A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines

Improving adherence to severe malaria treatment guidelines in children at a Ugandan regional hospital: assessment of a quality improvement initiative

BACKGROUND

Malaria is the leading cause of hospitalizations and death in Uganda, particularly in children under the age of five. Studies have shown that adherence to the World Health Organization (WHO) guidelines for the management of severe malaria reduces mortality in hospitalized children. This study aimed to determine the impact of targeted interventions on adherence to the WHO severe malaria treatment guidelines in children at a Ugandan hospital as part of a quality improvement initiative.

METHODS

Interventions included workflow changes, such as obtaining patient blood samples for diagnostic testing by the admitting healthcare provider as well as utilizing patient caregivers to assist nursing staff in timing medications. An additional intervention was the use of an admission checklist sticker. The post-intervention sample was compared to the baseline assessment. The primary outcome was the proportion of patients receiving care consistent with all aspects of the WHO guidelines. Secondary outcomes included the proportion of patients receiving malaria diagnostic testing, those receiving at least 3 doses of artesunate, the timely administration of artesunate, and adherence to other guideline components. Statistical analyses were conducted using GraphPad PRISM 9.0. Comparisons between groups were analysed using Chi-square or Fisher's exact test for categorical variables and Mann-Whitney test for continuous variables.

RESULTS

The post-intervention group included 230 patients with a median age of 5 years [4-8], and 58% of patients were male. Adherence to all aspects of the WHO guidelines was achieved in 10% of patients in the post-intervention group compared to 3% of patients in the baseline (P = 0.007). Appropriate malaria diagnostic testing was performed in 85% of patients post-intervention compared to 66% of patients in the baseline (P < 0.0001). Patients in the post-intervention group were more likely to receive the minimum 3 doses of artesunate (86%) than in the baseline (74%) (P = 0.008). Patients in the post-intervention group were more likely to receive artesunate doses on time than in the baseline (dose 2 P = 0.02, dose 3 P = 0.003).

CONCLUSIONS

Targeted, low-cost interventions led to improvement in adherence to severe malaria treatment guidelines. The most notable changes were in malaria diagnostic testing and antimalarial administration.

Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort

Background

Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia.

Methods

This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission.

Findings

Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission.

Interpretation

Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care.

Funding

The Bill & Melinda Gates Foundation (OPP1131320).

Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort

Background

Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries.

Methods

We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates.

Findings

We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions.

Interpretation

Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support.

Funding

Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.

Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study

OBJECTIVES

This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings.

DESIGN AND SETTING

We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries.

PARTICIPANTS

A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study.

PRIMARY OUTCOME MEASURES

We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations.

RESULTS

Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted.

CONCLUSIONS

Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.

The Enterics for Global Health (EFGH) Shigella Surveillance Study in Kenya

Background

Although Shigella is an important cause of diarrhea in Kenyan children, robust research platforms capable of conducting incidence-based Shigella estimates and eventual Shigella-targeted clinical trials are needed to improve Shigella-related outcomes in children. Here, we describe characteristics of a disease surveillance platform whose goal is to support incidence and consequences of Shigella diarrhea as part of multicounty surveillance aimed at preparing sites and assembling expertise for future Shigella vaccine trials.

Methods

We mobilized our preexisting expertise in shigellosis, vaccinology, and diarrheal disease epidemiology, which we combined with our experience conducting population-based sampling, clinical trials with high (97%-98%) retention rates, and healthcare utilization surveys. We leveraged our established demographic surveillance system (DSS), our network of healthcare centers serving the DSS, and our laboratory facilities with staff experienced in performing microbiologic and molecular diagnostics to identify enteric infections. We joined these resources with an international network of sites with similar capabilities and infrastructure to form a cohesive scientific network, designated Enterics for Global Health (EFGH), with the aim of expanding and updating our knowledge of the epidemiology and adverse consequences of shigellosis and enriching local research and career development priorities.

Conclusions

Shigella surveillance data from this platform could help inform Shigella vaccine trials.

