Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan.
BMC Public Health. 2011 Apr 13;11 Suppl 3(Suppl 3):S13. doi: 10.1186/1471-2458-11-S3-S13.
Each year almost one million newborns die from infections, mostly in low-income countries. Timely case management would save many lives but the relative mortality effect of varying strategies is unknown. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST).
We conducted systematic searches of multiple databases to identify relevant studies with mortality data. Standardized abstraction tables were used and study quality assessed by adapted GRADE criteria. Meta-analyses were undertaken where appropriate. For interventions with biological plausibility but low quality evidence, a Delphi process was undertaken to estimate effectiveness.
Searches of 2876 titles identified 7 studies. Among these, 4 evaluated oral antibiotics for neonatal pneumonia in non-randomised, concurrently controlled designs. Meta-analysis suggested reductions in all-cause neonatal mortality (RR 0.75 95% CI 0.64- 0.89; 4 studies) and neonatal pneumonia-specific mortality (RR 0.58 95% CI 0.41- 0.82; 3 studies). Two studies (1 RCT, 1 observational study), evaluated community-based neonatal care packages including injectable antibiotics and reported mortality reductions of 44% (RR = 0.56, 95% CI 0.41-0.77) and 34% (RR = 0.66, 95% CI 0.47-0.93), but the interpretation of these results is complicated by co-interventions. A third, clinic-based, study reported a case-fatality ratio of 3.3% among neonates treated with injectable antibiotics as outpatients. No studies were identified evaluating injectable antibiotics alone for neonatal pneumonia. Delphi consensus (median from 20 respondents) effects on sepsis-specific mortality were 30% reduction for oral antibiotics, 65% for injectable antibiotics and 75% for injectable antibiotics on pneumonia-specific mortality. No trials were identified assessing effect of hospital management for neonatal infections and Delphi consensus suggested 80%, and 90% reductions for sepsis and pneumonia-specific mortality respectively.
Oral antibiotics administered in the community are effective for neonatal pneumonia mortality reduction based on a meta-analysis, but expert opinion suggests much higher impact from injectable antibiotics in the community or primary care level and even higher for facility-based care. Despite feasibility and low cost, these interventions are not widely available in many low income countries.
This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.
每年有近 100 万新生儿死于感染，主要发生在低收入国家。及时进行病例管理可以挽救许多生命，但不同策略的相对死亡率影响尚不清楚。我们估算了在家庭或一级医疗机构中提供口服或注射抗生素，以及住院治疗对肺炎和败血症引起的新生儿死亡率的影响，以便在“拯救生命工具”（LiST）中使用。
我们对多个数据库进行了系统检索，以确定具有死亡率数据的相关研究。使用标准化的抽象表，并根据改编的 GRADE 标准评估研究质量。在适当的情况下进行荟萃分析。对于具有生物学合理性但证据质量低的干预措施，通过德尔菲法来估计其效果。
对 2876 个标题进行搜索，确定了 7 项研究。其中，4 项研究评估了非随机、同期对照设计的新生儿肺炎的口服抗生素。荟萃分析表明，所有原因的新生儿死亡率（RR 0.75，95%CI 0.64-0.89；4 项研究）和新生儿肺炎特异性死亡率（RR 0.58，95%CI 0.41-0.82；3 项研究）均降低。两项研究（1 项 RCT，1 项观察性研究）评估了包括注射用抗生素在内的基于社区的新生儿护理包，并报告死亡率降低了 44%（RR = 0.56，95%CI 0.41-0.77）和 34%（RR = 0.66，95%CI 0.47-0.93），但这些结果的解释因共同干预而变得复杂。第三个基于诊所的研究报告称，在门诊接受注射用抗生素治疗的新生儿中，病死率为 3.3%。没有研究评估单独使用注射用抗生素治疗新生儿肺炎。德尔菲共识（来自 20 位受访者的中位数）对败血症特异性死亡率的影响为口服抗生素降低 30%，注射用抗生素降低 65%，注射用抗生素降低肺炎特异性死亡率 75%。没有评估新生儿感染的医院管理效果的试验，德尔菲共识认为败血症和肺炎特异性死亡率分别降低 80%和 90%。
基于荟萃分析，社区中使用的口服抗生素对降低新生儿肺炎死亡率有效，但专家意见表明，社区或初级保健水平的注射用抗生素的影响要高得多，在医疗机构中治疗的效果甚至更高。尽管具有可行性和低成本，但这些干预措施在许多低收入国家并未广泛应用。
这项工作得到了比尔及梅琳达·盖茨基金会的支持，该基金会通过向美国儿基会的联合国儿童基金会美国基金和拯救儿童组织的“拯救新生儿生命”项目提供赠款，支持这项工作。
