Intended for healthcare professionals

Feature Perinatal infection

The scourge of avoidable neonatal mortality in Malawi

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3434 (Published 09 August 2018) Cite this as: BMJ 2018;362:k3434
  1. Madlen Davies, journalist
  1. Bureau of Investigative Journalism, London WC1X 8DP, UK
  1. madlendavies{at}tbij.com

Sanitation is lacking, infection is common, only limited antibiotics are available, and microbial resistance is rising, writes Madlen Davies

The infants at Chatinkha nursery, the baby ward in Queen Elizabeth hospital in Blantyre, Malawi’s second city, are lined up in wooden cots, wrapped in brightly coloured fabric. Many have nasogastric tubes. Some are crying, others are listless. Kondwani Kawaza, Malawi’s first ever neonatologist, looks out over the ward. Many of the infants will die before the end of the month.

About 15 of the 200 babies admitted every month are diagnosed as having sepsis, but Kawaza says that this is the “tip of the iceberg.” He thinks that if they could diagnose it properly it would be the leading cause of death.

Survival decreases substantially for every hour that a patient with septic shock doesn’t receive effective antibiotics. Those that don’t die face brain damage, organ impairment, and lifelong behavioural problems.

“You have a mother who has waited for nine months to get a baby,” says Kawaza, “And then you lose that baby to a potentially treatable condition.”

Resistance to stocked antibiotics

Throughout Malawi healthcare facilities are struggling to reduce the number of babies dying from preventable causes like sepsis. Queen Elizabeth hospital now faces an extra threat: the bacteria that commonly cause bloodstream infections have developed resistance to all of the antibiotics it regularly stocks.

In the past, babies mainly had infections of Group B streptococcus or Streptococcus pneumoniae, Kawaza explains. But these have largely disappeared through vaccinating babies or screening high risk mothers. In their wake, infections of the gram negative bacteria commonly found in the gut have risen, mainly Klebsiella and Escherichia coli. Traditionally, these were hospital acquired infections in people who had been in intensive care for a long time or who had cannulas inserted. Whether transmission to babies is from their mothers or other people coming into the nursery is not known.

Resistance has soared, according to a surveillance study in adults and paediatric patients by the Malawi Liverpool Wellcome Centre, the research institute next to Queen Elizabeth hospital.1 Over 18 years to 2016, although the number of bloodstream infections fell, the proportion involving resistant bacteria increased, says Nicholas Feasey, an infectious diseases researcher who led the study. By 2016 more than half of infections were resistant to the antibiotics that would be given in the first case in Malawi—penicillin, ampicillin, and chloramphenicol—as well as co-trimoxazole.

In 2003 12% of bloodstream infections caused by Klebsiella produced extended spectrum β lactamases, enzymes that break down penicillin and cephalosporin antibiotics. By 2016 the figure had risen to more than 90%. A rise was also seen in E coli, from less than 1% to more than 30%.

Feasey thinks that the rise was triggered by the introduction of ceftriaxone, which is the drug option of last resort available in most Malawian hospitals.

From 2002 Malawi has had major problems with drug resistant Salmonella, which can cause meningitis in immunosuppressed people. Ceftriaxone, introduced in 2004, can pass into the brain and treat meningitis. It needs to be given only once a day, compared with four times for penicillin, saving time in overburdened hospitals. “It definitely saved a lot of lives,” Feasey says. “So it was the right thing.”

Yet it fuelled resistance. Now Chatinkha nursery is struggling with what Feasey calls “locally untreatable” bacteria. In other countries, with more drugs available, these resistant infections would be “difficult to treat, but it would be far from impossible,” he says. In Malawi they are “effectively untreatable” owing to the high cost of the antibiotics needed.

