I nvestigating neonatal sepsis: anti-Infectives, diagnostics and Guidelines used in Health sysTems across sub-Saharan Africa – The INSIGHTS study

BACKGROUND: Sepsis is a leading cause of neonatal mortality in sub-Saharan Africa (SSA), where microbiological diagnostic capacity and antibiotic access are limited. High antimicrobial resistance (AMR) rates limit the effectiveness of current treatment guidelines, with concern that available antibiotics are rarely adequate treatment for neonatal sepsis in the region. METHODS: A cross-sectional online survey was electronically distributed in English, French and Portuguese to neonatal clinicians across SSA between April and June 2025. Questions focused on the management of neonatal sepsis including diagnostic, antibiotic and guideline use. Responses were analysed descriptively and presented as percentages of the total number of responses. RESULTS: Of 169 responses (40/48 countries; 83.3%) from SSA, 71.6% were senior doctors, 88.8% managed neonatal sepsis at least weekly and 58.0% worked in central healthcare facilities.14.9% (95% CI 10.3% to 21.0%) of respondents never and 28.6% (CI 22.3% to 35.8%) less than half of the time received blood culture results in time to impact patient care. Guidelines were almost universally used (97.6% (CI 94.0% to 99.1%)). The most common guideline for early-onset neonatal sepsis advised amoxicillin/ampicillin plus aminoglycosides (46.4% of responses (CI 39.1% to 54.0%)). 50.3% (CI 42.8% to 57.7%) of respondents had difficulties accessing antibiotics, with carbapenems and piperacillin-tazobactam least accessible. 45.4% (CI 38.0% to 53.1%) had attempted to author local guidelines with insufficient local AMR data (45.6% (CI 35.7% to 55.8%)) the most common barrier to guideline development. CONCLUSIONS: This large survey highlighted widespread challenges in diagnostic and antibiotic access for neonatal sepsis in SSA. We find that clinicians rely on guidelines to guide starting antibiotics and to guide agent choice. Their practices reflect advice in global guidelines. Attempts to author locally applicable guidelines are hindered by insufficient AMR data. These findings strengthen calls to improve microbiological diagnostic access and support data sharing to generate evidence-based, locally appropriate guidelines.