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Wen SCH, Ezure Y, Rolley L, Spurling G, Lau CL, Riaz S, Paterson DL, Irwin AD. Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003787. [PMID: 34582466 PMCID: PMC8478175 DOI: 10.1371/journal.pmed.1003787] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 09/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms, which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries. We therefore completed a systematic review and meta-analysis of available data from all low- and lower-middle-income countries (LLMICs) since 2010, with a focus on regional differences in Gram-negative infections and AMR. METHODS AND FINDINGS All studies published from 1 January 2010 to 21 April 2021 about microbiologically confirmed bloodstream infections or meningitis in neonates and AMR in LLMICs were assessed for eligibility. Small case series, studies with a small number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. We included 88 studies (4 cohort studies, 3 randomised controlled studies, and 81 cross-sectional studies) comprising 10,458 Gram-negative isolates from 19 LLMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 55% to 65%). Klebsiella spp. was the most common, with a pooled proportion of 38% of Gram-negative sepsis (95% CI 33% to 43%). Regional differences were observed, with higher proportions of Acinetobacter spp. in Asia and Klebsiella spp. in Africa. Resistance to aminoglycosides and third-generation cephalosporins ranged from 42% to 69% and from 59% to 84%, respectively. Study limitations include significant heterogeneity among included studies, exclusion of upper-middle-income countries, and potential sampling bias, with the majority of studies from tertiary hospital settings, which may overestimate the burden caused by Gram-negative bacteria. CONCLUSIONS Gram-negative bacteria are an important cause of neonatal sepsis in LLMICs and are associated with significant rates of resistance to WHO-recommended first- and second-line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required.
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Affiliation(s)
- Sophie C. H. Wen
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- * E-mail:
| | - Yukiko Ezure
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Lauren Rolley
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
| | - Geoff Spurling
- Primary Care Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Colleen L. Lau
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Saba Riaz
- Institute of Microbiology and Molecular Genetics, University of the Punjab, Lahore, Pakistan
| | - David L. Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Adam D. Irwin
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
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