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A multicenter study of serious infections in young infants WHO

A multicenter study of serious infections in young infants WHO. Infant mortality in the developing world. 126,000,000 live births 8,000,000 infant deaths 5,000,000 neonatal deaths 3,300,000 early neonatal deaths. Neonatal deaths. global estimate 5 million per year

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A multicenter study of serious infections in young infants WHO

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  1. A multicenter study of serious infections in young infantsWHO

  2. Infant mortality in the developing world • 126,000,000 live births • 8,000,000 infant deaths • 5,000,000 neonatal deaths • 3,300,000 early neonatal deaths

  3. Neonatal deaths • global estimate 5 million per year • 98% in developing countries • 92% in Asia or Africa • data from developing countries, particularly the first week of life likely to be an underestimate

  4. Causes of neonatal mortality • 5 million deaths per year • infection - 1.78 million • prematurity - 1.15 million • birth asphyxia/trauma - 1.38 million • congenital anomalies - 0.52 million • other perinatal causes - 0.17 million WHO MSM Programme

  5. Deaths from neonatal infection • 1.6 million: • 750,000 pneumonia • 350,000 tetanus • 300,000 sepsis • 150,000 diarrhoea • 50,000 meningitis ie. pneumonia/sepsis/meningitis is responsible for 1.1 million neonatal deaths per year

  6. Views about the causes neonatal sepsis in developing countries in 1989 • Most Klebsiella or Staphylococcal • Contribution of pneumococcus or Hib unknown • Contribution of GBS unknown • Clinical signs are unlikely to be helpful in identifying high risk infants at the primary care level

  7. Multicentre study objectives • To identify the bacterial and viral agents responsible for serious infections in infants under 90 days of age in developing countries • To identify the simple clinical signs that best predict serious infection in infants under 90 days of age

  8. WHO multicentre study of pneumonia/sepsis/meningitis in young infants • Study Co-ordination: S. Gove, P. Margolis, F. McCaul, S. Parker, C. John; Writing Committee: K. Mulholland, P. Margolis, K. Mason, S. Gove; Data Management: P. Byass; Statistical Analysis: F. Harrell, K. Mason, J. Carlin; Gambia team: Clinicians:K. Mulholland (PI), O. Ogunlesi, M. Weber, M. Manary, A. Palmer; Laboratory: R. Adegbola, H. Whittle, O. Secka, B. Sam, D. Hazlett, M. Aidoo, Data management: J. Bangali; Director: B. Greenwood; Ethiopia:Clinicians:L. Muhe (PI), M. Tilahun, S. Lulseged, S. Kebede; Laboratory: A. Yohanes*, B. Belete, S. Ringertz; Radiology: T. Desta; Data management: K. Woldeyesus; Director: N. Tafari; Papua New Guinea: Clinicians and nurses: D. Lehmann (PI), G. Saleu, A. Rongap, M. Kakazo, P. Namuigi, S. Lupiwa, R. Sehuko; Laboratory: A. Clegg, R. Sanders , A. Michael, T. Lupiwa, M. Omena, M. Mens, B. Marjen, P. Wai’in, M. Sungu; Data management: D. Lewis; Director: M. Alpers; Philippines:Clinicians: S. Gatchalian (PI), B. Quiambao, A.M. Moreles, L. Abraham; Laboratory: L. Sombrero, F. Palladin, V. Sariano, A.M. Obach; Data management: E. Sunico, T. Cedulla; Study advisors: H. Eichenwald, C. Broome, M.Gratten, P. Margolis, R. Facklam, T. Nolan; Reference Laboratory Support: J. Hendrichsen, P.H. Makela, M. Grandien, J. Schachter, L. Moore, G. Cassell, L. Duffy, R. Facklam, F. Tenover, B. Metchock; Radiology Working Group: H. Tschappeler, M. Hendry, A. Lamont, P. Palmer.

