Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh.

Ahmed Ehsanur Rahman,Ziaul Ahsan,M Shahidullah,Goutom Banik,Wahida Siraj,Qazi Sadeq-Ur Rahman,Stephen N Wall,Sayed Rubayet,Rezaul Hasan,M Mohiuddin Osmani,Abu Bakkar Siddique,Lara M E Vaz,Shams E L Arifeen,M Altaf Hossain,Samantha Herrera,M Jahurul Islam,Anisuddin Ahmed,Laura Folgori

doi:10.1371/journal.pone.0232675

Abstract

BackgroundSerious infections account for 25% of global newborn deaths annually, most in low-resource settings where hospital-based treatment is not accessible or feasible. In Bangladesh, one-third of neonatal deaths are attributable to serious infection; in 2014, the government adopted new policy for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral was not possible. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines.MethodsPSBI management was introduced as part of the Comprehensive Newborn Care Package in 2015. The study piloted this package through government health systems with limited partner support to inform scale-up efforts. Data collection included facility register reviews for cases seen at primary level facilities; facility readiness and provider knowledge and skills assessments; household surveys capturing caregiver knowledge of newborn danger signs and care-seeking for newborn illness; and follow-up case tracking, capturing treatment adherence and outcomes. Analysis consisted of descriptive statistics.ResultsOver the 15-month implementation period, 1432 young infants received care, of which 649 (45%) were classified as PSBI. Estimated coverage of care-seeking increased from 22% to 42% during the implementation period. Although facility readiness and providers’ skills increased, providers’ adherence to guidelines was not optimal. Among locally managed PSBI cases, 75% completed the oral antibiotic course and 15% received the fourth day follow-up. Care-seeking remained high among private providers (95%), predominantly village health doctors (over 80%).ConclusionsFacility readiness, including health care provider knowledge and skills were strengthened; future efforts should focus on improving provider adherence to guidelines. Social and behavior change strategies targeting families and communities should explore shifting care-seeking from private, possibly less-qualified providers. Strategies to improve private sector management of PSBI cases and improved linkages between private and public sector providers could be explored.

Highlights

Possible serious bacterial Infections (PSBI) or syndromic sepsis is a global public health concern for newborns and young infants (0–59 days), with an estimated 30 million cases per year [1, 2]
In cases where referral is not feasible or accepted, the revised guideline recommends treating possible serious bacterial infections (PSBI) cases—without sign(s) of critical illness—through outpatient care with simplified antibiotic regimens consisting of fewer doses of injectable antibiotics, along with oral antibiotics that can be administered at home [19]
The estimated case management coverage of PSBI cases increased gradually from 22% in quarter 1 to 51% in quarter 5, with an estimated coverage of 31% over the 15-month period; the largest increase was observed between quarter 3 and quarter 4

Summary

Introduction

Possible serious bacterial Infections (PSBI) or syndromic sepsis is a global public health concern for newborns and young infants (0–59 days), with an estimated 30 million cases per year [1, 2]. The multi-country Simplified Antibiotic Therapy Trials (SATT) in South Asia (Bangladesh and Pakistan) and the African Neonatal Sepsis Trial (AFRINEST) in Democratic Republic of Congo, Kenya, and Nigeria, tested and demonstrated the safety and efficacy of simplified antibiotic regimens for treating PSBI in young infants [16,17,18] in outpatient settings. In cases where referral is not feasible or accepted, the revised guideline recommends treating PSBI cases—without sign(s) of critical illness—through outpatient care with simplified antibiotic regimens consisting of fewer doses of injectable antibiotics, along with oral antibiotics that can be administered at home [19]. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines

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