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Morsli M, Boudet A, Kerharo Q, Stephan R, Salipante F, Dunyach-Remy C, Houhamdi L, Fournier PE, Lavigne JP, Drancourt M. Real-time metagenomics-based diagnosis of community-acquired meningitis: A prospective series, southern France. EBioMedicine 2022; 84:104247. [PMID: 36087524 PMCID: PMC9463524 DOI: 10.1016/j.ebiom.2022.104247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Point-Of-Care (POC) diagnosis of life-threatening community-acquired meningitis currently relies on multiplexed RT-PCR assays, that lack genotyping and antibiotic susceptibility profiling. We assessed the usefulness of real-time metagenomics (RTM) directly applied to the cerebrospinal fluid (CSF) for the identification, typing and susceptibility profiling of pathogens responsible for community-acquired meningitis. METHODS A series of 52 CSF samples from patients suspected of having community-acquired meningitis, were investigated at POC by direct RTM in parallel to routine real-time multiplex PCR (RT-PCR) and bacterial culture, for the detection of pathogens. RTM-generated sequences were blasted in real-time against an in-house database incorporating the panel of 12 most prevalent pathogens and against NCBI using EPI2ME online software, for pathogen identification. In-silico antibiogram and genotype prediction were determined using the ResFinder bio-tool and MLST online software. FINDINGS Over eight months, routine multiplex RT-PCR yielded 49/52 positive CSFs, including 21 Streptococcus pneumoniae, nine Neisseria meningitidis, eight Haemophilus influenzae, three Streptococcus agalactiae, three Herpesvirus-1, two Listeria monocytogenes, and one each of Escherichia coli, Staphylococcus aureus and Varicella-Zoster Virus. Parallel RTM agreed with the results of 47/52 CSFs and revealed two discordant multiplex RT-PCR false positives, one H. influenzae and one S. pneumoniae. Both multiplex RT-PCR and RTM agreed on the negativity of three CSFs. While multiplex RT-PCR routinely took 90 min, RTM took 120 min, although the pipeline analysis detected the pathogen genome after 20 min of sequencing in 33 CSF samples; and after two hours in 14 additional CSFs; yielding > 50% genome coverage in 19 CSFs. RTM identified 14 pathogen genotypes, including a majority of H. influenzae b, N. meningitidis B and S. pneumoniae 11A and 3A. In all 16 susceptible cultured bacteria, the in-silico antibiogram agreed with the in-vitro antibiogram in 10 cases, available within 48 h in routine bacteriology. INTERPRETATION In addition to pathogen detection, RTM applied to CSF samples offered supplementary information on bacterial profiling and genotyping. These data provide the proof-of-concept that RTM could be implemented in a POC laboratory for one-shot diagnostic and genomic surveillance of pathogens responsible for life-threatening meningitis. FUNDING This work was supported by the French Government under the Investments in the Future programme managed by the National Agency for Research reference: Méditerranée Infection 10-IAHU-03.
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Affiliation(s)
- Madjid Morsli
- IHU Méditerranée Infection, Marseille, France; IRD, MEPHI, IHU Méditerranée Infection, Aix-Marseille-Université, France
| | - Agathe Boudet
- VBIC, INSERM U 1047, Université de Montpellier, France; Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Quentin Kerharo
- IHU Méditerranée Infection, Marseille, France; Laboratoire de Microbiologie, Assistance Publique-Hôpitaux de Marseille, IHU, Méditerranée Infection, Marseille, France
| | - Robin Stephan
- Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Florian Salipante
- Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France; Service de Biostatistique, Epidémiologie, Santé Publique, Innovation en Méthodologie, CHU Nîmes, Nîmes, France
| | - Catherine Dunyach-Remy
- VBIC, INSERM U 1047, Université de Montpellier, France; Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | | | - Pierre-Edouard Fournier
- IHU Méditerranée Infection, Marseille, France; VITROME, IHU Méditerranée Infection, Aix-Marseille Université, Marseille, France
| | - Jean Philippe Lavigne
- VBIC, INSERM U 1047, Université de Montpellier, France; Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Michel Drancourt
- IHU Méditerranée Infection, Marseille, France; IRD, MEPHI, IHU Méditerranée Infection, Aix-Marseille-Université, France; Laboratoire de Microbiologie, Assistance Publique-Hôpitaux de Marseille, IHU, Méditerranée Infection, Marseille, France.
