Blood culture versus antibiotic use for neonatal inpatients in 61 hospitals implementing with the NEST360 Alliance in Kenya, Malawi, Nigeria, and Tanzania: a cross-sectional study

Abstract

Background: Thirty million small and sick newborns worldwide require inpatient care each year. Many receive antibiotics for clinically diagnosed infections without blood cultures, the current 'gold standard' for neonatal infection detection. Low neonatal blood culture use hampers appropriate antibiotic use, fuelling antimicrobial resistance (AMR) which threatens newborn survival. This study analysed the gap between blood culture use and antibiotic prescribing in hospitals implementing with Newborn Essential Solutions and Technologies (NEST360) in Kenya, Malawi, Nigeria, and Tanzania.

Methods: Inpatient data from every newborn admission record (July 2019-August 2022) were included to describe hospital-level blood culture use and antibiotic prescription. Health Facility Assessment data informed performance categorisation of hospitals into four tiers: (Tier 1) no laboratory, (Tier 2) laboratory but no microbiology, (Tier 3) neonatal blood culture use < 50% of newborns receiving antibiotics, and (Tier 4) neonatal blood culture use > 50%.

Results: A total of 144,146 newborn records from 61 hospitals were analysed. Mean hospital antibiotic prescription was 70% (range = 25-100%), with 6% mean blood culture use (range = 0-56%). Of the 10,575 blood cultures performed, only 24% (95%CI 23-25) had results, with 10% (10-11) positivity. Overall, 40% (24/61) of hospitals performed no blood cultures for newborns. No hospitals were categorised as Tier 1 because all had laboratories. Of Tier 2 hospitals, 87% (20/23) were District hospitals. Most hospitals could do blood cultures (38/61), yet the majority were categorised as Tier 3 (36/61). Only two hospitals performed > 50% blood cultures for newborns on antibiotics (Tier 4).

Conclusions: The two Tier 4 hospitals, with higher use of blood cultures for newborns, underline potential for higher blood culture coverage in other similar hospitals. Understanding why these hospitals are positive outliers requires more research into local barriers and enablers to performing blood cultures. Tier 3 facilities are missing opportunities for infection detection, and quality improvement strategies in neonatal units could increase coverage rapidly. Tier 2 facilities could close coverage gaps, but further laboratory strengthening is required. Closing this culture gap is doable and a priority for advancing locally-driven antibiotic stewardship programmes, preventing AMR, and reducing infection-related newborn deaths.

Keywords: Antibiotics; Antimicrobial resistance; Blood culture; Infection; Inpatient care; Low- and middle-income countries; Neonatal; Newborn; Quality of care; Sepsis; Small and sick newborn care.

Fig. 1

Framework for neonatal infection pathway, reflecting detection and care gaps. This paper focuses on inpatient care for neonatal infection and, therefore, does not address the first gap which arises due to lack of access to healthcare. Adapted from Lawn et al., 2017 [20] and Rahman et al., 2020 [19]. * Includes aetiology ± antimicrobial sensitivity. Abbreviations: CSF; cerebrospinal fluid, AST; antimicrobial sensitivity testing

Fig. 2

Flow diagram for the selection of hospitals and newborn records included in the study (January 2019–August 2022)

Fig. 3

Neonatal infection detection and care gaps for countries implementing with NEST360; Kenya, Malawi, Nigeria, and Tanzania (N = 65 neonatal units and N = 144,146 newborn records), January 2019 – August 2022. Abbreviations: BC; blood culture, AST; antimicrobial sensitivity testing, n/a; not applicable. Note: Estimates are reported as pooled hospital means

Fig. 4

Neonatal unit blood culture use and antibiotic prescription with positive outliers for infection detection. a Scatter plot depicting blood culture use and antibiotic prescription per neonatal unit, as a percentage of total neonatal admissions. Each dot represents a neonatal unit. b Ranked positive outlier neonatal units* based on blood culture use for those newborns prescribed antibiotics during admission. *Positive outlier neonatal units are those with blood culture use, for newborns prescribed antibiotics, above the pooled hospital mean

Fig. 5

Tiered performance categorisation of hospitals implementing with NEST360 based on neonatal blood culture service availably and use (N = 65 neonatal units). *Defined as reported ability to perform blood culture at baseline Health Facility Assessment collection timepoint. Abbreviations: KN; Kenya, MW; Malawi, NG; Nigeria, TZ; Tanzania