The prompt administration of post-exposure prophylaxis (PEP) is one of the key strategies for ending human deaths from rabies. A delay in seeking the first dose of rabies PEP, or failure to complete the recommended dosage, may result in clinical rabies and death. We assessed the efficacy of short message system (SMS) phone texts in improving the adherence to scheduled PEP doses among bite patients in rural eastern Kenya. We conducted a single-arm, before-after field trial that compared adherence among bite patients presenting at Makueni Referral Hospital between October and December 2018 (control) and between January and March 2019 (intervention). Data on their demographics, socio-economic status, circumstances surrounding the bite, and expenditures related to the bite were collected. A total of 186 bite patients were enrolled, with 82 (44%) in the intervention group, and 104 (56%) in the control group. The odds of PEP completion were three times (OR 3.37, 95% CI 1.28, 10.20) more likely among patients who received the SMS reminder, compared to the control. The intervention group had better compliance on the scheduled doses 2 to 5, with a mean deviation of 0.18 days compared to 0.79 days for the control group (p = 0.004). The main reasons for non-compliance included lack of funds (30%), and forgetfulness (23%) on days for follow-up treatment, among others. Nearly all (96%, n = 179) the bite patients incurred indirect transport costs, at an average of USD 4 (USD 0–45) per visit. This study suggests that the integration of SMS reminders into healthcare service delivery increases compliance with PEP, and may strengthen rabies control and elimination strategies.

Background: Limited diagnostic access in resource-limited settings contributes to poor health outcomes among bacterial sepsis patients and the spread of antimicrobial resistance (AMR). Molecular diagnostic profiling of AMR may enable faster targeting of antibiotic therapies, improving clinical outcomes, reducing AMR development, and saving costs. Methods: We modeled the impact of a culture-dependent molecular test for pathogen identification and resistance testing among hospitalized bloodstream infection patients to guide effective and cost-efficient implementation of these tools. We evaluated patient mortality, antibiotic use, hospital-associated infections, hospital days, and costs under the standard of care (empiric therapy, blood culture, phenotypic susceptibility testing) compared with molecular diagnostics by varying culture and susceptibility testing coverage, culture turnaround time, and AMR prevalence. Results: The greatest impact of the molecular test occurred with 100% diagnostic coverage, shorter culture turnaround time, and high AMR prevalence, reducing up to 6% of deaths (interquartile range [IQR], 0%–12.1%), 5% of hospital days (IQR, 0.1%–10.7%), and 21% of days on inappropriate antibiotic therapy (IQR, 18.2%–24.4%). The minimum cost per molecular test performed, offset by cost savings, ranged from $109 in India to $585 in South Africa across all modeled scenarios. Conclusions: In high AMR burden settings with blood culture infrastructure supporting fast turnaround times, a molecular test could improve health outcomes of bloodstream infection. Impact is limited by delayed turnaround times and the effectiveness of empiric therapy. Molecular diagnostics implemented at $100 or less can generate healthcare-system cost savings, supporting their adoption to improve health outcomes and reduce AMR while remaining cost-neutral.

Background: Antimicrobial resistance (AMR) is a growing global health threat, with children in low- and middle-income countries bearing a disproportionate burden. Data on resistance patterns and diagnostic practices in pediatric populations remain limited. This study evaluated diagnostic utilization and AMR among children hospitalized with bacterial infections at a national referral hospital in Kenya. Methods: We conducted a retrospective cohort study of pediatric inpatients (0–12 years) admitted with bacterial infections between 2017 and 2021. Patient records were identified using ICD-10 codes and reviewed for diagnostic testing and antimicrobial susceptibility. Descriptive statistics were conducted to show infection counts, diagnostic testing, and resistance outcomes. Results: Among 1608 patients, 1009/1608 (63%) were infants under one year. Culture was conducted in 640/1608 (40%) and antimicrobial sensitivity testing in 111/640 (17%) patients. Gastroenteritis (46%) was the most common infection and blood the most frequently collected specimen (31%). Of 1039 cultured specimens, 896/1039 (86%) showed no growth. The most commonly isolated organisms were Klebsiella pneumoniae 19/128 (15%), Staphylococcus epidermidis (13%, 17/128), and Enterococcus faecium (13%, 16/128). Notably, K. pneumoniae showed 100% resistance to third-generation cephalosporins, suggestive of ESBL production. Among the tested samples, 92/128 (72%) had MDROs, and 26/92 (28%) were extensively drug-resistant (XDR). Among the patients tested, 84/111 (76%) had MDROs, of which 25/84 (30%) were XDR. Children under 5 years had higher odds (OR = 5.84, 95% CI: 1.17-38.21) of having MDRO infections, as well as those with multiple admissions (OR = 3.77, 95% CI: 1.06–20.34). Further, increasing age was inversely associated with MDRO presence. The odds of MDRO infection decreased by 24% for every year increase in age (aOR = 0.76; 95% CI: 0.60–0.93; p = 0.006). Conclusions: The findings highlight the limited diagnostic use and a high burden of MDROs and XDR infections in hospitalized children. Strengthening diagnostic capacity and pediatric antimicrobial stewardship is urgently needed in such settings.