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Impact of MenAfriVac on Meningococcal A Meningitis in Cameroon: A Retrospective Study Using Case-by-Case-Based Surveillance Data from 2009 to 2015. J Trop Med 2021; 2021:4314892. [PMID: 34616456 PMCID: PMC8490062 DOI: 10.1155/2021/4314892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022] Open
Abstract
Meningococcal meningitis is a public health concern in Africa. Conjugated vaccine against serogroup A Neisseria meningitidis (MenAfriVac) was used in mass vaccination and was proved to have a good impact in the meningitis belt. There is a lack of information about the impact of this intervention in Cameroon after mass vaccination was undertaken. This study aimed at filling the gap in its unknown impact in Cameroon. A retrospective longitudinal study using biological monitoring data of case-by-case-based surveillance for meningitis was obtained from the National Reference Laboratories from 1 January 2009 to 20 September 2015. Immunization coverage data were obtained from Regional Public Health Delegations where immunizations took place. We compared the risks of vaccine serogroup occurrence before and after vaccinations and calculated the global impact using Halloran's formula. Annual cases of meningitis A decreased gradually from 92 in 2011 to 34 in 2012 and then to 1 case in 2013, and since 2014, no cases have been detected. The impact was estimated at 14.48% (p=0.41) in 2012 and then at 98.63% (p < 0.0001) after the end of vaccinations in 2013. This survey confirms the effectiveness of the MenAfriVac vaccine in Cameroon as expected by the WHO. The surveillance must be pursued and enhanced to monitor coming immunizations measures with multivalent conjugated vaccines for this changing threat.
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Mbiydzenyuy NE, Pieme CA, Brown RE, Nguemeni C. Neuroscience education and research in Cameroon: Current status and future direction. IBRO Neurosci Rep 2021; 10:216-224. [PMID: 34179870 PMCID: PMC8211920 DOI: 10.1016/j.ibneur.2021.02.006] [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: 09/14/2020] [Revised: 12/22/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022] Open
Abstract
Neurological disorders comprise 20% of hospital admissions in Cameroon. The burden of neurological disorders is increasing, especially in children and the elderly. However, there are very few neurologists, psychiatrists, gerontologists and neuropsychologists trained in the treatment of neurological disorders in Cameroon and there are very few facilities for training in basic and clinical neuroscience. Although non-governmental organizations such as the International Brain Research Organization (IBRO), International Society of Neurochemistry (ISN), and Teaching and Research in Natural Sciences for Development (TReND) in Africa have stepped in to provide short training courses and workshops in neuroscience, these are neither sufficient to train African neuroscientists nor to build the capacity to train neuroscience researchers and clinicians. There has also been little support from universities and the government for such training. While some participants of these schools have managed to form collaborations with foreign researchers and have been invited to study abroad, this does not facilitate the training of neuroscientists in Cameroon. Moreover, the research infrastructure for training in neuroscience remains limited. This is reflected in the low research output from Cameroonian universities in the field. In this review, we describe the burden of neurological disorders in Cameroon and outline the outstanding efforts of local scientists to develop the discipline of neuroscience, which is still an emerging field in Cameroon. We identify key actionable steps towards the improvement of the scientific capacity in neuroscience in Cameroon: (1) develop targeted neuroscience training programs in all major universities in Cameroon; (2) implement a thriving scientific environment supported by international collaborations; (3) focus on the leadership and the mentorship of both local and senior neuroscientists; (4) develop public awareness and information of policy makers to increase governmental funding for neuroscience research. Improving scientific capacity to tackle the neurological diseases burden in Cameroon is urgent. Neuroscience schools and advocated researchers shape the future of neuroscience in Cameroon. Public-private partnerships are required for sustainable country impact of neuroscience schools.
