatal management, and the introduction of an on-call doctor for high-risk deliveries might have contributed to the reduction in neonatal mortality over time.

Antibiotic regimens for neonatal sepsis - a protocol for a systematic review with meta-analysis

BACKGROUND

Sepsis is a major cause of morbidity and mortality among neonates and infants. Antibiotics are a central part of the first line treatment for sepsis in neonatal intensive care units worldwide. However, the evidence on the clinical effects of the commonly used antibiotic regimens for sepsis in neonates remains scarce. This systematic review aims to assess the efficacy and harms of antibiotic regimens for neonatal sepsis.

METHODS

Electronic searches will be conducted in MEDLINE, Embase, The Cochrane Library, CINAHL, ZETOC and clinical trial registries (clinicaltrials.gov and ISRCTN). We will include randomised controlled trials of different antibiotic regimens for sepsis of neonates and infants. Eligible interventions will be any antibiotic regimen. Two reviewers will independently screen, select, and extract data. The methodological quality of individual studies will be appraised following Cochrane methodology. Primary outcomes will be 'all-cause mortality' and 'serious adverse events'. Secondary outcomes will be 'need for respiratory support', 'need for circulatory support', 'neurodevelopmental impairment', ototoxicity, nephrotoxicity and necrotizing enterocolitis. We plan to perform a meta-analysis with trial sequential analysis.

DISCUSSION

This is the study protocol for a systematic review on the effects of different antibiotic regimens for neonatal sepsis. The results of this systematic review intent to adequately inform stakeholders or health care professionals in the field of neonatal sepsis, and to aid appropriate development of treatment guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO reference number: CRD42019134300.

Population-based study of early-onset neonatal sepsis in Canada

OBJECTIVE

To determine the incidence, types of organisms and resistance patterns involved in early-onset neonatal sepsis in Canada.

STUDY DESIGN

Early-onset neonatal sepsis cases were identified through the Canadian Paediatric Surveillance Program. Neonates were excluded if they were asymptomatic or if intracranial procedures preceded a positive cerebrospinal fluid culture.

RESULTS

One hundred and twenty-seven cases were identified (0.17 cases per 1000 live births). Group B Streptococcus accounted for 41.7%, Escherichia coli for 35.4%. Antibiotic resistance was present in 33.9% of all cases. 55.6% of E coli cases were resistant, most commonly to ampicillin. Infecting organism species were associated with gestational age, being very low birth weight, time at sepsis presentation, maternal antibiotic prophylaxis and rupture of membranes lasting over 18 hours. Group B Streptococcus was most common in term and E coli in preterm neonates. Twenty-two per cent of E coli cases presented after 48 hours, compared to 6% of Group B Streptococcus cases.

CONCLUSION

We identify a lower rate of early-onset neonatal sepsis than historically suggested, with differing dominant organisms based on gestational ages and other factors, as well as high rates of resistance especially among E coli cases.

In search of a primary outcome for community-based newborn infection trials in Eastern Uganda: a nested cohort study within the BabyGel pilot trial

Background

Due to their immature immune system, neonates are at high risk of infection. This vulnerability when combined with limited resources and health education in developing countries can lead to sepsis, resulting in high global neonatal mortality rates. Many of these deaths are preventable. The BabyGel pilot trial tested the feasibility of conducting the main randomised trial, with the provision of alcohol handgel to postpartum mothers for prevention of neonatal infective morbidity in the rural community. This secondary analysis sought to evaluate the methods of detecting infections in babies up to 3 months of age.

Methods

The pilot two-arm cluster randomised controlled trial took place in 10 villages around Mbale, Eastern Uganda. Women were eligible and recruited antenatally if their gestation was ≥ 34 weeks. All infants of mothers participating in the BabyGel pilot trial were followed up for the first 3 months of life. Evidence for infant infection was collected using five different methods: clinician diagnosed infection, microbiologically confirmed infection, maternally reported infection, a positive infection screen using the World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) screening criteria, and reported antibiotic use identified during home and clinic visits. These methods were assessed quantitatively regarding the detection rates of suspected infections and qualitatively by exploring the challenges collecting data in the rural community setting.

Results

A total of 103 eligible women participated in the BabyGel pilot trial, with 1 woman delivering twins. Of the 99 mother-infant pairs who consented to participate in the study, 55 infants were identified with infection in total. Maternal report of illness provided the highest estimate, with mothers reporting suspected illness for 45 infants (81.8% of the total suspected infections identified). The WHO IMCI screening criteria identified 30 infants with suspected infection (54.5%), and evidence for antibiotic use was established in 22 infants (40%). Finally, clinician-diagnosed infection identified 19 cases (34.5%), which were also microbiologically confirmed in 5 cases (9.1%). Data collection in the rural setting was hindered by poor communication between mothers and the research team, limited staff awareness of the study in health centres resulting in reduced safeguarding of clinical notes, and widespread use of antibiotics prior to notification and clinical review. Furthermore, identification of suspected infection may not have been limited to severe infections, with ambiguity and no official clinical diagnosis being given to those identified solely by maternal report of infection.

