 Okay so good morning everybody. Today I'm presenting the results of an investigation of reported increase in mortality due to near-natal sepsis in a near-natal unit that MSF runs in Kuita, Pakistan and what we found is that there was it was a case of antibiotic resistance. So to provide some background, MSF works in Balochistan province of Pakistan which is the life pale color there. They work in three districts working in mother-child health care. Balochistan has the worst health indicators for the whole of Pakistan with very high maternal mortality and infant mortality. MSF established a pediatric hospital in 2011 with 60 beds, 20 beds of which are part of a neonatal unit. MSF also have a mother-child health clinic which is about 20 minutes from the hospital providing basic emergency obstetric care and outpatient care for children under five and treatment of other conditions. So the pediatrician and the team in the neonatal unit in Kuita raised concerns that there might be an outbreak of neonatal sepsis and they also raised concerns that they felt there was growing resistance to the current treatment protocol. So in response to that we analysed routinely collected clinical data with these two questions in mind. Is there an outbreak of neonatal sepsis in the neonatal unit and what are the causative pathogens of neonatal sepsis and their resistance profiles. So just for everyone to realise neonatal sepsis is defined as bacterial meningitis that occurs during the first 28 days after birth. Early onset sepsis occurs within 72 hours and late onset sepsis occurs between 72 hours and 7 days. So the case definition adopted by the team is the OCB case definition and as can be seen here there's many many symptoms and the case definition is very broad. So in the presence of one of these danger signs or in the presence of two of these danger signs a neonator is classified as having neonatal sepsis. The case definition is very sensitive but not very specific. At the time we conducted the analysis the treatment protocol was in line with the WHO treatment protocol and based on the MSF 2013 neonatal guidelines and included ampicillin and gentamicin for at least 10 days and if a staphylococcus infection was suspected cloxacillin and gentamicin were used as first line treatment. After two to three days if there was no response the second and third line treatments incorporated the catholosporins. So we conducted a routinely a data of routinely sorry an analysis a retrospective analysis of routinely collected data. The neonatal sepsis line list had been established in February 2016 and a suspected case of neonatal sepsis was one that met the case definition. Antibiotic resistance profiles were also recorded in the line list. Antibiotic susceptibility testing was conducted using the disk diffusion method at Aga Khan University Hospital reference laboratory in Karachi. The MSF laboratory advisor had visited the laboratory at the end of 2015 conducting a quality assessment and the two dot points there show that the quality assessment tool she used and she found that the lab met all the minimum standards well above what was required. So data was analysed from February 18th to July 14th and it was exempt from ethics review as it was a retrospective analysis. So the characteristics of our neonates out of the 274 neonates that were admitted to the unit during that time period 1998 met the case definition for neonatal sepsis. 70% were male and 60% were classified as having low birth weight. The median age at birth was 38 weeks gestation and the majority of the neonates had early onset sepsis. So where did they come from? 10% came from the MSF facility in Kuchluck. 26% were home births that had presented at the emergency department at the hospital and 64% had been transferred from another health facility. So not to get overwhelmed by this graph it's basically just to show the diversity of pathogens that were highlighted that were isolated rather. The graph shows all of the cultures the bloods that had been sent for culture from the neonates during that period with week seven being the middle of February and week 28 being the middle of July. The dark grey show that out of all of the bloods that were sent for culture the number of culture results that did not come back to the unit that were not reported. The light grey shows the number of cultures that reported no growth and the colours show the different pathogens that were isolated and for those of you that are familiar with your bugs you'll see there's a mix of gram negative and gram positive bacteria. The red line represents the case fatality rate which as you can see is not consistent during this period it's kind of all over the place. So there were 97 blood cultures sent of which 43 there were no results reported, 55 we had results for of which 22 out of the 55 were culture positive. So of these 22 culture results we had 13 that were gram negative bacteria. Nearly half of these were klebsiella and as we can see from this graph there's a very high resistance to ampicillin and genitomycin and to the kephalosporins with sensitivity to amicase and imipenem and pippuricillin and tazobactym. So the light the grey represents susceptible the green intermediate resistance and red is resistant. Out of the 22 isolates nine were gram positive bacteria and of concern here was the majority of which were staflococcus the concern here was that seven were oxacillin resistant. So the limitations we faced is that infection control could not be assessed and blood collection practices could not be assessed. I was unable to visit the unit in Quetta. Data was incomplete as we discussed earlier the diagnosis of sepsis is based on a syndromic case definition meaning it's very broad so many of these babies may have been misclassified. 