Case study

Lilan Matchaya’s daughter Abigail caught resistant Klebsiella, although the infection wasn’t diagnosed for four days. Abigail was born prematurely at seven months, weighing just 1.8 kg. The next day she started vomiting after breastfeeding. There was blood in her stool and nurses found her passed out. She was given penicillin and gentamicin antibiotics, but her fever continued, so doctors tried ceftriaxone and metronidazole. She remained desperately ill. A day later she passed out again.

Tests showed resistant Klebsiella. She needed amikacin or meropenem, expensive antibiotics that the hospital doesn’t always stock. Fortunately, it had amikacin, but this can trigger serious side effects, like kidney or nerve damage or deafness. Abigail was given amikacin but died a month later.

“We should have all the antibiotics that we need,” Kawaza says, exasperated. “Everybody believes that we have the capacity and the resources to treat their infections. But the organisms making babies sick are not easy to treat.”

Meropenem and amikacin supply is erratic. There are fears that if they are introduced and used widely resistance will emerge, leaving even fewer options.

The battle with infection

Outside of Blantyre little is known about resistance patterns. District hospitals and health centres cannot perform blood cultures, which require costly equipment and trained staff. There, they use “fever” as a catch all phrase for infection. The cause of sepsis is not known. Babies requiring complicated care must be referred to one of four major hospitals. Many die, from the severity of their condition or because the journey can take hours. “It makes you feel helpless because you cannot do anything more for the patient,” says Linda Kayange, senior medical officer at Machinga District Hospital.

Better hygiene would prevent many infections and avert the need for antibiotics. But Malawi is one of the poorest countries in the world. Healthcare facilities are stretched and lack resources for infection control. More than half fail to meet World Health Organization standards of having running water in facilities, according to Unicef.2 Even Queen Elizabeth hospital, Malawi’s biggest, does not have running water in every room.

Nyambi healthcare centre, in the rural Machinga district, is where mothers from surrounding villages come to give birth. Electricity blackouts are common in Malawi, and midwives warn of babies dying in incubators as a result. At Nyambi, blackouts mean equipment like forceps cannot always be sterilised. Women are asked to bring candles or torches in case there is no power.

A razor blade lies rusting on a sink next to metal kidney dishes. Pregnant women are told to bring their own to cut the cord, as well as a plastic sheet called a macintosh, on which to give birth.

Unhygienic and smelly

Two pregnant women, Ruth White and Jenifa Lyson, aged 23 and 24, sit in the waiting room.

The centre has no running water. There are six toilets, all but one broken. Roughly 300 people—pregnant women, families, and staff—share it. There is no incinerator for placentas. “This place is very unhygienic, and it stinks,” says Lyson.

The mothers stay here in case their waters break. They sleep on the macintosh on which they will later give birth, risking catching an infection or passing one to their baby. “We are in financial crisis, so it is difficult to tackle all the problems at once.” says Sphiwe Kachimangha, infection prevention control lead for Machinga district.

Many healthcare facilities report “stockouts,” when supplies for infection prevention such as soap, bleach, and sterile gloves run out. A three month spike in sepsis rates from October 2017 occurred at the same time as a shortage of chlorhexidine, an antiseptic put on a baby’s cord after cutting to prevent infection, says Wezi Kalumbo, an adviser on child health for USAid’s health programme, Organised Network of Services for Everyone’s Health.

Clean water makes a huge difference. At Nayuchi health centre, on the border of Mozambique, the charity WaterAid has installed a borehole and solar panelled pump. Tamandua Chirwa, who runs the centre, says that until they had water it was difficult to recruit staff, and pregnant women would give birth at home because conditions at the centre were unhygienic. “If they got an infection, even a severe one like sepsis,” he says, “they would avoid coming in for fear of being reprimanded by doctors for not seeking healthcare sooner.”

Back in Queen Elizabeth hospital, Kawaza says that his biggest fear is failing to control infection and rising resistance. “Some people think that antibiotic resistance is a hypothetical threat. But every day we see babies change suddenly from robustly active to profoundly sick.”

Acknowledgments

I thank Josephine Chinele for fixing and translating.

Footnotes

References

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