产前皮质类固醇护理包可降低坦桑尼亚资源匮乏国家早产儿死亡率。
A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country.
机构信息
Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
出版信息
PLoS One. 2018 Mar 7;13(3):e0193146. doi: 10.1371/journal.pone.0193146. eCollection 2018.
BACKGROUND
Preterm neonatal mortality (NM) has remained high and unchanged for many years in Tanzania, a resource-limited country. Major causes of mortality include birth asphyxia, respiratory insufficiency and infections. Antenatal corticosteroids (ACS) have been shown to significantly reduce mortality in developed countries. There is inconsistent use of ACS in Tanzania.
OBJECTIVE
To determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature < 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (< 7 days) by 35%.
METHODS
A Pre (September 2014 to May 2015) and Post (June 2015 to June 2017) Implementation strategy was used and introduced at three University-affiliated and one District Hospital. Dexamethasone, as the ACS, was added to the national formulary in May 2015, facilitating its free use down to the district level.
FINDINGS
NM was reduced 26% from 166 to 122/1000 livebirths (P = 0.005) and fresh stillbirths (FSB) 33% from 162/1000 to 111/1000 (p = 0.0002) Pre versus Post Implementation. Medications including combinations increased significantly at all sites (p<0.0001). By logistic regression, combinations of ACS, maternal and NA (odds ratio (OR) 0.33), ACS and NA (OR 0.30) versus no treatment were significantly associated with reduced NM. NM significantly decreased per 250g birthweight increase (OR 0.59), and per one week increase in EGA (OR 0.87). Moderate hypothermia declined pre versus post implementation (p<0.0001) and was two-fold more common in infants who died versus survivors.
INTERPRETATION
A low-cost care bundle, ~$6 per patient, was associated with a significant reduction in NM and FSB rates. The former presumably by reducing respiratory morbidity with ACS and minimizing infections with antibiotics. If these findings can be replicated in other resource-limited settings, the potential for further reduction of <5 year mortality rates becomes enormous.
背景
在坦桑尼亚，一个资源有限的国家，早产新生儿死亡率（NM）多年来一直居高不下且没有变化。主要死亡原因包括出生窒息、呼吸功能不全和感染。产前皮质类固醇（ACS）已被证明可显著降低发达国家的死亡率。然而，在坦桑尼亚，ACS 的使用并不一致。
目的
确定包括 ACS、产妇抗生素（MA）、新生儿抗生素（NA）和避免体温中度降低（<36°C）在内的护理包的实施是否可以将估计胎龄（EGA）为 28 至 34 6/7 周的婴儿的 NM（<7 天）降低 35%。
方法
采用预（2014 年 9 月至 2015 年 5 月）和后（2015 年 6 月至 2017 年 6 月）实施策略，并在三家大学附属医院和一家区医院实施。2015 年 5 月，地塞米松被纳入国家处方，便于在区一级免费使用。
结果
NM 从实施前的 166 例/1000 活产儿降至 122 例/1000 活产儿（P=0.005），新鲜死胎（FSB）从 162 例/1000 降至 111 例/1000（P=0.0002）。所有地点的药物治疗，包括联合治疗，均显著增加（p<0.0001）。通过逻辑回归，ACS、产妇和 NA 的组合（比值比（OR）0.33）、ACS 和 NA 的组合（OR 0.30）与无治疗相比，与 NM 降低显著相关。NM 随每增加 250 克体重而降低（OR 0.59），每增加一周 EGA 而降低（OR 0.87）。中度低温在实施前后均降低（p<0.0001），且在死亡患儿中比在存活患儿中更为常见（两倍）。
解释
该低成本护理包（每位患者约 6 美元）与 NM 和 FSB 发生率的显著降低相关。前者可能通过 ACS 减少呼吸疾病，并通过抗生素最小化感染。如果这些发现可以在其他资源有限的环境中得到复制，那么进一步降低 5 岁以下死亡率的潜力将是巨大的。
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