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IntroductionInappropriate healthcare practices are major contributors to poor outcomes of maternal and paediatric patients. Where resources are scarce, provider-level targeted interventions, such as implementation of standardised, evidence-based protocols and quality improvement initiatives, are particularly needed to address these gaps in care. Simulation-based tools have been shown to have a promising effect on improving clinical care management. This study aims to evaluate the effectiveness of a simulation-based platform called E-Patient Quality improvement and Standardisation (EQIS) in improving maternal and paediatric healthcare in Bangladesh.Methods and analysisThe study employs a prospective, open-cohort design and will be conducted across five tertiary-level hospitals in Dhaka, Bangladesh. All physicians engaged in providing maternal or paediatric care will be recruited. The EQIS platform will facilitate the development of online simulated cases, aiming to enhance physician practice and patient outcomes through involvement and immediate personalised feedback. The development of cases will consist of several stages of review by expert clinicians, ensuring that the cases align with national and local practice guidelines. Each participant physician will work on three cases per round, completing one of six rounds every 4 months for 2 years. The primary outcome will be the change in mean EQIS clinical performance score among participating physicians across evaluation rounds. Descriptive and inferential analysis will be done to assess trends in clinical performance and pinpoint areas for improvement. In addition, patient-level pre-impact and post-impact data will be collected. These data will evaluate the impact of the EQIS platform on physician performance, as measured by changes in patient satisfaction, treatment costs, referrals and facility utilisation.Ethics and disseminationThe study protocol was approved by the National Research Ethics Committee of the Bangladesh Medical Research Council (registration number: 59524062024). Dissemination of the study findings will be through meetings with stakeholders, conference presentations and publications in peer-reviewed journals.

Abstract not available J Bangladesh Coll Phys Surg 2021; 39(3): 148-151

Background: Although national population-based birth defect prevalence estimates are unavailable for Bangladesh specifically, data extrapolated from the March Dimes Global Birth Defects Report indicate a prevalence of neural tube defects (NTDs) of 4.7 per 1,000 live births.Purpose: This study aimed to determine the prevalence of NTD among infants born at a tertiary care multidisciplinary referral hospital in Bangladesh.Methods: Live born infants with NTD were prospectively enrolled in 2015–2021. Each enrolled NTD case was examined for type, location, and associated anomalies. The overall and annual prevalence rates were then calculated.Results: A total of 10,372 newborns were enrolled; of them, 68 had NTD (incidence, 6.4 [range, 4.59–11.2] per 1,000 live births). The mean maternal age was 27.49± 4.72 years. Three-quarters of the NTD cases were detected at birth, and 94% of the mothers reported not taking periconceptional folic acid supplements. The meningomyelocele complex was the most frequent location. Two peaks in incidence were noted in 2017 and 2021 (10.28 and 11.2 per 1,000 live births, respectively). The distribution of different NTD types included meningomyelocele at 53%, encephalocele at 26.6%, meningocele at 16%, and anencephaly at 4.4%. A male predominance was noted overall except for anencephaly. The most common location was the lumbosacrum (47%). The NTD was isolated in 20.59% (14 of 68) of cases and associated with other malformations in 80% (54 of 68) of cases.Conclusion: The incidence of NTD was 6.4 per 1,000 live births at a leading tertiary care multidisciplinary referral center in Bangladesh. However, this figure might not reflect the incidence of NTD in the wider population.