Trajectories of resting energy expenditure and performance of predictive equations in children hospitalized with an acute illness and malnutrition: a longitudinal study

There is scarce data on energy expenditure in ill children with different degrees of malnutrition. This study aimed to determine resting energy expenditure (REE) trajectories in hospitalized malnourished children during and after hospitalization. We followed a cohort of children in Bangladesh and Malawi (2-23 months) with: no wasting (NW); moderate wasting (MW), severe wasting (SW), or edematous malnutrition (EM). REE was measured by indirect calorimetry at admission, discharge, 14-and-45-days post-discharge. 125 children (NW, n = 23; MW, n = 29; SW, n = 51; EM, n = 22), median age 9 (IQR 6, 14) months, provided 401 REE measurements. At admission, the REE of children with NW and MW was 67 (95% CI [58, 75]) and 70 (95% CI [63, 76]) kcal/kg/day, respectively, while REE in children with SW was higher, 79 kcal/kg/day (95% CI [74, 84], p = 0.018), than NW. REE in these groups was stable over time. In children with EM, REE increased from admission to discharge (65 kcal/kg/day, 95% CI [56, 73]) to 79 (95% CI [72, 86], p = 0.0014) and was stable hereafter. Predictive equations underestimated REE in 92% of participants at all time points. Recommended feeding targets during the acute phase of illness in severely malnourished children exceeded REE. Acutely ill malnourished children are at risk of being overfed when implementing current international guidelines.

The diagnosis and management of dehydration in children with wasting or nutritional edema: A systematic review

Dehydration is a major cause of death among children with wasting and diarrhea. We reviewed the evidence for the identification and management of dehydration among these children. Two systematic reviews were conducted to assess 1) the diagnostic performance of clinical signs or algorithms intended to measure dehydration, and 2) the efficacy and safety of low-osmolarity ORS versus ReSoMal on mortality, treatment failure, time to full rehydration, and electrolyte disturbances (management review). We searched PubMed/Medline, Embase, and Global Index Medicus for studies enrolling children 0-60 months old with wasting and diarrhea. The diagnostic review included four studies. Two studies found the Integrated Management of Childhood Illness (IMCI) and the Dehydration: Assessing Kids Accurately (DHAKA) algorithms had similar diagnostic performance, but both algorithms had high false positive rates for moderate (41% and 35%, respectively) and severe (76% and 82%, respectively) dehydration. One further IMCI algorithm study found a 23% false positive rate for moderate dehydration. The management review included six trials. One trial directly compared low osmolarity ORS to ReSoMal and found no difference in treatment failure rates, although ReSoMal had a shorter duration of treatment (16.1 vs. 19.6 hours, p = 0.036) and a higher incidence of hyponatremia. Both fluids failed to correct a substantial number of hypokalemia cases across studies. In conclusion, the IMCI dehydration assessment has comparable performance to other algorithms among wasted children. Low osmolarity ORS may be an alternative to ReSoMal for children with severe wasting, but might require additional potassium to combat hypokalemia.

The role of oxygen in the development and treatment of bronchopulmonary dysplasia

Oxygen (O2) is crucial for both the development and treatment of one of the most important consequences of prematurity: bronchopulmonary dysplasia (BPD). In fetal life, the hypoxic environment is important for alveolar development and maturation. After birth, O2 becomes a double-edged sword. While O2 is needed to prevent hypoxia, it also causes oxidative stress leading to a plethora of morbidities, including retinopathy and BPD. The advent of continuous O2 monitoring with pulse oximeters has allowed clinicians to recognize the narrow therapeutic margins of oxygenation for the preterm infant, but more knowledge is needed to understand what these ranges are at different stages of the preterm infant's life, including at birth, in the neonatal intensive care unit and after hospital discharge. Future research, especially in innovative technologies such as automated O2 control and remote oximetry, will improve the understanding and treatment of the O2 needs of infants with BPD.

Provider adherence to clinical care recommendations for infants and children who died in seven low- and middle-income countries in the Child Health and Mortality Prevention Surveillance (CHAMPS) network

Background

Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe adherence to World Health Organization recommendations for the management of leading causes of death among children.

Methods

We conducted a retrospective, descriptive study examining clinical data for children aged 1-59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016-June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration.

Findings

CHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h.

Interpretation

Provision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence.

Funding

Bill & Melinda Gates Foundation.

