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Community-acquired neonatal and infant sepsis in developing countries: efficacy of WHO's currently recommended antibiotics—systematic review and meta-analysis
  1. Lilian Downie1,
  2. Raffaela Armiento1,
  3. Rami Subhi1,
  4. Julian Kelly1,2,
  5. Vanessa Clifford2,
  6. Trevor Duke1
  1. 1Centre for International Child Health, Department of Paediatrics, University of Melbourne, MCRI, Royal Children's Hospital, Melbourne, Victoria, Australia
  2. 2Departments of General Medicine, Infectious Disease and Intensive Care, Royal Children's Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Professor Trevor Duke, Centre for International Child Health, Department of Paediatrics, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, VIC 3052, Australia; trevor.duke{at}


Objective To review the aetiology and antibiotic resistance patterns of community-acquired sepsis in developing countries in infants where no clear focus of infection is clinically identified. To estimate the likely efficacy of WHO's recommended treatment for infant sepsis.

Design A systematic review of the literature describing the aetiology of community-acquired neonatal and infant sepsis in developing countries. Using meta-analytical methods, susceptibility was determined to the antibiotic combinations recommended by WHO: (1) benzylpenicillin/ampicillin and gentamicin, (2) chloramphenicol and benzylpenicillin, and (3) third-generation cephalosporins.

Results 19 studies were identified from 13 countries, with over 4000 blood culture isolates. Among neonates, Staphylococcus aureus, Klebsiella spp. and Escherichia coli accounted for 55% (39–70%) of culture positive sepsis on weighted prevalence. In infants outside the neonatal period, the most prevalent pathogens were S aureus, E coli, Klebsiella spp., Streptococcus pneumoniae and Salmonella spp., which accounted for 59% (26–92%) of culture positive sepsis. For neonates, penicillin/gentamicin had comparable in vitro coverage to third-generation cephalosporins (57% vs 56%). In older infants (1–12 months), in vitro susceptibility to penicillin/gentamicin, chloramphenicol/penicillin and third-generation cephalosporins was 63%, 47% and 64%, respectively.

Conclusions The high rate of community-acquired resistant sepsis—especially that caused by Klebsiella spp. and S aureus—is a serious global public health concern. In vitro susceptibility data suggest that third-generation cephalosporins are not more effective in treating sepsis than the currently recommended antibiotics, benzylpenicillin and gentamicin; however, with either regimen a significant proportion of bacteraemia is not covered. Revised recommendations for effective second-line antibiotics in neonatal and infant sepsis in developing countries are urgently needed.

  • Tropical Paediatrics
  • General Paediatrics
  • Neonatology
  • Infectious Diseases
  • Microbiology

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