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Affiliation(s)
- Ngala Elvis Mbiydzenyuy
- Department of Basic Medical Science, School of Medicine, Copperbelt University, Ndola, Zambia
| | | | - Richard E Brown
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Carine Nguemeni
- Department of Neurology, University Hospital of Würzburg, Germany
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Lamelas A, Hamid AWM, Dangy JP, Hauser J, Jud M, Röltgen K, Hodgson A, Junghanss T, Harris SR, Parkhill J, Bentley SD, Pluschke G. Loss of Genomic Diversity in a Neisseria meningitidis Clone Through a Colonization Bottleneck. Genome Biol Evol 2018; 10:2102-2109. [PMID: 30060167 PMCID: PMC6110524 DOI: 10.1093/gbe/evy152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 01/11/2023] Open
Abstract
Neisseria meningitidis is the leading cause of epidemic meningitis in the "meningitis belt" of Africa, where clonal waves of colonization and disease are observed. Point mutations and horizontal gene exchange lead to constant diversification of meningococcal populations during clonal spread. Maintaining a high genomic diversity may be an evolutionary strategy of meningococci that increases chances of fixing occasionally new highly successful "fit genotypes". We have performed a longitudinal study of meningococcal carriage and disease in northern Ghana by analyzing cerebrospinal fluid samples from all suspected meningitis cases and monitoring carriage of meningococci by twice yearly colonization surveys. In the framework of this study, we observed complete replacement of an A: sequence types (ST)-2859 clone by a W: ST-2881 clone. However, after a gap of 1 year, A: ST-2859 meningococci re-emerged both as colonizer and meningitis causing agent. Our whole genome sequencing analyses compared the A population isolated prior to the W colonization and disease wave with the re-emerging A meningococci. This analysis revealed expansion of one clone differing in only one nonsynonymous SNP from several isolates already present in the original A: ST-2859 population. The colonization bottleneck caused by the competing W meningococci thus resulted in a profound reduction in genomic diversity of the A meningococcal population.
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Affiliation(s)
- Araceli Lamelas
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
- Red de Estudios Moleculares Avanzados, Instituto de Ecología A. C., Xalapa, Veracruz, México
| | - Abdul-Wahab M Hamid
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
- Navrongo Health Research Centre, Ministry of Health, Navrongo, Ghana
| | - Jean-Pierre Dangy
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Julia Hauser
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Maja Jud
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Katharina Röltgen
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Abraham Hodgson
- Navrongo Health Research Centre, Ministry of Health, Navrongo, Ghana
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Thomas Junghanss
- Section of Clinical Tropical Medicine, University Hospital Heidelberg, Germany
| | - Simon R Harris
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, United Kingdom
| | - Julian Parkhill
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, United Kingdom
| | - Stephen D Bentley
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, United Kingdom
| | - Gerd Pluschke
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
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Oordt-Speets AM, Bolijn R, van Hoorn RC, Bhavsar A, Kyaw MH. Global etiology of bacterial meningitis: A systematic review and meta-analysis. PLoS One 2018; 13:e0198772. [PMID: 29889859 PMCID: PMC5995389 DOI: 10.1371/journal.pone.0198772] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/24/2018] [Indexed: 12/16/2022] Open
Abstract
Bacterial meningitis is a global public health concern, with several responsible etiologic agents that vary by age group and geographical area. The aim of this systematic review and meta-analysis was to assess the etiology of bacterial meningitis in different age groups across global regions. PubMed and EMBASE were systematically searched for English language studies on bacterial meningitis, limited to articles published in the last five years. The methodological quality of the studies was assessed using a customized scoring system. Meta-analyses were conducted to determine the frequency (percentages) of seven bacterial types known to cause meningitis: Escherichia coli, Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae, group B Streptococcus agalactiae, Staphylococcus aureus, and Listeria monocytogenes, with results being stratified by six geographical regions as determined by the World Health Organization, and seven age groups. Of the 3227 studies retrieved, 56 were eligible for the final analysis. In all age groups, S. pneumoniae and N. meningitidis were the predominant pathogens in all regions, accounting for 25.1-41.2% and 9.1-36.2% of bacterial meningitis cases, respectively. S. pneumoniae infection was the most common cause of bacterial meningitis in the 'all children' group, ranging from 22.5% (Europe) to 41.1% (Africa), and in all adults ranging from 9.6% (Western Pacific) to 75.2% (Africa). E. coli and S. pneumoniae were the most common pathogens that caused bacterial meningitis in neonates in Africa (17.7% and 20.4%, respectively). N. meningitidis was the most common in children aged ±1-5 years in Europe (47.0%). Due to paucity of data, meta-analyses could not be performed in all age groups for all regions. A clear difference in the weighted frequency of bacterial meningitis cases caused by the different etiological agents was observed between age groups and between geographic regions. These findings may facilitate bacterial meningitis prevention and treatment strategies.