Plasma proteomic signatures of enteric permeability among hospitalized and community children in Kenya and Pakistan

We aimed to establish if enteric permeability was associated with similar biological processes in children recovering from hospitalization and relatively healthy children in the community. Extreme gradient boosted models predicting the lactulose-rhamnose ratio (LRR), a biomarker of enteric permeability, using 7,500 plasma proteins and 34 fecal biomarkers of enteric infection among 89 hospitalized and 60 community children aged 2-23 months were built. The R2 values were calculated in test sets. The models performed better among community children (R2: 0.27 [min-max: 0.19, 0.53]) than hospitalized children (R2: 0.07 [min-max: 0.03, 0.11]). In the community, LRR was associated with biomarkers of humoral antimicrobial and cellular lipopolysaccharide responses and inversely associated with anti-inflammatory and innate immunological responses. Among hospitalized children, the selected biomarkers had few shared functions. This suggests enteric permeability among community children was associated with a host response to pathogens, but this association was not observed among hospitalized children.

Characterising paediatric mortality during and after acute illness in Sub-Saharan Africa and South Asia: a secondary analysis of the CHAIN cohort using a machine learning approach

BACKGROUND

A better understanding of which children are likely to die during acute illness will help clinicians and policy makers target resources at the most vulnerable children. We used machine learning to characterise mortality in the 30-days following admission and the 180-days after discharge from nine hospitals in low and middle-income countries (LMIC).

METHODS

A cohort of 3101 children aged 2-24 months were recruited at admission to hospital for any acute illness in Bangladesh (Dhaka and Matlab Hospitals), Pakistan (Civil Hospital Karachi), Kenya (Kilifi, Mbagathi, and Migori Hospitals), Uganda (Mulago Hospital), Malawi (Queen Elizabeth Central Hospital), and Burkina Faso (Banfora Hospital) from November 2016 to January 2019. To record mortality, children were observed during their hospitalisation and for 180 days post-discharge. Extreme gradient boosted models of death within 30 days of admission and mortality in the 180 days following discharge were built. Clusters of mortality sharing similar characteristics were identified from the models using Shapley additive values with spectral clustering.

FINDINGS

Anthropometric and laboratory parameters were the most influential predictors of both 30-day and post-discharge mortality. No WHO/IMCI syndromes were among the 25 most influential mortality predictors of mortality. For 30-day mortality, two lower-risk clusters (N = 1915, 61%) included children with higher-than-average anthropometry (1% died, 95% CI: 0-2), and children without signs of severe illness (3% died, 95% CI: 2-4%). The two highest risk 30-day mortality clusters (N = 118, 4%) were characterised by high urea and creatinine (70% died, 95% CI: 62-82%); and nutritional oedema with low platelets and reduced consciousness (97% died, 95% CI: 92-100%). For post-discharge mortality risk, two low-risk clusters (N = 1753, 61%) were defined by higher-than-average anthropometry (0% died, 95% CI: 0-1%), and gastroenteritis with lower-than-average anthropometry and without major laboratory abnormalities (0% died, 95% CI: 0-1%). Two highest risk post-discharge clusters (N = 267, 9%) included children leaving against medical advice (30% died, 95% CI: 25-37%), and severely-low anthropometry with signs of illness at discharge (46% died, 95% CI: 34-62%).

INTERPRETATION

WHO clinical syndromes are not sufficient at predicting risk. Integrating basic laboratory features such as urea, creatinine, red blood cell, lymphocyte and platelet counts into guidelines may strengthen efforts to identify high-risk children during paediatric hospitalisations.

FUNDING

Bill & Melinda Gates FoundationOPP1131320.

Diagnostic, Management, and Research Considerations for Pediatric Acute Respiratory Distress Syndrome in Resource-Limited Settings: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

Diagnosis of pediatric acute respiratory distress syndrome (PARDS) in resource-limited settings (RLS) is challenging and remains poorly described. We conducted a review of the literature to optimize recognition of PARDS in RLS and to provide recommendations/statements for clinical practice and future research in these settings as part of the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2).

