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Riddell A, Cook A, Khavessian N, Ellis S, Bilardi D, Correia E, Kostyanev T, Nardone A, Russell N, Vilken T, Stohr W, Adhisivam B, de Moraes IRA, Ahmed NU, Bekker A, Berezin EN, Boonkasidecha S, Carvalheiro CG, Chauhan P, Chiurchiù S, Chorafa E, Dramowski A, DS M, Feng J, Jia S, Kong Y, Kyohere M, Kontou A, Lochindarat S, De Luca M, Mphaphuli A, Mussi-Pinhata MM, Murunga S, Nakwa FL, Nangia S, Nassolo E, Hoang NTB, Obiero CW, Olson L, Ping W, Plakkal N, Prasad P, Preedisripipat K, Rahman SW, Seef T, Sukrakanchana PO, Thomas R, Yu Z, Zhang Q, Walker AS, Bielicki J, Heath PT, Sharland M, Munera-Huertas T. Challenges in the Implementation of the NeoOBS Study, a Global Pragmatic Observational Cohort Study, to Investigate the Aetiology and Management of Neonatal Sepsis in the Hospital Setting. Antibiotics (Basel) 2023; 12:923. [PMID: 37237826 PMCID: PMC10215156 DOI: 10.3390/antibiotics12050923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network.
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Affiliation(s)
- Amy Riddell
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | | | | | | | | | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerpen, Belgium
| | | | - Neal Russell
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Tuba Vilken
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerpen, Belgium
| | - Wolfgang Stohr
- MRC Clinical Trials Unit, University College London, London WC1V 6LJ, UK
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry 605006, India
| | | | | | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa
| | | | | | - Cristina G. Carvalheiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Prachi Chauhan
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi 110001, India
| | - Sara Chiurchiù
- Academic Department of Pediatrics (DPUO), Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Elisavet Chorafa
- Infectious Diseases Unit, 3rd Dept Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, 546 43 Thessaloniki, Greece
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa
| | - Madhusudhan DS
- Seth G. S. Medical College & KEM Hospital, Mumbai 400012, India
| | - Jinxing Feng
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen 518048, China
| | - Shengnan Jia
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100051, China
| | - Yuan Kong
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen 518048, China
| | - Mary Kyohere
- MUJHU Research Collaboration, Kampala P.O. Box 23491, Uganda
| | - Angeliki Kontou
- 1st Neonatology Department and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | | | - Maia De Luca
- Academic Department of Pediatrics (DPUO), Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Aripfani Mphaphuli
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa AND Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Sheila Murunga
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi P.O. Box 230, Kenya
| | - Firdose Lambey Nakwa
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 1864, South Africa
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi 110001, India
| | - Erinah Nassolo
- MUJHU Research Collaboration, Kampala P.O. Box 23491, Uganda
| | - Ngoc Thi Bin Hoang
- Department of Microbiology, Vietnam National Children’s Hospital, Hanoi 100000, Vietnam
| | - Christina W. Obiero
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi P.O. Box 230, Kenya
- Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Department of Global Health, 1081 Amsterdam, The Netherlands
| | - Linus Olson
- Department of Women’s and Children’s Health, Karolinska institutet, Stockholm, Sweden and Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Wang Ping
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry 605006, India
| | - Priyanka Prasad
- Seth G. S. Medical College & KEM Hospital, Mumbai 400012, India
| | | | | | - Tiffany Seef
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa AND Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
| | | | - Reenu Thomas
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 1864, South Africa
| | - Zhang Yu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Qiaoru Zhang
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100051, China
| | - A. Sarah Walker
- MRC Clinical Trials Unit, University College London, London WC1V 6LJ, UK
| | - Julia Bielicki
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Paul T. Heath
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Michael Sharland
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Tatiana Munera-Huertas
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