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Affiliation(s)
| | - Renee Bolijn
- Pallas Health Research and Consultancy BV, Rotterdam, The Netherlands
| | - Rosa C. van Hoorn
- Pallas Health Research and Consultancy BV, Rotterdam, The Netherlands
| | | | - Moe H. Kyaw
- Sanofi Pasteur Inc, Swiftwater, Pennsylvania, United States of America
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Lamelas A, Hauser J, Dangy JP, Hamid AWM, Röltgen K, Abdul Sater MR, Hodgson A, Sie A, Junghanss T, Harris SR, Parkhill J, Bentley SD, Pluschke G. Emergence and genomic diversification of a virulent serogroup W:ST-2881(CC175) Neisseria meningitidis clone in the African meningitis belt. Microb Genom 2017; 3:e000120. [PMID: 29026659 PMCID: PMC5610715 DOI: 10.1099/mgen.0.000120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 05/10/2017] [Indexed: 12/21/2022] Open
Abstract
Countries of the African 'meningitis belt' are susceptible to meningococcal meningitis outbreaks. While in the past major epidemics have been primarily caused by serogroup A meningococci, W strains are currently responsible for most of the cases. After an epidemic in Mecca in 2000, W:ST-11 strains have caused many outbreaks worldwide. An unrelated W:ST-2881 clone was described for the first time in 2002, with the first meningitis cases caused by these bacteria reported in 2003. Here we describe results of a comparative whole-genome analysis of 74 W:ST-2881 strains isolated within the framework of two longitudinal colonization and disease studies conducted in Ghana and Burkina Faso. Genomic data indicate that the W:ST-2881 clone has emerged from Y:ST-175(CC175) bacteria by capsule switching. The circulating W:ST-2881 populations were composed of a variety of closely related but distinct genomic variants with no systematic differences between colonization and disease isolates. Two distinct and geographically clustered phylogenetic clonal variants were identified in Burkina Faso and a third in Ghana. On the basis of the presence or absence of 17 recombination fragments, the Ghanaian variant could be differentiated into five clusters. All 25 Ghanaian disease isolates clustered together with 23 out of 40 Ghanaian isolates associated with carriage within one cluster, indicating that W:ST-2881 clusters differ in virulence. More than half of the genes affected by horizontal gene transfer encoded proteins of the 'cell envelope' and the 'transport/binding protein' categories, which indicates that exchange of non-capsular antigens plays an important role in immune evasion.
