A review of some of the latest low-resourcs emergency medicine evidence
Implementing WHO guidelines for unwell newborns.
Ayede A et al.
To test the feasibility of implementing an outpatient protocol for suspected neonatal sepsis when referral isn’t possible.
The WHO has developed guidelines that recommend a simplified outpatient antibiotic regime; however the implementation of these guidelines has not been examined.
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)
Within primary healthcare settings in a single district in Nigeria.
<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.
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.
Re-treatment for infection within 28 days
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
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.
Large well implemented programme
Demonstrate the possible implementation of the WHO guidelines.
Realistic real-world setting.
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.