Treatment of Infections in Young Infants in Low- and Middle-Income Countries:A Systematic Review and Meta-analysis of Frontline Health Worker Diagnosis and Antibiotic Access

BACKGROUND: Inadequate illness recognition and access to antibiotics contribute to high case fatality from infections in young infants (<2 months) in low- and middle-income countries (LMICs). We aimed to address three questions regarding access to treatment for young infant infections in LMICs: (1) Can frontline health workers accurately diagnose possible bacterial infection (pBI)?; (2) How available and affordable are antibiotics?; (3) How often are antibiotics procured without a prescription? METHODS AND FINDINGS: We searched PubMed, Embase, WHO/Health Action International (HAI), databases, service provision assessments (SPAs), Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and grey literature with no date restriction until May 2014. Data were identified from 37 published studies, 46 HAI national surveys, and eight SPAs. For study question 1, meta-analysis showed that clinical sign-based algorithms predicted bacterial infection in young infants with high sensitivity (87%, 95% CI 82%-91%) and lower specificity (62%, 95% CI 48%-75%) (six studies, n = 14,254). Frontline health workers diagnosed pBI in young infants with an average sensitivity of 82% (95% CI 76%-88%) and specificity of 69% (95% CI 54%-83%) (eight studies, n = 11,857) compared to physicians. For question 2, first-line injectable agents (ampicillin, gentamicin, and penicillin) had low variable availability in first-level health facilities in Africa and South Asia. Oral amoxicillin and cotrimoxazole were widely available at low cost in most regions. For question 3, no studies on young infants were identified, however 25% of pediatric antibiotic purchases in LMICs were obtained without a prescription (11 studies, 95% CI 18%-34%), with lower rates among infants <1 year. Study limitations included potential selection bias and lack of neonatal-specific data. CONCLUSIONS: Trained frontline health workers may screen for pBI in young infants with relatively high sensitivity and lower specificity. Availability of first-line injectable antibiotics appears low in many health facilities in Africa and Asia. Improved data and advocacy are needed to increase the availability and appropriate utilization of antibiotics for young infant infections in LMICs. REVIEW REGISTRATION: PROSPERO International prospective register of systematic reviews (CRD42013004586). Please see later in the article for the Editors' Summary

Diabetes mellitus and vaccinations

For patients with diabetes mellitus (DM), pneumococcal, influenza, zoster, and hepatitis B vaccines are especially relevant and are recommended by several scientific bodies. For these infections either the risk of infection or of complicated infections is significantly higher in patients with than in patients without diabetes mellitus. Especially the combination of pneumococcal and influenza vaccines should be administered and carefully monitored by the general practitioner and the diabetes specialist as these infections can have synergistic effects. For DM patients both the increased risk of pneumonia and the increased risk of cardiovascular complications can be influenced dramatically by the administration of both vaccines. DM patients with comorbidities especially with renal insufficiency have an even higher risk for infectious complications and have a reduced response to some of the vaccines. Therefore, adapted immunization schedules, ., for hepatitis B and travel vaccinations should be used in these patients. All recommended vaccines are effective, have a high level of safety, and no negative effects on the underlying disease. Additionally booster vaccinations (e.aEuro., tetanus and pertussis) depending on the vaccination history and patients' age as well as travel vaccinations or other vaccinations should be administered if indicated