title: 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.
abstract: 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?
  
  
  RESULTS
  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.
  
  
  BACKGROUND
  PROSPERO International prospective register of systematic reviews (CRD42013004586). Please see later in the article for the Editors' Summary.
authors.affiliation: Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Anne C C
authors.initials: AC
authors.lastname: Lee
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Aruna
authors.initials: A
authors.lastname: Chandran
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Hadley K
authors.initials: HK
authors.lastname: Herbert
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Naoko
authors.initials: N
authors.lastname: Kozuki
authors.affiliation: Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Perry
authors.initials: P
authors.lastname: Markell
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America; Department of Health and Nutrition. Save the Children, Washington (D.C.), United States of America.
authors.forename: Rashed
authors.initials: R
authors.lastname: Shah
authors.affiliation: Global Health Academy and Centre for Population Health Sciences, The University of Edinburgh Medical School, Edinburgh, Scotland, United Kingdom.
authors.forename: Harry
authors.initials: H
authors.lastname: Campbell
authors.affiliation: Global Health Academy and Centre for Population Health Sciences, The University of Edinburgh Medical School, Edinburgh, Scotland, United Kingdom.
authors.forename: Igor
authors.initials: I
authors.lastname: Rudan
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001424:Bacterial Infections / Q000175:diagnosis* / Q000188:drug therapy*; D002648:Child; D003150:Community Health Workers; D003906:Developing Countries; D006801:Humans
chemical_list: D000900:Anti-Bacterial Agents