Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria

Ayede A et al.

Aim

To test the feasibility of implementing an outpatient protocol for suspected neonatal sepsis when referral isn’t possible. 

Rationale

The WHO has developed guidelines that recommend a simplified outpatient antibiotic regime; however the implementation of these guidelines has not been examined. 

Design

An implementation study design (this I have not come across before but they used a reconcised framework of RE-AIM; Reach, efficacy, adoption, implementation and maintenance)

Setting

Within primary healthcare settings in a single district in Nigeria.

Population

<2 months old attending clinics with signs of suspected bacterial infection (RR>60, severe chest indrawaing, no movement or only when stimulated, not feeding, convulsions or fever).

Exclusion; nil; not a comparative study. 

Intervention

Bundle of interventions the most important of which were; referral to a tertiary centre but if not possible treatment with x2 days of IM gentamicin and 7 days of oral amoxicillin. The research team guided implementation of these guidelines. 

Control

No control 

Primary outcome

Re-treatment for infection within 28 days

Results

1212 out of 5278 screened live births had signs of infection. 

Only 8.5% accepted hospital referral

Amongst all groups of infection the total number of deaths was 4 (0.5%). All of these patients had signs of severe infection or critical illness

Author’s Discussion

The author’s highlight the success in integrating into the current system, involving stakeholders and successful staff training. They also had a system in place to identify challenges and overcome these.

They also identified issues with drugs supply, low staff pay (leading to low motivation) in particular the need to have a network to allow home visits. 

Strengths

Important question 

Large well implemented programme

Demonstrate the possible implementation of the WHO guidelines.

Realistic real-world setting. 

Weakness

Small but significant numbers loss to follow up

No parallel comparison location (compared to other countries implementation)

My humble opinion

This is an excellent, well conducted trial that although isn’t a true randomised trial or systematic analysis nonetheless provides good evidence that the WHO guidelines for potentially serious bacterial infection in the newborn period are effective. On a personal level this makes me more reassured about the many neonates we have to treat with oral medication if IV antibiotics aren’t available. There are also lots of lessons here about the barriers to implementing a new guideline and how to overcome them.