30% of neonates had already received antibiotic treatment. They were missing lab results and the sample size of our positive results was very small. However relevance to practice is that we did identify multiple pathogens. There is a high risk for outbreak and therefore it's imperative that infection control guidelines are strictly adhered to in the unit and that there's a regular monitoring and evaluation that these guidelines are being put into place. There's also a need for review of the treatment guidelines. So results are consistent with other studies so even though we had a very small sample size of 22 isolates they are consistent with findings in the scientific literature. One that I want to highlight today is a study conducted by Salim in 2013 which looked at neonatal sepsis in a neonatal intensive care unit in the Aga Khan hospital in Karachi in Pakistan and of 104 Klebsiella pneumonia isolates. Over 80% were resistant to ampicillin, genitomycin and the Keflosporins. So the translational action that came from this analysis was that treatment protocols were changed in February 2017. There is a need for antimicrobial stewardship policies and advocacy for the implementation of these policies. There's a need for continual staff development in this area. There is a need for regular surveillance of AMR to monitor changing patterns over time. There's a need for regular review of scientific literature to also recognize findings from others who are conducting studies in these areas and a regular review of treatment protocols. There's also a need for strengthening of laboratory capacity in order to ensure that we get timely results that we can act on. So the question I'd like to leave with you today is are the days for universal treatment protocols over? I'd like to acknowledge the team that were involved in this study and leave you with the references that I mentioned earlier. Thank you very much. Great. Tamry, thank you. So quite a concerning sort of study. We'll have another study presented from India by the next speaker. Any questions? While you think of your questions, I have one for you. The last question that you posed, universal treatment protocols are the days over. In one of the ways we increased the quality of the care that we provide in MSF was to by introducing standardized treatment guidelines and protocols. So how would we sort of tackle this in the future where you have to personalize treatment? How would that work? Any thoughts on that? Well from my side, I think, especially in today's landscape of growing antimicrobial resistance, and with neonates, they don't have a lot of grace and a lot of time, so we need to make sure that whatever treatment we give, they respond to straight away. We don't have time to play around and change with antibiotics. So I think now, just with the change in climate that we have, it's just imperative that we strengthen lab capacity in all the areas that we work so that we can actually do antimicrobial testing and do it regularly. Not that we have to do it all the time, but usually, you know, doing over a time period to monitor changes so that we can adapt. Because regionally it does change. We've done that in tuberculosis to some extent, and hopefully we can do that for common infections as well. There's one question from our online viewer. Hi. So the question is, are the days of universal treatment protocols over? That's one of the questions that has been asked by our online viewers. Are you asking it back to me? That's the question that she posed as well. Just say that the presenter agrees. I might leave that question for the panel to discuss. Yes, there's someone in the back. Please state your name and where you're from and then ask the question. Hi, I'm Dr. Sramadip Vermik. I work for the BMJ Global Health and also for the Public Health Foundation of India. So it's regards to the question you asked, and this was one of my dissertation topics I had done. So I think one of the key issues with clinical practice guidelines and protocols is also to monitor and evaluate them how relevant they are. So I think the answer to your question is that we need to check how the protocols are relevant to this and to be able to modify them because a clinical practice guideline can improve the quality of guideline, quality of care only if its quality is good enough for that purpose and that context. So that was a common question. It's a comment and a question. State your name and where you're from, please. I'm Jyothi from Centre for Disease Dynamics, Economics and Policy in South Asia office. And my question is, you know, clinicians and lab, they generally don't tend to work together. So one, the question is what was the practice in your region like you send the samples, reports came back, but is there consultation because surveillance and treatment protocols need to be devised together, unless it's done in sync and constantly monitored based on the practice, it's no longer going to be relevant. So what was the practice and how was it taken about? Okay, I will take the liberty of answering this question, although I'm not from Quetta. So the Quetta team, please forgive me if I misrepresent anything. But from my understanding after talking with the team is that from Quetta, the lab results get sent, there is an Aga Khan laboratory reciprocal next door. They take the lab results and then send them on to Karachi, where they're analyzed. And this link, this link is now being strengthened. So MSF has now implemented a new position in Quetta as a laboratory support person. And they're now making stronger links and stronger efforts with the Aga Khan laboratory in Karachi, with the plan of implementing regular surveillance, where every neonate that's admitted to the unit is swabbed and samples are sent to look for the pathogens that are actually highly prevalent in the unit. So this is something that the team have recognized is important that communication with the lab. And now they've made efforts to improve that. Yes. Morning. Thanks for a very good presentation. Please state your name. I'm Dr. Ishwara from SGBV team, Delhi. So my question is, there are 26% home deliveries. And 26% home deliveries, sepsis, and 10% from MSF facility. So where went wrong in the MSF facility? Because you follow international standards and all. And at the same time, actually, anti neutral checkup, whether you scream for the mother's had any infection. So resistance, whether during anti-natal mother took any antibiotics or screened for any genital infection. Was there any, I mean, like, to have any guidelines? One thing I probably failed to mention in the beginning, I think if it's 70% of all births in this province of Pakistan are home births and women receive no antenatal care. So some of the women that come to the mother child health service in in Kuchla are coming when they're delivering. So they some of them, you know, many of them would not have also accessed anti-natal care. So as far as the the 10% that came from the MSF clinic, I don't have the authority to answer that. I'm not I'm not sure. But I couldn't even apologize. Sorry about that. We'll take one more question, and then we'll move on to the next presenter. Anyone? All right. In that sense, I will invite the next speaker to thank you.