Neonatal Infections; a hospital-based study in The Gambia examining aetiology and associated maternal Colonisation

An estimated 2.6 million newborns die each year, mostly from largely preventable causes – prematurity, intrapartum-related complications and infections. Data on neonatal infection aetiology and pathways of acquisition of infection are lacking particularly in sub-Saharan Africa (sSA), yet are essential to inform prevention. In a systematic review of neonatal infection aetiology studies in sSA, Klebsiella species, Escherichia coli, Staphylococcus aureus, Group B Streptococci, and Enterococcus were the top five reported bacterial pathogens across all regions. Application of the Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI) checklist highlighted wide variation in clarity and completeness of reporting, impeding comparability and utility. A four-year audit of neonatal admissions and quality of care at The Gambia’s largest referral hospital showed that possible serious bacterial infection (pSBI) accounted for 44% (2166/4944) of admissions. There was a striking mismatch of high antibiotic use (95%) and low microbiological investigation for infection (1% blood culture and 2% lumbar puncture) was evident. A hospital-based matched case-control study was undertaken in the three main referral health facilities in The Gambia to describe neonatal infection aetiology, and evaluate the role of maternal bacterial colonisation. Sick newborn-mother pairs (n=203) and healthy newborn-mother pairs (n=203) were recruited. Pathogenic bacteria were isolated from blood cultures of 45% (91/202) of the sick newborns, and the most frequently identified isolates were S. aureus, Klebsiella, and Burkholderia cepacia. There was notable lack of GBS detected by culture but in the molecular sub-study, GBS was identified in 5% (2/42) of cases. Klebsiella demonstrated near universal resistance to WHO-recommended first- and second-line antibiotics. For 14 mother-infant pairs, the isolates from infant blood and maternal rectovaginal cultures matched suggesting possible vertical transmission This PhD shows that infections are a major problem among hospitalised newborns in The Gambia. Programmatic implications and priorities for research are outlined.