Lung auscultation is not included in the WHO Integrated Management of Childhood Illness algorithm, partly due to concerns regarding feasibility and reliability when performed by non-physician primary health workers in low-resource settings. In this feasibility study, we evaluated whether non-physician primary care health workers (community health care providers (CHCPs)) can record quality lung sounds from children aged 2–59 months. Feasibility was predefined as more than 50% of children having quality recordings at the overall sample level. After receiving three days of structured training, nine CHCPs recorded lung sounds from four chest positions using a digital stethoscope (Sonavi Labs, United States) in 990 children attending first-level rural clinics in Bangladesh between November 2019 and December 2020, with enrolment paused during the COVID-19 pandemic. A blinded paediatrician listening panel, trained to a standardised interpretation protocol, classified the recordings. A quality recording was defined a priori as the panel classifying three of four chest positions on a participant as interpretable. Lung sounds were recorded from 990 children, and the panel classified 867 children as having a quality recording (87.6%; 95% confidence interval: 85.4%, 89.6%). Among children with quality recordings and available timing data, 89.8% (766/853) were recorded within five minutes. This study demonstrates CHCPs at rural, first-level clinics in Bangladesh are capable of timely, quality recordings of lung sounds from most children using a digital stethoscope.

Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0-59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016). We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines. Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions-including engaging informal providers in treatment of the infant-to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses. Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines.

Rising antimicrobial resistance (AMR) in Salmonella Typhi restricts typhoid treatment options, heightening concerns for pan-oral drug-resistant outbreaks. However, lack of long-term temporal surveillance data on AMR in countries with high burden like Bangladesh is scarce. Our study explores the AMR trends of Salmonella Typhi isolates from Bangladesh, drawing comparisons with antibiotic consumption to optimize antibiotic stewardship strategies for the country. The typhoid fever surveillance from 1999 to 2022 included two pediatric hospitals and three private clinics in Dhaka, Bangladesh. Blood cultures were performed at treating physicians' discretion; cases were confirmed by microbiological, serological, and biochemical tests. Antibiotic susceptibility was determined following CLSI guidelines. National antibiotic consumption data for cotrimoxazole, ciprofloxacin, and azithromycin was obtained from IQVIA-MIDAS database for comparison. Over the 24 years of surveillance, we recorded 12,435 culture-confirmed typhoid cases and observed declining resistance to first-line drugs (amoxicillin, chloramphenicol, and cotrimoxazole); multidrug resistance (MDR) decreased from 38% in 1999 to 17% in 2022. Cotrimoxazole consumption dropped from 0.8 to 0.1 Daily defined doses (DDD)/1000/day (1999-2020). Ciprofloxacin non-susceptibility persisted at >90% with unchanged consumption (1.1-1.3 DDD/1000/day, 2002-2020). Low ceftriaxone resistance (<1%) was observed, with slightly rising MIC (0.03 to 0.12 mg/L, 1999-2019). Azithromycin consumption increased (0.1 to 3.8 DDD/1000/day, 1999-2020), but resistance remained ≤4%. Our study highlights declining MDR amongst Salmonella Typhi in Bangladesh; first-line antimicrobials could be reintroduced as empirical treatment options for typhoid fever if MDR rates further drops below 5%. The analysis also provides baseline data for monitoring the impact of future interventions like typhoid conjugate vaccines on typhoid burden and associated AMR.

Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) using simplified antibiotic regimens when compliance with hospital referral is not feasible. Bangladesh was one of the first countries to adopt WHO's guidelines for implementation. We report results of an implementation research study that assessed facility readiness and provider performance in three rural sub-districts of Bangladesh during August 2015-August 2016. This study took place in 19 primary health centers. Facility readiness was assessed using checklists completed by study staff at three time points. To assess provider performance, we extracted data for all infection cases from facility registers and compared providers' diagnosis and treatment against the guidelines. We plotted classification and dosage errors across the study period and superimposed a locally weighted smoothed (LOWESS) curve to analyze changes in performance over time. Focus group discussions (N = 2) and in-depth interviews (N = 28) with providers were conducted to identify barriers and facilitators for facility readiness and provider performance. At baseline, none of the facilities had adequate supply of antibiotics. During the 10-month period, 606 sick infants with signs of infection presented at the study facilities. Classification errors were identified in 14.9% (N = 90/606) of records. For infants receiving the first dose(s) of antibiotic treatment (N = 551), dosage errors were identified in 22.9% (N = 126/551) of the records. Distribution of errors varied by facility (35.7% [IQR: 24.7-57.4%]) and infection severity. Errors were highest at the beginning of the study period and decreased over time. Qualitative data suggest errors in early implementation were due to changes in providers' assessment and treatment practices, including confusion about classifying an infant with multiple signs of infection, and some providers' concerns about the efficacy of simplified antibiotic regimens. Strategies to monitor early performance and targeted supports are important for enhancing implementation fidelity when introducing complex guidelines in new settings. Future research should examine providers' assessment of effectiveness of simplified treatment and address misconceptions about superiority of broader spectrum antibiotics for treating community-acquired neonatal infections in this context.