Background: Sepsis contributes to nearly 50% of neonatal deaths in resource-limited settings. Accurate, timely diagnosis can improve outcomes, reduce inappropriate antibiotic use, and save healthcare costs. We aimed to determine the minimum technical requirements and cost of a point-of-care test (POCT) for neonatal sepsis to be clinically effective in hospitals and community settings in low-resource settings. Methods: We modeled the diagnosis and treatment of hospitalized neonates and infants at primary care facilities with suspected sepsis. Health outcomes (mortality, hospital stays, and healthcare-associated infections [HAIs]) were compared under empiric treatment with varied blood culture scenarios to a POCT. Test performance, bacterial infection prevalence, and discharge criteria were varied. A threshold economic analysis identified maximum allowable costs for a cost-neutral POCT. Results: A POCT could reduce neonatal deaths significantly at hospitals (up to 19%) and community levels (up to 70%), compared with baseline, by enabling faster therapy initiation and reducing unnecessary hospitalizations and HAIs. Healthcare costs could drop by 17%–43% in hospitals and 48%–81% in primary care settings. A POCT priced at $21 for hospitals and $3 for community use could remain cost-neutral. Conclusions: A POCT for neonatal sepsis, even with moderate accuracy, could improve outcomes by accelerating diagnosis, supporting antibiotic stewardship, and lowering costs. High sensitivity is essential to minimize deaths from missed diagnoses and delayed antibiotic therapy. Our results suggest 85% sensitivity and 80% specificity for hospitalized neonates, and 90% sensitivity and 70% specificity in primary care settings are the minimum necessary technical requirements for the POCT.

Introduction Sepsis accounts for up to 50% of neonatal deaths in resource-limited countries. Accurate and timely diagnosis could improve clinical outcomes, reduce inappropriate antibiotic use, and provide healthcare cost savings. We aimed to identify the minimum technical specifications and cost required of a point-of-care test (POCT) for neonatal sepsis to be clinically useful in hospital and community levels in low-resource settings. Methods We modeled the diagnosis and treatment of two cohorts: hospitalized neonates and infants presenting to primary health care facilities with suspected sepsis. We compared health outcomes, including mortality, length of hospital stays, and acquisition of healthcare-associated infections (HAIs), under a POCT compared to empiric treatment and blood culture across varying test performance, prevalence of bacterial infection and discharge eligibility. A threshold health economic analysis was performed to determine the allowable POCT price to remain cost neutral to the healthcare system. Results A POCT could lead to a net reduction in neonatal deaths at both the hospital level (up to 19% of deaths averted compared to baseline) and community level (up to 76% deaths averted) through faster initiation of appropriate therapy and reducing unnecessary hospitalizations and HAIs. Healthcare costs could be reduced substantially with implementation of a POCT (17%–43% of baseline costs saved in hospital and 48%–81% saved in primary healthcare settings across the range of analyzed scenarios), suggesting a POCT costing up to $21 in hospitals and $3 in community settings could be cost neutral. Conclusions A POCT for neonatal sepsis, even with imperfect accuracy, could substantially improve clinical outcomes by improving time to diagnosis, while also supporting antibiotic de-escalation and stewardship and lowering healthcare costs. However, high clinical sensitivity is required to avoid causing deaths through missed diagnoses due to false negative results and delayed antibiotic initiation. What is already known on this topic?It is known that neonatal sepsis and possible serious bacterial infections in infants are a serious cause of mortality; however, diagnosis to provide proper treatment and care remains difficult. What does this study add?This study generates evidence on what the technical specifications and costs are required of a novel point-of-care test through mathematical modeling. How might this study affect research, practice, or policy?These results can be used as criteria to guide the development of a novel point-of-care test for neonatal sepsis and bacterial infection in infants.

: Antimicrobial resistance poses a growing threat to pediatric care, yet data on its clinical and economic burden in low-resource settings remain limited. The impact of antibiotic-resistant infections on mortality, hospital stay, and treatment costs was assessed among children admitted to a national referral hospital in Kenya in the present study. A retrospective review of medical records for pediatric patients (0–12 years) hospitalized with bacterial infections between January 2017 and December 2021 was conducted. Diagnoses included gastroenteritis, pneumonia, sepsis, urinary tract infections, meningitis, and others. Data on treatment, laboratory testing, outcomes, hospital stays, and costs were abstracted. Statistical analyses included Kaplan–Meier survival curves, Cox regression, and mixed-effects negative binomial and generalized linear models. Among 1,608 patients, 63% were infants, and 38% were referrals. Gastroenteritis (46%) and pneumonia (28%) were the most common diagnoses. Antibiotic-resistant infections occurred in 27% of participants and were associated with higher mortality (26% versus 9% in susceptible participants) and an attributable risk of 17%; the population attributable fraction was 65%. After adjustment, resistance was associated with increased mortality (HR 1.44), longer hospital stays (60% increase), and higher treatment costs (33% increase). Antimicrobial resistance significantly increases mortality, hospital stays, and healthcare costs in pediatric patients. Strengthening diagnostics, antimicrobial stewardship, and policy interventions is critical to address this threat.