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

We included studies related to precipitating factors for PARDS, mechanical ventilation (MV), pulmonary and nonpulmonary ancillary treatments, and long-term outcomes in children who survive PARDS in RLS.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Seventy-seven studies were identified for full-text extraction. We were unable to identify any literature on which to base recommendations. We gained consensus on six clinical statements (good practice, definition, and policy) and five research statements. Clinicians should be aware of diseases and comorbidities, uncommon in most high-income settings, that predispose to the development of PARDS in RLS. Because of difficulties in recognizing PARDS and to avoid underdiagnosis, the PALICC-2 possible PARDS definition allows exclusion of imaging criteria when all other criteria are met, including noninvasive metrics of hypoxemia. The availability of MV support, regular MV training and education, as well as accessibility and costs of pulmonary and nonpulmonary ancillary therapies are other concerns related to management of PARDS in RLS. Data on long-term outcomes and feasibility of follow-up in PARDS survivors from RLS are also lacking.

CONCLUSIONS

To date, PARDS remains poorly described in RLS. Clinicians working in these settings should be aware of common precipitating factors for PARDS in their patients. Future studies utilizing the PALICC-2 definitions are urgently needed to describe the epidemiology, management, and outcomes of PARDS in RLS.

Implementing essential diagnostics-learning from essential medicines: A scoping review

The World Health Organization (WHO) model list of Essential In vitro Diagnostic (EDL) introduced in 2018 complements the established Essential Medicines List (EML) and improves its impact on advancing universal health coverage and better health outcomes. We conducted a scoping review of the literature on implementing the WHO essential lists in Africa to inform the implementation of the recently introduced EDL. We searched eight electronic databases for studies reporting on implementing the WHO EDL and EML in Africa. Two authors independently conducted study selection and data extraction, with disagreements resolved through discussion. We used the Supporting the Use of Research Evidence (SURE) framework to extract themes and synthesised findings using thematic content analysis. We used the Mixed Method Appraisal Tool (MMAT) version 2018 to assess the quality of included studies. We included 172 studies reporting on EDL and EML after screening 3,813 articles titles and abstracts and 1,545 full-text papers. Most (75%, n = 129) studies were purely quantitative in design, comprising descriptive cross-sectional designs (60%, n = 104), 15% (n = 26) were purely qualitative, and 10% (n = 17) had mixed-methods approaches. There were no qualitative or randomised experimental studies about EDL. The main barrier facing the EML and EDL was poorly equipped health facilities-including unavailability or stock-outs of essential in vitro diagnostics and medicines. Financial and non-financial incentives to health facilities and workers were key enablers in implementing the EML; however, their impact differed from one context to another. Only fifty-six (33%) of the included studies were of high quality. Poorly equipped and stocked health facilities remain an implementation barrier to essential diagnostics and medicines. Health system interventions such as financial and non-financial incentives to improve their availability can be applied in different contexts. More implementation study designs, such as experimental and qualitative studies, are required to evaluate the effectiveness of essential lists.

Health Care Providers' Knowledge, Attitude, and Practice Regarding Facility-Based Management of Children With Severe Acute Malnutrition in Bangladesh

BACKGROUND

Severe acute malnutrition (SAM) contributes to a substantial number of child deaths globally per year. The mortality rates can be lowered markedly if guideline-based management protocol is properly followed. However, case-fatality rates in resource-poor centers remain high even after introducing the guidelines. Perhaps, the lack of adequate knowledge leading to inappropriate management by the health care providers is responsible for such burden.

OBJECTIVE

We aimed to evaluate health care providers' knowledge, attitude, and practice regarding the facility-based management of children with SAM in Bangladesh.

METHODS

This was a qualitative study where data were collected cross-sectionally from 4 district and 2 tertiary care hospitals. Twenty-six semi-structured in-depth interviews were conducted among the doctors and nurses involved in inpatient care of SAM. Twenty-eight hours of observation were done in each facility to obtain information regarding the management practices.

RESULTS

The doctors had substantial knowledge in managing children with SAM in the facilities. However, knowledge of nurses was found suboptimal when evaluated based on the national guideline. Both doctors and nurses demonstrated favorable attitude toward management of childhood SAM. Identification of SAM at the facilities was poor due to lack of practice in relation to anthropometric measurements. In addition, improper practices related to blood glucose testing, dehydration monitoring, essential micronutrient administration, and follow-up of children with SAM were observed.

