Time to tackle early-onset sepsis in low-income and middle-income countries

June 10, 2022

Luregn Schlapbach

NOMIS researcher Luregn Schlapbach and colleagues have published a commentary on the results from the Burden of Antibiotics Resistance in Neonates from Developing Societies (BARNARDS) study, which were presented in The Lancet Global Health.

In 2015, the UN adopted the Sustainable Development Goals (SDG) representing integrated actions to improve health, prosperity, and peace on the planet. SDG 3 focuses on health and specifically targets preventable neonatal deaths to achieve neonatal mortality below 12 per 1000 livebirths by 2030. Although, compared to 1990, neonatal mortality rates had been halved to 18 per 1000 livebirths by 2017, extrapolation of these trends indicate that we will fail to meet the SDG goals even in optimistic scenarios. Neonatal infections account for over 3 million of the approximatively 20 million sepsis cases in children under 5 years, with an average mortality of 7·6%. Post-discharge mortality and long-term morbidities further aggravate this impact. Altogether, these findings provide a strong impetus to identify and target potentially modifiable factors contributing to excess neonatal deaths due to sepsis worldwide.

In this context, results from the Burden of Antibiotics Resistance in Neonates from Developing Societies (BARNARDS) study presented in this issue of The Lancet Global Health provide valuable insights. Contrary to previous studies limited to neonatal intensive care unit settings that miss pre-hospital deaths, the authors did a facility-based study and assessed 29 483 mothers with 30 557 livebirths across seven low-income and middle-income countries (LMIC) including those with high neonatal mortality in Africa and south Asia. Maternal socioeconomic, demographic, environmental, and health factors, as well as perinatal and facility-specific data, were prospectively captured and the birth cohort followed up longitudinally until 60 days, although in 55% of neonates, follow-up was available only up to a median of 7 days. The authors previously reported on microbiological and treatment characteristics of neonates with confirmed sepsis, highlighting high rates of antimicrobial resistance, and questioning adequacy of current antibiotic treatment recommendations. In the present report, the authors focus on outcomes and risk factors in facility-born neonates, where one in six developed clinically suspected sepsis (166 per 1000 livebirths)—a quarter of which was microbiologically confirmed. All-cause mortality was seven times higher in infants with clinically suspected sepsis and 14 times higher in those with laboratory-confirmed sepsis compared with uninfected infants, confirming a major effect of sepsis on neonatal mortality. Incidence rates varied dramatically across sites; however, as the authors acknowledge, it remains difficult to untangle to what degree this represents true variability as opposed to methodological differences in laboratory techniques. Although the authors identify a range of risk factors such as caesarean section, preterm delivery, preterm rupture of membranes, and prenatal exposure to antibiotics, these often overlap and absence of information on chorioamnionitis as a key confounder make it challenging to draw firm conclusions on prioritising future interventions. In addition, it remains unclear whether perinatally acquired early-onset sepsis and hospital-acquired versus community-acquired late-onset sepsis can be reliably discriminated in the dataset, despite the fact that these entities could warrant fundamentally different approaches. Finally, given strong associations of sepsis outcomes with quality of care, as well as with recognition, timing, and appropriateness of both maternal and infant treatment, future studies should assess such quality indicators.

Continue reading this The Lancet Global Health publication