Effect of Intrapartum Azithromycin vs Placebo on Neonatal Sepsis and Death: A Randomized Clinical Trial

Importance

Neonatal sepsis is a leading cause of neonatal mortality. New interventions are needed to decrease neonatal sepsis and mortality in regions with highest burden.

Objective

To evaluate the efficacy of intrapartum azithromycin to reduce neonatal sepsis or mortality, as well as neonatal and maternal infections.

Design, Setting, and Participants

This double-blind, placebo-controlled, randomized clinical trial enrolled and followed up birthing parents and their infants at 10 health facilities in The Gambia and Burkina Faso, West Africa, between October 2017 and May 2021.

Interventions

Participants were assigned at random to receive oral azithromycin (2 g) or placebo (ratio 1:1) during labor.

Main Outcomes and Measures

The primary outcome was a composite of neonatal sepsis or mortality, with the former defined based on microbiologic or clinical criteria. Secondary outcomes were neonatal infections (skin, umbilical, eye and ear infections), malaria, and fever; postpartum infections (puerperal sepsis, mastitis), fever, and malaria; and use of antibiotics during 4-week follow-up.

Results

The trial randomized 11 983 persons in labor (median age, 29.9 years). Overall, 225 newborns (1.9% of 11 783 live births) met the primary end point. The incidence of neonatal mortality or sepsis was similar in the azithromycin and placebo groups (2.0% [115/5889] vs 1.9% [110/5894]; risk difference [RD], 0.09 [95% CI, -0.39 to 0.57]), as was the incidence of neonatal mortality (0.8% vs 0.8%; RD, 0.04 [95% CI, -0.27 to 0.35]) and neonatal sepsis (1.3% vs 1.3%; RD, 0.02 [95% CI, -0.38 to 0.43]). Newborns in the azithromycin group compared with the placebo group had lower incidence of skin infections (0.8% vs 1.7%; RD, -0.90 [95% CI, -1.30 to -0.49]) and need for antibiotics (6.2% vs 7.8%; RD, -1.58 [95% CI, -2.49 to -0.67]). Postpartum parents in the azithromycin group had lower incidence of mastitis (0.3% vs 0.5%; RD, -0.24 [95% CI, -0.47 to -0.01]) and puerperal fever (0.1% vs 0.3%; RD, -0.19 [95% CI, -0.36 to -0.01]).

Conclusions and Relevance

Azithromycin administered orally during labor did not reduce neonatal sepsis or mortality. These results do not support routine introduction of oral intrapartum azithromycin for this purpose.

Trial Registration

ClinicalTrials.gov Identifier: NCT03199547.

PO 8471 A SURVEY OF CURRENT CLINICAL DATA MANAGEMENT PRACTICES IN SUB-SAHARAN AFRICA

Background

Information on clinical data management (CDM) practices in clinical trials in sub-Saharan Africa is scarce. As part of ALERRT (the African coalition for Epidemic Research, Response and Training, an EDCTP-funded project) we want to gauge current CDM and ICT practices and identify possible gaps within different research institutions in sub-Saharan Africa. This information will be used to develop a scalable, GCP-compliant, robust CDM/ICT infrastructure suitable for resource-poor settings and response-ready in the event of an outbreak.

Methods

An online survey was designed to assess the experience of the participating sites with the various CDM processes, CDM documentation and facilities, the availability of dedicated staff and their experience with GCP. In addition, ICT features essential to CDM will be assessed. Lastly, information on the use of CDM software will be obtained. Respondents can request to receive personalised feedback (aimed to improve their CDM practices) based on their results. The survey, in English and French, will be sent out to 100 sites in sub-Saharan Africa. Sites with intermittent internet connections will receive an MS-Office Word-version of the survey.

Results

The survey will be closed after a month. Personalised feedback (if requested) will be sent to the respondents. Descriptive analysis of the survey results will be done, and results will be used to design standard data management tools, tailored to the needs of research sites in sub-Saharan Africa and suitable for emergency research. Both results and tools will be disseminated to the scientific community.

Conclusion

The results of this survey will provide relevant information on the current CDM and ICT practices in sub-Saharan Africa. Potential pitfalls will be identified and opportunities for improvement will be addressed. Furthermore, the survey will offer a chance to exchange ideas between African and European partners on how to implement good CDM and ICT practices.

Factors Affecting Access to Healthcare: An Observational Study of Children under 5 Years of Age Presenting to a Rural Gambian Primary Healthcare Centre

Main Objective

Prompt access to primary healthcare before onset of severe illness is vital to improve morbidity and mortality rates. The Gambia has high rates of child mortality and research is needed to investigate contributing factors further. This study aimed to identify factors affecting access to primary healthcare for children <5 years (y) in rural Gambia focusing on delayed presentation and severe illness at presentation as indicators in a setting where primary healthcare is delivered free of charge.

Methods

Data were extracted from an electronic medical records system at a rural primary healthcare clinic in The Gambia for children (0–5y) between 2009 and 2012. First clinic attendances with malaria, lower respiratory tract infections (LRTI) and diarrhoeal disease, the main contributors to mortality in this setting, were identified and categorized as delayed/non-delayed and severe/non-severe representing our two main outcome measures. Potential explanatory variables, identified through a comprehensive literature review were obtained from an ongoing demographic surveillance system for this population. Variables associated with either delayed/non-delayed and/or with severe/non-severe presentations identified by univariate analysis (p<0.1) were assessed in multivariate models using logistic regression (p<0.05).

Results

Out of 6554 clinic attendances, 571 relevant attendances were identified. Delayed presentation was common (45% of all presentations) and there was a significantly reduced risk associated with being from villages with free regular access to transport (OR 0.502, 95%CI[0.310, 0.814], p = 0.005). Children from villages with free regular transport were also less likely to present with severe illness (OR 0.557, 95%CI[0.325, 0.954], p = 0.033).

Conclusions

Transport availability rather than distance to health clinic is an important barrier to accessing healthcare for children in The Gambia, and public health interventions should aim to reduce this barrier.