Abstract
Inadequate illness recognition and access to antibiotics contribute to high case fatality from infections in young infants (<2 months) in low- and middle-income countries (LMICs). We aimed to address three questions regarding access to treatment for young infant infections in LMICs: (1) Can frontline health workers accurately diagnose possible bacterial infection (pBI)?; (2) How available and affordable are antibiotics?; (3) How often are antibiotics procured without a prescription? We searched PubMed, Embase, WHO/Health Action International (HAI), databases, service provision assessments (SPAs), Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and grey literature with no date restriction until May 2014. Data were identified from 37 published studies, 46 HAI national surveys, and eight SPAs. For study question 1, meta-analysis showed that clinical sign-based algorithms predicted bacterial infection in young infants with high sensitivity (87%, 95% CI 82%-91%) and lower specificity (62%, 95% CI 48%-75%) (six studies, n = 14,254). Frontline health workers diagnosed pBI in young infants with an average sensitivity of 82% (95% CI 76%-88%) and specificity of 69% (95% CI 54%-83%) (eight studies, n = 11,857) compared to physicians. For question 2, first-line injectable agents (ampicillin, gentamicin, and penicillin) had low variable availability in first-level health facilities in Africa and South Asia. Oral amoxicillin and cotrimoxazole were widely available at low cost in most regions. For question 3, no studies on young infants were identified, however 25% of pediatric antibiotic purchases in LMICs were obtained without a prescription (11 studies, 95% CI 18%-34%), with lower rates among infants <1 year. Study limitations included potential selection bias and lack of neonatal-specific data. Trained frontline health workers may screen for pBI in young infants with relatively high sensitivity and lower specificity. Availability of first-line injectable antibiotics appears low in many health facilities in Africa and Asia. Improved data and advocacy are needed to increase the availability and appropriate utilization of antibiotics for young infant infections in LMICs. PROSPERO International prospective register of systematic reviews (CRD42013004586). Please see later in the article for the Editors' Summary.
Highlights
In 2010, there were an estimated 6.8 million cases of possible severe bacterial infection, including 2.5 million cases of meningitis, pneumonia, sepsis or tetanus, diagnosed in neonates in South Asia, sub-Saharan Africa, and Latin America [1]
Trained frontline health workers may screen for possible bacterial infection (pBI) in young infants with relatively high sensitivity and lower specificity
We systematically reviewed the literature to answer the following specific study questions within the above described framework: (1) Can frontline health workers use clinical sign algorithms to accurately diagnose possible bacterial infection in young infants, as compared to physicians? (2) How available and affordable are antibiotics for treating neonatal infections in health facilities/pharmacies in low- or middle-income country (LMIC)? (3) What fraction of antibiotic purchases for treating neonatal/pediatric infections is accessed without prescription by a health provider in LMICs?
Summary
In 2010, there were an estimated 6.8 million cases of possible severe bacterial infection (pSBI), including 2.5 million cases of meningitis, pneumonia, sepsis or tetanus, diagnosed in neonates in South Asia, sub-Saharan Africa, and Latin America [1]. In this systematic review and meta-analysis, the researchers investigate access to treatment for neonatal bacterial infections in LMICs by first asking whether frontline health workers in LMICs can accurately diagnose bacterial infections in neonates and young infants (babies less than 2 months old). They ask whether antibiotics for treating neonatal infections are available and affordable in LMICs. they ask whether antibiotics for treating neonatal infections are available and affordable in LMICs They ask how often antibiotics are procured for young children (children up to the age of 5 years) without a prescription. A systematic review uses pre-defined criteria to identify all the research on a given topic; meta-analysis uses statistical methods to combine the results of several studies
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