Pathogen aetiology and risk factors for death among neonates with bloodstream infections at lower-tier South African hospitals: a cross-sectional study.

Abstract

Infections are among the top causes of neonatal mortality, particularly in low-income and middle-income countries. We aimed to describe the clinical characteristics of neonates diagnosed with culture-confirmed bloodstream infections at six lower-tier hospitals in South Africa. We did a cross-sectional study of culture-confirmed bloodstream infections among neonates (aged 0-27 days) at six lower-tier hospitals in South Africa. Clinical, demographic, and pathogen data from sick, hospitalised neonates were analysed and bloodstream infections were categorised as early-onset sepsis (EOS; 0-2 days of life) or late-onset sepsis (LOS; 3-27 days of life). Incidence of bloodstream infection and crude in-hospital mortality in neonates with bloodstream infection were calculated and factors associated with death were analysed using multivariable logistic regression models. From Oct 1, 2019 to Sept 30, 2020, we identified 907 neonatal bloodstream infection episodes. Incidence was 6·4 cases per 1000 patient-days. Most neonates were preterm (median gestation 33 weeks [IQR 29-37]), with 30·5% (n=277) of bloodstream infections classified as EOS and 69·5% (n=630) as LOS. Gram-negative pathogens dominated (63·2% [n=573]), including Klebsiella pneumoniae (25·7% [n=233]) and Acinetobacter baumannii (19·2% [n=174]). Crude in-hospital mortality in neonates with bloodstream infection was 25·5% (n=231), accounting for 21·4% (231 of 1078 cases) of all in-hospital neonatal deaths. Increased all-cause mortality was associated with Gram-negative bloodstream infection (vs Gram-positive pathogens, adjusted odds ratio 3·70 [95% CI 1·46-9·39]; p=0·0059), inborn LOS (vs EOS, 2·42 [1·11-5·29];  p=0·027), preterm birth (5·00 [2·16-11·59]; p=0·0002), and neonatal intensive care unit admission (3·26 [1·51-7·03]; p=0·0026). Hospitalised, preterm neonates who developed Gram-negative bloodstream infections had high in-hospital mortality. Many small vulnerable newborns require prolonged stays in lower-tier hospitals and acquire life-threatening bloodstream infection; appropriate resources are needed at this level of care to prevent infections and save lives. Bill & Melinda Gates Foundation.