1. WHAT WAS KNOWN?

• Neonates in hospitals are at risk of healthcare-associated infections (HCAIs), many of which are antimicrobial resistant and threaten their survival  • In low and middle-income countries (LMIC), HCAIs & antimicrobial resistance (AMR) are largely undetected during routine care due to limited access, or underuse, of blood culture – the current ‘gold standard’ for infection detection despite its limitations  • Multi-country reviews of neonatal blood culture use are few, especially for LMIC. The NEST360 Alliance aims to report findings and learnings from implementing and scaling a small and sick newborn care package in hospitals in Kenya, Malawi, Nigeria, and Tanzania, including an assessment of neonatal infection detection

2. WHAT WAS DONE THAT IS NEW?

• This cross-sectional study described the gap between antibiotic prescribing and blood culture use for over 140,000 neonatal inpatients in 61 hospitals, using individually-linked clinical and microbiological data collected from newborn admission records  • Health Facility Assessment data were used to classify hospitals into four performance Tiers based on the availability of laboratories, microbiology services, and neonatal blood culture use for those newborns prescribed antibiotics

3. WHAT WAS FOUND?

• We found a major gap between antibiotic prescribing (70%) and blood culture use (6%) for admitted newborns  • Of the 61 included hospitals, 34 were District, 22 were Secondary/Regional/Zonal, and 9 were Tertiary/National hospitals. All hospitals had laboratories, but 24 (39%) did no blood cultures for newborns, 16 of which were District hospitals with no microbiology capacity  • Most hospitals (36/61) were classified as Tier 3 sites with microbiology services but < 50% blood culture use for newborns on antibiotics, revealing that culture is underused even when available. Importantly, two facilities had > 50% blood culture use (Tier 4), highlighting the potential to perform more blood cultures for hospitalised newborns in LMIC

4. WHAT NEXT?

• The infection detection gap for neonatal inpatients needs to be closed. Short-term, quality improvement strategies could improve blood culture use, especially at Tier 3 hospitals missing opportunities for infection detection. Establishing active microbiology services in District hospitals remains a priority as countries aim to achieve global neonatal mortality targets  • High-performing hospitals (Tier 4) show that doing more routine blood cultures for newborns is possible in these contexts. However, qualitative research into local barriers and enablers is required, including exploring the interface between neonatal unit and laboratory departments and how it might be strengthened  • Improved blood culture use, alongside innovation for neonatal sepsis diagnostics, can enhance HCAI and AMR detection, surveillance, and outbreak control, facilitate antimicrobial stewardship programmes and reduce neonatal deaths