Effect of case management on neonatal mortality due to sepsis and pneumonia

Anita K M Zaidi,Simon Cousens,Sana Syed,Robert Black,Anne Cc Lee,Zulfiqar A Bhutta,Hammad A Ganatra,Joy E Lawn

doi:10.1186/1471-2458-11-s3-s13

Abstract

BackgroundEach year almost one million newborns die from infections, mostly in low-income countries. Timely case management would save many lives but the relative mortality effect of varying strategies is unknown. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST).MethodsWe conducted systematic searches of multiple databases to identify relevant studies with mortality data. Standardized abstraction tables were used and study quality assessed by adapted GRADE criteria. Meta-analyses were undertaken where appropriate. For interventions with biological plausibility but low quality evidence, a Delphi process was undertaken to estimate effectiveness.ResultsSearches of 2876 titles identified 7 studies. Among these, 4 evaluated oral antibiotics for neonatal pneumonia in non-randomised, concurrently controlled designs. Meta-analysis suggested reductions in all-cause neonatal mortality (RR 0.75 95% CI 0.64- 0.89; 4 studies) and neonatal pneumonia-specific mortality (RR 0.58 95% CI 0.41- 0.82; 3 studies). Two studies (1 RCT, 1 observational study), evaluated community-based neonatal care packages including injectable antibiotics and reported mortality reductions of 44% (RR= 0.56, 95% CI 0.41-0.77) and 34% (RR =0.66, 95% CI 0.47-0.93), but the interpretation of these results is complicated by co-interventions. A third, clinic-based, study reported a case-fatality ratio of 3.3% among neonates treated with injectable antibiotics as outpatients. No studies were identified evaluating injectable antibiotics alone for neonatal pneumonia. Delphi consensus (median from 20 respondents) effects on sepsis-specific mortality were 30% reduction for oral antibiotics, 65% for injectable antibiotics and 75% for injectable antibiotics on pneumonia-specific mortality. No trials were identified assessing effect of hospital management for neonatal infections and Delphi consensus suggested 80%, and 90% reductions for sepsis and pneumonia-specific mortality respectively.ConclusionOral antibiotics administered in the community are effective for neonatal pneumonia mortality reduction based on a meta-analysis, but expert opinion suggests much higher impact from injectable antibiotics in the community or primary care level and even higher for facility-based care. Despite feasibility and low cost, these interventions are not widely available in many low income countries.FundingThis work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.

Highlights

Each year almost one million newborns die from infections, mostly in low-income countries
Deaths occurring in the neonatal period each year account for 41% (3.6 million) of all deaths in children under 5 years [1]. The majority of these deaths occur in low income countries and almost 1 million of these deaths are attributable to infectious causes including neonatal sepsis, meningitis and pneumonia [1]
The objective of this review is to provide estimates of the effectiveness of three interventions in preventing neonatal deaths from severe infection: (i) case management with oral antibiotic therapy alone for pneumonia and sepsis; (ii) case management with injectable antibiotics (± oral antibiotics) as an outpatient or at home for neonatal sepsis /meningitis and pneumonia; and (iii) hospital-based case management, including injectable antibiotics, intravenous fluids, oxygen therapy, second line injectable antibiotics if needed, and other supportive therapy (Table 1)

Summary

Introduction

Each year almost one million newborns die from infections, mostly in low-income countries. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST). Deaths occurring in the neonatal period each year account for 41% (3.6 million) of all deaths in children under 5 years [1] The majority of these deaths occur in low income countries and almost 1 million of these deaths are attributable to infectious causes including neonatal sepsis, meningitis and pneumonia [1]. These deaths occur because of lack of preventive care (clean birth care, breastfeeding) and appropriate case management [2]. Recent trials have demonstrated the effect of community-based packages for prevention and treatment of neonatal bacterial infections, with the potential to save many lives [4,5]

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