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Neonatal sepsis remains a leading cause of newborn mortality in sub-Saharan Africa, yet the systems designed to manage it are increasingly out of step with reality.

Neonatal sepsis remains a leading cause of newborn mortality in sub-Saharan Africa, yet the systems designed to manage it are increasingly out of step with reality. In many clinical settings, care is shaped less by formal guidelines and more by constraints – limited diagnostics, delayed results, inconsistent antibiotic access, and the growing pressure of antimicrobial resistance.

New findings from the INSIGHTS study bring this tension into focus, revealing a fundamental misalignment between global recommendations and the conditions under which clinicians are actually working. The issue is no longer simply about access to guidelines, but whether those guidelines are still fit for purpose.

For Prof Angela Dramowski, a paediatric infectious diseases specialist at Stellenbosch University and Tygerberg Hospital who leads neonatal infection research in the Department of Paediatrics and Child Health, the publication reflects the complexity of frontline decision-making. “Clinicians are often forced to act quickly, without the diagnostic certainty they need,” she explains. “They must decide how to treat a critically ill newborn while balancing effectiveness, safety, and the risk of further resistance – often with incomplete or delayed information.”

The study arrives at a pivotal moment. With global efforts underway to revisit neonatal sepsis diagnostics and treatment strategies, it adds important evidence from the settings most affected. “There is increasing recognition that we need better data, better diagnostics, and treatment approaches that are grounded in local realities,” Prof Dramowski says. “Without that alignment, even well-intentioned guidelines can fall short.”

A more responsive approach, she argues, starts with context. “Countries need reliable, local data on infection patterns and antimicrobial resistance, and that data must directly inform treatment guidelines and antibiotic access,” she notes. “At the same time, strengthening diagnostic systems and infection prevention is essential to reduce the burden of sepsis itself.”

For Dr Larisse Bolton, a researcher at the South African Centre for Epidemiological Modelling and Analysis (SACEMA) and computational/data science lead for the neonatal infections research group at Tygerberg Hospital, the work is both scientific and deeply personal. Her research focuses on improving maternal and neonatal health in Africa by integrating applied mathematics, epidemiology, and data science to strengthen real-world healthcare systems.“The life expectancy of its youngest members mirrors the well-being of a society,” she reflects. “To build healthy societies, we must start with healthy neonates.”

Her involvement in the INSIGHTS study included supporting data systems and contributing to the research process, but it is the people behind the work that have had the greatest impact. “I have been deeply inspired by the relentless efforts of clinicians and researchers working to save infant lives in under-resourced settings,” she says. “My role has been to support that effort – contributing my computational expertise and helping generate the evidence needed to strengthen care where it matters most.”

 

PUBLICATION

Neonatal sepsis is a key driver of under-5 mortality in Africa, contributing to the about 94,100 sepsis and other infectious condition deaths among newborns in sub-Saharan Africa in 2021. These life-threatening bacterial infections within the first 28 days of life unevenly affect low-and-middle income countries (LMICs) where diagnostic, prevention and treatment resources are limited. Neonates with these infections deteriorate rapidly, with survival hinging on rapid detection and treatment. Sadly, survivors of neonatal sepsis are often plagued with long-term effects such as vision loss and seizures. In resource-limited settings, clinicians are often left to treat neonatal sepsis in the absence of laboratory confirmation (i.e. empiric treatment) due to limited laboratory capacity, long delays in diagnostic results and high costs of processing blood cultures – the gold-standard diagnostic test for neonatal sepsis. The WHO provides recommendations for the empiric treatment of neonatal sepsis; however, these recommendations have not been revised since 2005 and do not consider local pathogen and antimicrobial resistance (AMR) patterns, reducing their effectiveness with increasing AMR within the region. In a recent study, clinicians caring for sub-Saharan African neonates were surveyed to obtain a complete view of the challenges facing the management of neonatal sepsis in the region, particularly the current state of access to diagnostics and guideline use in practice. Study responses were received from 83% of the targeted countries in sub-Saharan Africa and comprised of mostly senior doctors (72%), those working in central (58%) public healthcare facilities (70%) and involved in neonatal sepsis treatment daily. 29% of respondents rarely received blood culture results in time to guide treatment, with low- and low-middle income countries (LLMICs) similarly challenged by slow diagnostic turnaround times compared to their high-income counterparts that seldom face these difficulties. More than 50% of respondents reported difficulty accessing antibiotics, with supply issues  (including antibiotic registration, formulation, access and cost) being the most frequently reported hindrance to access; more so for some antibiotics than others. The WHO guidelines are still widely used to manage neonatal sepsis in practice across the region, with more than 45% of the respondents having attempted to or been involved in the writing of local guidelines during their careers. Those who have not opted to be involved in local guideline writing mostly cited the scarcity of local AMR data as the primary obstacle. Study findings emphasise the overall dependence on empiric treatment guidelines which are misaligned with the local pathogen and AMR patterns in much of sub-Saharan Africa. This is against the backdrop of growing evidence of the rapid rise of multi-drug resistant neonatal sepsis-causing organisms. This misalignment between guidelines and AMR patterns increases the chances  of ineffective initial treatment for neonatal sepsis, resulting in poor patient outcomes and increasing the spread of resistant organisms.  Neonatal sepsis care in sub-Saharan Africa is thus constrained not by a lack of guidelines, but by a lack of alignment – between diagnostics, data, and the realities of AMR infections. This misalignment should be at the forefront of global health priorities, encouraging decision-makers to leverage successes from other domains to secure access to inexpensive, rapid diagnostic tests and effective antibiotics for neonatal sepsis to optimise neonatal survival and health in sub-Saharan Africa.

 

Stanley JL, Hettle D, Poffley R, Bolton L, Gres E, Coelho I, et al. Investigating neonatal sepsis: anti-Infectives, diagnostics and Guidelines used in Health sysTems across sub-Saharan Africa –The INSIGHTS study. BMJ Paediatrics Open. 2026;10:e004132.

https://doi.org/10.1136/bmjpo-2025-004132 (full list of references available here)

 

International Recognition

Dr Larisse Bolton, a researcher at SACEMA and computational/data science lead for the neonatal infections research group at Tygerberg Hospital, has received international recognition for her work in maternal and neonatal health.

She has been selected as a heiAIMS Incoming Young Researcher at Heidelberg University, where she will collaborate with Dr Florian Marx on the NEO-CARE project. This research will evaluate the cost-effectiveness and antimicrobial resistance impact of empiric antibiotic use for early-onset neonatal sepsis in South African neonatal units. She has also been awarded a Baden-Württemberg Scholarship, supporting her two-month research visit to Heidelberg. The work is expected to generate evidence-based recommendations for neonatal sepsis treatment, while strengthening international collaboration and enabling valuable skills and knowledge exchange. Congratulations!

LarisseÂ’s research bridges applied mathematics, epidemiology, and data science to improve maternal and neonatal health systems in Africa, with a focus on real-world impact in low- and middle-income settings.

 

Text: Katrine Anker-Nilssen

News date: 2026-04-08

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