CONCLUSION

The study results underscore the importance of taking appropriate measures to enhance knowledge and ensure proper practice in relation to inpatient care of children with SAM according to the national guideline in Bangladesh.

Treatment-seeking and recovery among young undernourished children post-hospital discharge in Bangladesh: A qualitative study

INTRODUCTION

Post-hospital discharge mortality is high among undernourished children in many low and middle-income countries. Although a number of quantitative studies have highlighted a range of potential socio-cultural, economic and health system factors influencing paediatric post-discharge treatment-seeking and recovery, few studies have explored family and provider perspectives of the post-discharge period in-depth.

METHODS

This work was part of a large, multi-country prospective cohort study, the Childhood Acute Illness and Nutrition (CHAIN) Network. We conducted a qualitative sub-study to understand the post-discharge treatment-seeking and recovery experiences of families of undernourished children aged 2-23 months admitted in a rural and urban icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) hospital. Methods included repeat in-depth interviews (73 interviews in total) with 29 family members of 17 purposively selected children. These data were supplemented by interviews with 33 health workers, and by observations in hospitals and homes.

RESULTS

Important drivers of treatment-seeking perceived to support recovery included advice provided to family members while in hospital, media campaigns on hygiene practice, availability of free treatment, and social and financial support from family members, relatives and neighbours. Key perceived challenges included low household incomes, mothers having to juggle multiple responsibilities in addition to caring for the sick child, lack of support (sometimes violence) from the child's father, and family members' preference for relatively accessible drug shops, physicians or healers over hospital admission.

CONCLUSION

Development of interventions that address the challenges that families face is essential to support post-discharge adherence to medical advice and recovery. Potential interventions include strengthening information giving during hospitalization on what post-discharge care is needed and why, reducing direct and indirect costs associated with hospital visits, engaging fathers and other 'significant others' in post-discharge advice, and building mobile phone-based support for follow-up care.

Childhood mortality during and after acute illness in Africa and south Asia: a prospective cohort study

BACKGROUND

Mortality among children with acute illness in low-income and middle-income settings remains unacceptably high and the importance of post-discharge mortality is increasingly recognised. We aimed to explore the epidemiology of deaths among young children with acute illness across sub-Saharan Africa and south Asia to inform the development of interventions and improved guidelines.

METHODS

In this prospective cohort study, we enrolled children aged 2-23 months with acute illness, stratified by nutritional status defined by anthropometry (ie, no wasting, moderate wasting, or severe wasting or kwashiorkor), who were admitted to one of nine hospitals in six countries across sub-Saharan Africa and south Asia between Nov 20, 2016, and Jan 31, 2019. We assisted sites to comply with national guidelines. Co-primary outcomes were mortality within 30 days of hospital admission and post-discharge mortality within 180 days of hospital discharge. A priori exposure domains, including demographic, clinical, and anthropometric characteristics at hospital admission and discharge, as well as child, caregiver, and household-level characteristics, were examined in regression and survival structural equation models.

FINDINGS

Of 3101 children (median age 11 months [IQR 7-16]), 1120 (36·1%) had no wasting, 763 (24·6%) had moderate wasting, and 1218 (39·3%) had severe wasting or kwashiorkor. Of 350 (11·3%) deaths overall, 234 (66·9%) occurred within 30 days of hospital admission and 168 (48·0%) within 180 days of hospital discharge. 90 (53·6%) post-discharge deaths occurred at home. The proportion of children who died following discharge was relatively preserved across nutritional strata. Numerically large high-risk and low-risk groups could be disaggregated for early mortality and post-discharge mortality. Structural equation models identified direct pathways to mortality and multiple socioeconomic, clinical, and nutritional domains acting indirectly through anthropometric status.

INTERPRETATION

Among diverse sites in Africa and south Asia, almost half of mortality occurs following hospital discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a child-centred, risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality, and clinical trials of these approaches with outcomes of mortality, readmission, and cost are warranted.

FUNDING

The Bill & Melinda Gates Foundation.