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Affiliation(s)
- Araceli Lamelas
- 1Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.,2Red de Estudios Moleculares Avanzados, Instituto de Ecologia, Veracruz, Mexico
| | - Julia Hauser
- 1Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.,3University of Basel, Basel, Switzerland
| | - Jean-Pierre Dangy
- 1Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.,3University of Basel, Basel, Switzerland
| | - Abdul-Wahab M Hamid
- 3University of Basel, Basel, Switzerland.,4Navrongo Health Research Centre, Navrongo, Ghana
| | - Katharina Röltgen
- 1Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.,3University of Basel, Basel, Switzerland
| | - Mohamad R Abdul Sater
- 1Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.,3University of Basel, Basel, Switzerland
| | | | - Ali Sie
- 5Center de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Thomas Junghanss
- 6Section of Clinical Tropical Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon R Harris
- 7Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge CB10 1SA, UK
| | - Julian Parkhill
- 7Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge CB10 1SA, UK
| | - Stephen D Bentley
- 7Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge CB10 1SA, UK
| | - Gerd Pluschke
- 1Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland.,3University of Basel, Basel, Switzerland
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Mustapha MM, Marsh JW, Harrison LH. Global epidemiology of capsular group W meningococcal disease (1970-2015): Multifocal emergence and persistence of hypervirulent sequence type (ST)-11 clonal complex. Vaccine 2016; 34:1515-1523. [PMID: 26876439 DOI: 10.1016/j.vaccine.2016.02.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 01/28/2016] [Accepted: 02/02/2016] [Indexed: 12/21/2022]
Abstract
Following an outbreak in Mecca Saudi Arabia in 2000, meningococcal strains expressing capsular group W (W) emerged as a major cause of invasive meningococcal disease (IMD) worldwide. The Saudi Arabian outbreak strain (Hajj clone) belonging to the ST-11 clonal complex (cc11) is similar to W cc11 causing occasional sporadic disease before 2000. Since 2000, W cc11 has caused large meningococcal disease epidemics in the African meningitis belt and endemic disease in South America, Europe and China. Traditional molecular epidemiologic typing suggested that a majority of current W cc11 burden represented global spread of the Hajj clone. However, recent whole genome sequencing (WGS) analyses revealed significant genetic heterogeneity among global W cc11 strains. While continued spread of the Hajj clone occurs in the Middle East, the meningitis belt and South Africa have co-circulation of the Hajj clone and other unrelated W cc11 strains. Notably, South America, the UK, and France share a genetically distinct W cc11 strain. Other W lineages persist in low numbers in Europe, North America and the meningitis belt. In summary, WGS is helping to unravel the complex genomic epidemiology of group W meningococcal strains. Wider application of WGS and strengthening of global IMD surveillance is necessary to monitor the continued evolution of group W lineages.
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Affiliation(s)
- Mustapha M Mustapha
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh, A525 Crabtree Hall,130 Desoto Street, Pittsburgh, PA 15261,USA
| | - Jane W Marsh
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh, A525 Crabtree Hall,130 Desoto Street, Pittsburgh, PA 15261,USA
| | - Lee H Harrison
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh, A525 Crabtree Hall,130 Desoto Street, Pittsburgh, PA 15261,USA.
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Seale AC, Obiero CW, Berkley JA. Rational development of guidelines for management of neonatal sepsis in developing countries. Curr Opin Infect Dis 2015; 28:225-30. [PMID: 25887615 PMCID: PMC4423591 DOI: 10.1097/qco.0000000000000163] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review discusses the rational development of guidelines for the management of neonatal sepsis in developing countries. RECENT FINDINGS Diagnosis of neonatal sepsis with high specificity remains challenging in developing countries. Aetiology data, particularly from rural, community-based studies, are very limited, but molecular tests to improve diagnostics are being tested in a community-based study in South Asia. Antibiotic susceptibility data are limited, but suggest reducing susceptibility to first-and second-line antibiotics in both hospital and community-acquired neonatal sepsis. Results of clinical trials in South Asia and sub-Saharan Africa assessing feasibility of simplified antibiotic regimens are awaited. SUMMARY Effective management of neonatal sepsis in developing countries is essential to reduce neonatal mortality and morbidity. Simplified antibiotic regimens are currently being examined in clinical trials, but reduced antimicrobial susceptibility threatens current empiric treatment strategies. Improved clinical and microbiological surveillance is essential, to inform current practice, treatment guidelines, and monitor implementation of policy changes.
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Affiliation(s)
- Anna C Seale
- University College London Department of Infectious Diseases Informatics, UCL Institute for Health Informatics, Farr Institute
- Imperial NHS Trust, London
| | | | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Centre for Tropical Medicine & Global Health, University of Oxford, UK
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