Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.
Johns Hopkins University-Bangladesh, Dhaka, Bangladesh.
PLoS One. 2020 Apr 22;15(4):e0229988. doi: 10.1371/journal.pone.0229988. eCollection 2020.
Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016.
This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance.
At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens.
Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.
新生儿感染仍然是全球新生儿死亡的主要原因。2015 年，世卫组织发布了管理婴幼儿（0-59 天）可能严重细菌感染（PSBI）的指南，当无法遵守医院转诊时，可使用简化的抗生素方案。孟加拉国是首批采用世卫组织指南实施的国家之一。我们报告了一项实施研究的结果，该研究评估了 2015 年 8 月至 2016 年 8 月期间孟加拉国三个农村分区的医疗机构准备情况和提供者的表现。
这项研究在 19 个初级保健中心进行。使用研究人员在三个时间点填写的检查表评估医疗机构准备情况。为了评估提供者的表现，我们从医疗机构登记册中提取了所有感染病例的数据，并将提供者的诊断和治疗与指南进行了比较。我们在整个研究期间绘制了分类和剂量错误，并叠加了局部加权平滑（LOWESS）曲线，以分析随时间变化的性能变化。与提供者进行了 2 次焦点小组讨论（N = 2）和 28 次深入访谈，以确定医疗机构准备情况和提供者表现的障碍和促进因素。
在基线时，没有一个设施有足够的抗生素供应。在 10 个月的时间里，有 606 名有感染迹象的患病婴儿在研究设施就诊。在 606 份记录中，有 14.9%（N = 90）记录存在分类错误。对于接受第一剂（N = 551）抗生素治疗的婴儿，在 551 份记录中，有 22.9%（N = 126）记录存在剂量错误。错误分布因设施而异（35.7%[IQR：24.7-57.4%]）和感染严重程度而异。在研究开始时错误最高，随着时间的推移逐渐减少。定性数据表明，早期实施中的错误是由于提供者评估和治疗实践的变化所致，包括对患有多种感染迹象的婴儿进行分类的困惑，以及一些提供者对简化抗生素方案疗效的担忧。
在新环境中引入复杂指南时，监测早期绩效和提供有针对性的支持的策略对于提高实施一致性非常重要。未来的研究应研究提供者对简化治疗效果的评估，并解决在这种情况下对更广泛抗生素治疗社区获得性新生儿感染优越性的误解。