Strategies Used for Implementing and Promoting Adherence to Antibiotic Guidelines in Low- and Lower-Middle-Income Countries: A Systematic Review

Containing antimicrobial resistance and reducing high levels of antibiotic consumption in low- and lower middle-income countries are a major challenge. Clinical guidelines targeting antibiotic prescribing can reduce consumption, however, the degrees to which clinical guidelines are adopted and adhered to are challenging for developers, policy makers and users. The aim of this study was to review the strategies used for implementing and promoting antibiotic guideline adherence in low- and lower middle-income countries. A review of published literature was conducted using PubMed, Cochrane Library, SCOPUS and the information systems of the World Health Organization and the Australian National University according to PRISMA guidelines and our PROSPERO protocol. The strategies were grouped into five broad categories based on the Cochrane Effective Practice and Organization of Care taxonomy. The 33 selected studies, representing 16 countries varied widely in design, setting, disease focus, methods, intervention components, outcomes and effects. The majority of interventions were multifaceted and resulted in a positive direction of effect. The nature of the interventions and study variability made it impossible to tease out which strategies had the greatest impact on improving CG compliance. Audit and feedback coupled with either workshops and/or focus group discussions were the most frequently used intervention components. All the reported strategies are established practices used in antimicrobial stewardship programs in high-income countries. We recommend interrupted time series studies be used as an alternative design to pre- and post-intervention studies, information about the clinical guidelines be made more transparent, and prescriber confidence be investigated.

Pediatric Hospital Medicine and Global Health: A Fitting Niche for an Emerging Subspecialty

As North American hospitals serve increasingly diverse patient populations, including recent immigrants, refugees, and returned travelers, all pediatric hospitalists (PHs) require foundational competency in global health, and a subset of PHs are carving out niches focused in global health. Pediatric hospitalists are uniquely positioned to collaborate with low- and middle-income country clinicians and child health advocates to improve the health of hospitalized children worldwide. Using the 2018 WHO standards for improving the quality of care for children and adolescents worldwide, we describe how PHs' skills align closely with what the WHO and others have identified as essential elements to bring high-quality, sustainable care to children in low- and middle-income countries. Furthermore, North American global health hospitalists bring home expertise that reciprocally benefits their home institutions.

Severe Pediatric TBI Management in a Middle-Income Country and a High-Income Country: A Comparative Assessment of Two Centers

Background: Traumatic brain injury (TBI) is a global public health issue with over 10 million deaths or hospitalizations each year. However, access to specialized care is dependent on institutional resources and public health policy. Phoenix Children's Hospital USA (PCH) and the Neiva University Hospital, Colombia (NUH) compared the management and outcomes of pediatric patients with severe TBI over 5 years to establish differences between outcomes of patients managed in countries of varying resources availability. Methods: We conducted a retrospective review of individuals between 0 and 17 years of age, with a diagnosis of severe TBI and admitted to PCH and NUH between 2010 and 2015. Data collected included Glasgow coma scores, intensive care unit monitoring, and Glasgow outcome scores. Pearson Chi-square, Fisher exact, T-test, or Wilcoxon-rank sum test was used to compare outcomes. Results: One hundred and one subjects met the inclusion criteria. NUH employed intracranial pressure monitoring less frequently than PCH (p = 0.000), but surgical decompression and subdural evacuation were higher at PCH (p = 0.031 and p = 0.003). Mortality rates were similar between the institutions (15% PCH, 17% NUH) as were functional outcomes (52% PCH, 54% NUH). Conclusions: Differences between centers included time to specialized care and utilization of monitoring. No significant differences were evidenced in survival and the overall functional outcomes.

Factors and Outcomes Related to the Use of Guideline-Recommended Antibiotics in Patients With Neutropenic Fever at the Uganda Cancer Institute

Background

Neutropenic fever (NF) is associated with significant morbidity and mortality for patients receiving cancer treatment in sub-Saharan Africa (sSA). However, the antibiotic management of NF in sub-Saharan Africa has not been well described. We evaluated the timing and selection of antibiotics for patients with NF at the Uganda Cancer Institute (UCI).

Methods

We conducted a retrospective chart review of adults with acute leukemia admitted to UCI from 1 January 2016 to 31 May 2017, who developed NF. For each NF event, we evaluated the association of clinical presentation and demographics with antibiotic selection as well as time to both initial and guideline-recommended antibiotics. We also evaluated the association between ordered antibiotics and the in-hospital case fatality ratio (CFR).