  9. WHO multicentre study of pneumonia/sepsis/meningitis in young infants • 4552 sick infants under 90 days of age studied in 4 developing countries • Papua New Guinea, The Gambia, The Philippines, Ethiopia • full history and examination on every infant • All infants with signs of infection investigated • outcome of all cases recorded

  10. Criteria for investigation

  11. Positive blood culture isolates • Staph. aureus 34 • Strep. pneumoniae 33 • Group A Streptococcus 29 • E. coli 19 • Salmonella spp. 17 • other Gram negs. 22 • H. influenzae 7 • other Streps. 6

  12. CSF isolates * one Group B Streptococcus was isolated

  13. Clinical features • 10% of the 2398 infants investigated died: • blood culture positive - 31% died • blood culture negative - 9% died • CSF culture positive - • death was associated with • positive CSF or blood culture • hypoxaemia • major x-ray abnormality • abnormal white cell count (<5.5 or >22)

  14. Gram-positive organisms • S. pneumoniae - 33 cases • 17 meningitis, 16 pneumonia • 11 deaths (33%) • mean age 47 days • Group A Streptococcus - 29 cases • 4 deaths (14%) • mean age 34 days • Staph aureus - 34 cases • 7 deaths (21%) • mean age 33 days

  15. Gm negative organisms • Salmonella spp. - 17 cases • 6 deaths (35%) • underweight (mean Z-score -2.4) • E. coli - 19 cases • 10 deaths (53%) • 6 meningitis • underweight (mean Z-score -2.7)

  16. Gambia (n=438) 51 RSV (12%) peak Sept-Oct 46 Influenza A (11%) 22 Influenza B (5%) 26 Parainfluenza (6%) Philippines (n=685) 101 RSV (15%) peak Sept-Oct 5 Influenza A 2 Influenza B 16 Parainfluenza (2%) Viruses

  17. Objectives to identify the best clinical predictors of serious infections in young infants in the hands of paediatricians to identify the simple signs most helpful for the identification of infants in need of referral for suspected serious infection Clinical signs study

  18. Problems very large amount of clinical data, much overlapping or duplicative measured, culture proven endpoint is only a fraction of the infants regarded by clinicians as in need of admission and antibiotics how to deal with deaths? Recorded deaths were not prevented by appropriate clinical care. Clinical signs study

  19. Method variables analysed as clusters determined by statistical association and clinical common sense Ordinal outcome scale: 2 = positive blood or CSF culture or SaO2<90% (adj.) 1 = positive chest x-ray or SaO2 90-95% 0 = none of the above Proportional odds assumption checked poor fit for auscultatory findings Clinical signs study

  20. Temperature Respiratory rate WAZ score Bulging fontanelle or convulsion Drowsy-unconscious Signs of respiratory effort (grunting, chest wall indrawing) Crepitations Poor feeding Apnea Clinical signs study - full model

  21. Respiratory rate (0-20 points) Temperature PR (0-7 points) WAZ score (0-6 points) Unable to suck (5 points) Crepitations (8 points) Cyanosis (5 points) History of convulsions (4 points) Lower chest wall indrawing (3 points) No arousal with minimal stimulus (2 points) History of change in activity (2 points) Clinical signs study - simplified model

  22. Probability of culture positive, SaO2<95%, or x-ray abnormal

  23. Conclusions • Infection, particularly pneumonia, meningitis and sepsis are major contributors to high mortality rates in very young infants in developing countries. • The most likely bacterial causes are: • S. pneumoniae • Group A Streptococcus • Staph. aureus • Gram negative enteric organisms, esp. E. coli

  24. Conclusions - II • Young infants in developing countries are frequently infected by the usual respiratory viruses, particularly RSV, with much morbidity but little mortality • Efforts to improve early infant mortality should focus on preventing bacterial infections, and early detection and prompt referral of suspected cases • Clinical signs can reliably identify those at greatest risk

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