Conclusions

A high rate of suspected infection was identified spanning the five sources of data collection, but no ideal method was found for detection of community neonatal infection. Although maternal self-reports of infant infection provided the highest detection rate, data collection via each source was limited and may have identified minor rather than major infections. Future studies could utilise the IMCI screening tool to detect severe community infection leading to referral for clinical confirmation. This should be combined with weekly contact with mothers to detect maternally suspected illness. Obtaining more details of the symptoms and timescale will improve the accuracy when detecting the total burden of suspected disease, and advising participants to retain medication packaging and prescriptions will improve identification of antibiotic use.

Trial registration

Babygel pilot trial - trial registration: ISCRCTN 67852437. Registered 02/03/2015.

Ceftriaxone Absorption Enhancement for Noninvasive Administration as an Alternative to Injectable Solutions

Neonatal sepsis is a major cause of infant mortality in developing countries because of delayed injectable treatment, making it urgent to develop noninjectable formulations that can reduce treatment delays in resource-limited settings. Ceftriaxone, available only for injection, needs absorption enhancers to achieve adequate bioavailability via nonparenteral administration. This article presents all available data on the nonparenteral absorption of ceftriaxone in humans and animals, including unpublished work carried out by F. Hoffmann-La Roche (Roche) in the 1980s and new data from preclinical studies with rabbits, and discusses the importance of these data for the development of noninjectable formulations for noninvasive treatment. The combined results indicate that the rectal absorption of ceftriaxone is feasible and likely to lead to a bioavailable formulation that can reduce treatment delays in neonatal sepsis. A bile salt, chenodeoxycholate sodium salt (Na-CDC), used as an absorption enhancer at a 125-mg dose, together with a 500-mg dose of ceftriaxone provided 24% rectal absorption of ceftriaxone and a maximal plasma concentration of 21 µg/ml with good tolerance in human subjects. The rabbit model developed can also be used to screen for the bioavailability of other formulations before assessment in humans.

Antimicrobial-resistant Gram-negative infections in neonates: burden of disease and challenges in treatment

PURPOSE OF REVIEW

This review summarizes the main challenges of antimicrobial resistance (AMR) in the neonatal population with a special focus on multidrug-resistant (MDR) Gram-negative pathogens.

RECENT FINDINGS

MDR-Gram-negative bacteria are a great concern in the neonatal population, with a worldwide rise in the reported incidence and with very limited therapeutic options. Extended-spectrum β-lactamase and carbapenem-resistant Enterobacteriaceae (CRE) have been reported as responsible for neonatal ICU outbreaks. Hospital data from low/middle-income countries show high proportions of isolates from neonates resistant to the WHO first-line and second-line recommended treatments. The spread of CRE has resulted in old antibiotics, such as colistin and fosfomycin, to be considered as alternative treatment options, despite the paucity of available data on safety and appropriate dosage.

SUMMARY

Improved global neonatal AMR surveillance programmes including both epidemiology and clinical outcomes are critical for defining the burden and designing interventions. The optimal empiric treatment for neonatal sepsis in settings of high rates of AMR is currently unknown. Both strategic trials of older antibiotics and regulatory trials of new antibiotics are required to improve clinical outcomes in MDR-Gram-negative neonatal sepsis.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review

OBJECTIVE

This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population.

DATA SOURCE

The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified.

DATA SYNTHESIS

A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs.

CONCLUSION

Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI): an extension of the STROBE statement for neonatal infection research

Neonatal infections are estimated to account for a quarter of the 2·8 million annual neonatal deaths, as well as approximately 3% of all disability-adjusted life-years. Despite this burden, few data are available on incidence, aetiology, and outcomes, particularly regarding impairment. We aimed to develop guidelines for improved scientific reporting of observational neonatal infection studies, to increase comparability and to strengthen research in this area. This checklist, Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE- NI), is an extension of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. STROBE-NI was developed following systematic reviews of published literature (1996-2015), compilation of more than 130 potential reporting recommendations, and circulation of a survey to relevant professionals worldwide, eliciting responses from 147 professionals from 37 countries. An international consensus meeting of 18 participants (with expertise in infectious diseases, neonatology, microbiology, epidemiology, and statistics) identified priority recommendations for reporting, additional to the STROBE statement. Implementation of these STROBE-NI recommendations, and linked checklist, aims to improve scientific reporting of neonatal infection studies, increasing data utility and allowing meta-analyses and pathogen-specific burden estimates to inform global policy and new interventions, including maternal vaccines.