Results

Forty-nine NF events occurred among 39 patients. The time to initial antibiotic order was <1 day. Guideline-recommended antibiotics were ordered for 37 (75%) NF events. The median time to guideline-recommended antibiotics was 3 days. Fever at admission, a documented physical examination, and abdominal abnormalities were associated with a shorter time to initial and guideline-recommended antibiotics. The in-hospital CFR was 43%. There was no difference in in-hospital mortality when guideline-recommended antibiotics were ordered as compared to when non-guideline or no antibiotics were ordered (hazard ratio, 0.51 [95% confidence interval {CI}, .10-2.64] and 0.78 [95% CI, .20-2.96], respectively).

Conclusions

Patients with acute leukemia and NF had delayed initiation of guideline-recommended antibiotics and a high CFR. Prospective studies are needed to determine optimal NF management in sub-Saharan Africa, including choice of antibiotics and timing of antibiotic initiation.

Knowledge, attitudes, and perceptions of Kenyan healthcare workers regarding pediatric discharge from hospital

OBJECTIVE

To assess attitudes, perceptions, and practices of healthcare workers regarding hospital discharge and follow-up care for children under age five in Migori and Homa Bay, Kenya.

METHODS

This mixed-methods study included surveys and semi-structured telephone interviews with healthcare workers delivering inpatient pediatric care at eight hospitals between November 2017 and December 2018.

RESULTS

The survey was completed by 111 (85%) eligible HCWs. Ninety-seven of the surveyed HCWs were invited for interviews and 39 (40%) participated. Discharge tasks were reported to be "very important" to patient outcomes by over 80% of respondents, but only 37 (33%) perceived their hospital to deliver this care "very well" and 23 (21%) believed their facility provides sufficient resources for its provision. The vast majority (97%) of participants underestimated the risk of pediatric post-discharge mortality. Inadequate training, understaffing, stock-outs of take-home therapeutics, and user fees were commonly reported health systems barriers to adequate discharge care while poverty was seen as limiting caregiver adherence to discharge and follow-up care. Respondents endorsed the importance of follow-up care, but reported supportive mechanisms to be lacking. They requested enhanced guidelines on discharge and follow-up care.

CONCLUSION

Kenyan healthcare workers substantially underestimated the risk of pediatric post-discharge mortality. Pre- and in-service training should incorporate instruction on discharge and follow-up care. Improved post-discharge deaths tracking-e.g., through vital registry systems, child mortality surveillance studies, and community health worker feedback loops-is needed, alongside dissemination which could leverage platforms such as routine hospital-based mortality reports. Finally, further interventional trials are needed to assess the efficacy and cost-effectiveness of novel packages to improve discharge and follow-up care.

Malawian children with fast-breathing pneumonia with and without comorbidities

Background

Due to high risk of mortality, children with comorbidities are typically excluded from trials evaluating pneumonia treatment. Understanding heterogeneity of outcomes among children with pneumonia and comorbidities is critical to ensuring appropriate treatment.

Methods

We explored whether the percentage of children with fast-breathing pneumonia cured at Day 14 was lower among those with selected comorbidities enrolled in a prospective observational study than among those enrolled in a concurrent randomized controlled trial evaluating treatment with amoxicillin in Lilongwe, Malawi.

Results

Among 79 children with fast-breathing pneumonia in the prospective observational cohort, 57 (72.2%) had HIV infection/exposure, 20 (25.3%) had malaria, 2 (2.5%) had severe acute malnutrition, and 17 (21.5%) had anemia. Treatment failure rate was slightly (not significantly) lower in children with comorbidities (4.1%, 3/73) compared to those without comorbidities (4.5%, 25/552) similarly treated. There was no significant difference in clinical cure rates by Day 14 (95.8% with vs 96.7% without comorbidity).

Conclusions

Children with fast-breathing pneumonia excluded from a concurrent clinical trial due to comorbidities did not fare worse. Children at higher risk whose caregivers seek care early and who receive appropriate risk assessment (e.g., pulse oximetry, hemoglobin, HIV/malaria testing) and treatment, can achieve clinical cure by Day 14.

Trial registration

ClinicalTrials.govNCT02960919; registered November 8, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41479-021-00081-y.

Antimicrobial resistance and COVID-19: Intersections and implications

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.