Typhoid and paratyphoid remain common bloodstream infections in areas with suboptimal water and sanitation infrastructure. Paratyphoid, caused by Salmonella Paratyphi A, is less prevalent than typhoid and its antimicrobial resistance (AMR) trends are less documented. Empirical treatment for paratyphoid is commonly based on the knowledge of susceptibility of Salmonella Typhi, which causes typhoid. Hence, with rising drug resistance in Salmonella Typhi, last-line antibiotics like ceftriaxone and azithromycin are prescribed for both typhoid and paratyphoid. However, unlike for typhoid, there is no vaccine to prevent paratyphoid. Here, we report 23-year AMR trends of Salmonella Paratyphi A in Bangladesh. From 1999 to 2021, we conducted enteric fever surveillance in two major pediatric hospitals and three clinics in Dhaka, Bangladesh. Blood cultures were performed at the discretion of the treating physicians; cases were confirmed by culture, serological and biochemical tests. Antimicrobial susceptibility was determined following CLSI guidelines. Over 23 years, we identified 2,725 blood culture-confirmed paratyphoid cases. Over 97% of the isolates were susceptible to ampicillin, chloramphenicol, and cotrimoxazole, and no isolate was resistant to all three. No resistance to ceftriaxone was recorded, and >99% of the isolates were sensitive to azithromycin. A slight increase in minimum inhibitory concentration (MIC) is noticed for ceftriaxone but the current average MIC is 32-fold lower than the resistance cut-off. Over 99% of the isolates exhibited decreased susceptibility to ciprofloxacin. Salmonella Paratyphi A has remained susceptible to most antibiotics, unlike Salmonella Typhi, despite widespread usage of many antibiotics in Bangladesh. The data can guide evidence-based policy decisions for empirical treatment of paratyphoid fever, especially in the post typhoid vaccine era, and with the availability of new paratyphoid diagnostics.

Background Hypothermia is a significant risk factor for newborn morbidity and mortality. Thus, thermoregulation is one of the central components of newborn care. Continuous temperature monitoring can prevent prolonged hypothermia and, subsequently, adverse outcomes. Aims To see the performance of the BEMPU hypothermia alert device over the conventional touch method among babies getting kangaroo mother care (KMC). Materials and Methods A randomized controlled trial was conducted in the Department of Neonatology in two tertiary care hospitals, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) at Shahbag, Dhaka, from June, 2019‐ September, 2020. Stable preterm low birth weight newborns (≤ 2000 g) eligible for KMC were enroled and monitored for 28 days. Results The mean detection of hypothermic episodes was significantly higher in the BEMPU group than in the conventional group (6.73 vs. 2.87, p = 0.001) over 28 days. The average duration of ensuring KMC per day was significantly more in the BEMPU group (mean ± SD, 7.19 ± 3.2 vs. 3.04 ± 1.69 h); p = 0.001). Weight gain over 28 days after discharge was more in the BEMPU group (20.96 ± 7.9) than in the conventional group (16.2 ± 7.6), which was statistically significant (p value 0.007). A significant daily weight gain was observed in the BEMPU group (20.96 ± 7.9vs 16.2 ± 7.6; p = 0.007). Conclusions The performance of the hypothermia alert device was found to be significantly higher than the conventional touch method.