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Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A, Han C, Bisignano C, Rao P, Wool E, Johnson SC, Browne AJ, Chipeta MG, Fell F, Hackett S, Haines-Woodhouse G, Kashef Hamadani BH, Kumaran EAP, McManigal B, Achalapong S, Agarwal R, Akech S, Albertson S, Amuasi J, Andrews J, Aravkin A, Ashley E, Babin FX, Bailey F, Baker S, Basnyat B, Bekker A, Bender R, Berkley JA, Bethou A, Bielicki J, Boonkasidecha S, Bukosia J, Carvalheiro C, Castañeda-Orjuela C, Chansamouth V, Chaurasia S, Chiurchiù S, Chowdhury F, Clotaire Donatien R, Cook AJ, Cooper B, Cressey TR, Criollo-Mora E, Cunningham M, Darboe S, Day NPJ, De Luca M, Dokova K, Dramowski A, Dunachie SJ, Duong Bich T, Eckmanns T, Eibach D, Emami A, Feasey N, Fisher-Pearson N, Forrest K, Garcia C, Garrett D, Gastmeier P, Giref AZ, Greer RC, Gupta V, Haller S, Haselbeck A, Hay SI, Holm M, Hopkins S, Hsia Y, Iregbu KC, Jacobs J, Jarovsky D, Javanmardi F, Jenney AWJ, Khorana M, Khusuwan S, Kissoon N, Kobeissi E, Kostyanev T, Krapp F, Krumkamp R, Kumar A, Kyu HH, Lim C, Lim K, Limmathurotsakul D, Loftus MJ, Lunn M, Ma J, Manoharan A, Marks F, May J, Mayxay M, Mturi N, Munera-Huertas T, Musicha P, Musila LA, Mussi-Pinhata MM, Naidu RN, Nakamura T, Nanavati R, Nangia S, Newton P, Ngoun C, Novotney A, Nwakanma D, Obiero CW, Ochoa TJ, Olivas-Martinez A, Olliaro P, Ooko E, Ortiz-Brizuela E, Ounchanum P, Pak GD, Paredes JL, Peleg AY, Perrone C, Phe T, Phommasone K, Plakkal N, Ponce-de-Leon A, Raad M, Ramdin T, Rattanavong S, Riddell A, Roberts T, Robotham JV, Roca A, Rosenthal VD, Rudd KE, Russell N, Sader HS, Saengchan W, Schnall J, Scott JAG, Seekaew S, Sharland M, Shivamallappa M, Sifuentes-Osornio J, Simpson AJ, Steenkeste N, Stewardson AJ, Stoeva T, Tasak N, Thaiprakong A, Thwaites G, Tigoi C, Turner C, Turner P, van Doorn HR, Velaphi S, Vongpradith A, Vongsouvath M, Vu H, Walsh T, Walson JL, Waner S, Wangrangsimakul T, Wannapinij P, Wozniak T, Young Sharma TEMW, Yu KC, Zheng P, Sartorius B, Lopez AD, Stergachis A, Moore C, Dolecek C, Naghavi M. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022; 399:629-655. [PMID: 35065702 PMCID: PMC8841637 DOI: 10.1016/s0140-6736(21)02724-0] [Citation(s) in RCA: 3886] [Impact Index Per Article: 1943.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR) poses a major threat to human health around the world. Previous publications have estimated the effect of AMR on incidence, deaths, hospital length of stay, and health-care costs for specific pathogen-drug combinations in select locations. To our knowledge, this study presents the most comprehensive estimates of AMR burden to date. METHODS We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen-drug combinations in 204 countries and territories in 2019. We obtained data from systematic literature reviews, hospital systems, surveillance systems, and other sources, covering 471 million individual records or isolates and 7585 study-location-years. We used predictive statistical modelling to produce estimates of AMR burden for all locations, including for locations with no data. Our approach can be divided into five broad components: number of deaths where infection played a role, proportion of infectious deaths attributable to a given infectious syndrome, proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antibiotic of interest, and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden based on two counterfactuals: deaths attributable to AMR (based on an alternative scenario in which all drug-resistant infections were replaced by drug-susceptible infections), and deaths associated with AMR (based on an alternative scenario in which all drug-resistant infections were replaced by no infection). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. We present final estimates aggregated to the global and regional level. FINDINGS On the basis of our predictive statistical models, there were an estimated 4·95 million (3·62-6·57) deaths associated with bacterial AMR in 2019, including 1·27 million (95% UI 0·911-1·71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27·3 deaths per 100 000 (20·9-35·3), and lowest in Australasia, at 6·5 deaths (4·3-9·4) per 100 000. Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000-1 270 000) deaths attributable to AMR and 3·57 million (2·62-4·78) deaths associated with AMR in 2019. One pathogen-drug combination, meticillin-resistant S aureus, caused more than 100 000 deaths attributable to AMR in 2019, while six more each caused 50 000-100 000 deaths: multidrug-resistant excluding extensively drug-resistant tuberculosis, third-generation cephalosporin-resistant E coli, carbapenem-resistant A baumannii, fluoroquinolone-resistant E coli, carbapenem-resistant K pneumoniae, and third-generation cephalosporin-resistant K pneumoniae. INTERPRETATION To our knowledge, this study provides the first comprehensive assessment of the global burden of AMR, as well as an evaluation of the availability of data. AMR is a leading cause of death around the world, with the highest burdens in low-resource settings. Understanding the burden of AMR and the leading pathogen-drug combinations contributing to it is crucial to making informed and location-specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics. There are serious data gaps in many low-income settings, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat. FUNDING Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.
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