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
Authors: Murless-Collins Sarah , Kawaza Kondwani , Salim Nahya , Molyneux Elizabeth M. , Chiume Msandeni , Aluvaala Jalemba , Macharia William M. , Ezeaka Veronica Chinyere , Odedere Opeyemi , Shamba Donat , Tillya Robert , Penzias Rebecca E. , Ezenwa Beatrice Nkolika , Ohuma Eric O. , Cross James H. , Lawn Joy E. ,   the NEST360 Infection Group, Bokea Helen , Bohne Christine , Waiyego Mary , Irimu Grace , Ogueji Ifeanyichukwu Anthony , Jenkins Georgia , Tongo Olukemi O. , Fajolu Iretiola , Olutekunbi Nike , Paul Cate , Baraka Jitihada , Kirby Rebecca , Palamountain Kara 
Published: November 2023

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 asTier 1because all had laboratories. OfTier 2hospitals, 87% (20/23) were District hospitals. Most hospitals could do blood cultures (38/61), yet the majority were categorised asTier 3(36/61). Only two hospitals performed > 50% blood cultures for newborns on antibiotics (Tier 4).

Conclusions

The twoTier 4hospitals, 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 3facilities are missing opportunities for infection detection, and quality improvement strategies in neonatal units could increase coverage rapidly.Tier 2facilities 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.