UTILISATION AND DETERMINANTS OF BLOOD CULTURE IN MANAGING SEPSIS AMONG HOSPITALISED CHILDREN <5 YEARS: A MIXED-METHOD STUDY AT FOUR AMR SURVEILLANCE SITES IN UGANDA, 2024-2025.

This mixed-methods study at four Ugandan AMR surveillance sites reveals that blood culture utilization for suspected sepsis in hospitalized children under five remains low (28.1%) despite high clinician awareness, driven primarily by systemic barriers, inefficient workflows, and emotional fatigue rather than knowledge gaps, with higher usage linked to clinical severity and senior clinician involvement.

The Gist

🩸 The Big Picture: The "Black Box" Problem

Imagine a child comes into a hospital with a high fever and looks very sick. The doctors suspect sepsis (a life-threatening reaction to an infection). To treat it correctly, they need to know exactly which germ is causing the trouble.

The "Gold Standard" tool for finding this out is a blood culture. Think of this like a detective's magnifying glass. Instead of guessing which antibiotic to give (which is like throwing darts in the dark), the blood culture grows the bacteria in a lab so the doctor can see the enemy clearly and pick the perfect weapon to kill it.

The Problem: In Uganda, even though doctors know this magnifying glass exists and is the best tool, they are only using it about 28% of the time. That means for every 100 sick children, they are guessing the treatment for 72 of them.

🔍 What the Researchers Did

The researchers acted like detectives themselves. They looked at two things:

1. The Paper Trail: They reviewed the medical records of 384 sick children (under 5 years old) across four major hospitals in Uganda.
2. The Human Story: They sat down and interviewed 20 doctors and nurses to ask, "Why do you sometimes skip the test?"

📉 The Findings: Who Gets the Test?

The study found that the decision to use the "magnifying glass" wasn't random. It depended on a few specific factors:

• The "VIP" Treatment: Children who looked very sick (had severe malnutrition, sickle cell disease, or were in critical danger) were more likely to get the test. It's like a triage nurse giving the best equipment to the most critical patients first.
• The "Senior Captain" Effect: If a senior doctor or a consultant was in charge, the test was more likely to be ordered. Junior doctors often felt like they needed permission or were too busy to ask for it.
• The "Monday Morning" Bias: Tests were ordered more often during the day and on weekdays. On weekends or late at night, when the lab is quiet or staff is tired, the tests often got skipped.
• The "Already Treated" Trap: If a child had already taken antibiotics at home before arriving, doctors were less likely to order the test. They thought, "Well, the medicine might have already killed the bacteria, so the test won't work anyway." (The study suggests this is a misconception; the test can still be useful).

🚧 Why Don't They Use It? (The Real Reasons)

The interviews revealed that the doctors weren't skipping the test because they were ignorant. They knew it was important. Instead, they were blocked by a wall of systemic problems.

Here are the main barriers, explained with analogies:

1. The "Empty Shelf" Problem (Supply Chain)

Imagine a chef who wants to bake a cake but the pantry is empty.

• Reality: The hospitals often ran out of the special bottles needed to collect the blood or the chemicals needed to grow the bacteria.
• Result: The doctor wants to order the test, but the lab says, "We have no bottles." So, they just treat the child with guesswork.

2. The "Broken Phone" Problem (Communication)

Imagine ordering a pizza, but the restaurant takes 3 days to deliver it, and by the time it arrives, you've already eaten dinner.

• Reality: Even when the test was done, the results often took 2–3 days to come back. By then, the child was either discharged or already recovering.
• Result: Doctors felt the test was useless because it didn't help them right now. They lost faith in the system.

3. The "Exhausted Runner" Problem (Emotional Fatigue)

Imagine a runner trying to sprint, but every time they take a step, they trip over a hurdle, and no one helps them up.

• Reality: Doctors and nurses were emotionally drained. They tried to do the right thing, but the system kept failing them (no bottles, no results, no staff).
• Result: They developed "adaptive behavior"—a fancy way of saying they stopped trying so hard because they felt helpless. They just treated the fever and moved on to the next patient.

4. The "Solo Act" Problem (Lack of Teamwork)

• Reality: When the senior doctors and the lab staff worked together and gave feedback, the test usage went up. When that mentorship stopped, usage went down.
• Result: It takes a team to make the system work. Without a coach (senior leader) reminding the team, the players (junior staff) forget the game plan.

💡 The Solution: How to Fix the Machine

The researchers concluded that you can't just tell doctors, "You need to know more!" because they already know. You have to fix the machine they are working in.

1. Stock the Pantry: Ensure the hospitals never run out of blood culture bottles.
2. Fix the Phone Line: Speed up the lab results so doctors get answers while the child is still in the hospital.
3. Hire More Coaches: Have senior doctors actively mentor the younger staff and remind them to order the tests.
4. Checklists: Put a simple checklist on the admission form that says, "Did you order a blood culture?" to remind everyone.

🏁 The Bottom Line

This study is a wake-up call. The problem isn't that Ugandan doctors don't know how to save children; it's that the system is broken.

To stop children from dying of sepsis and to stop the rise of "superbugs" (antibiotic resistance), we need to stop blaming the doctors and start fixing the supply chains, the lab speeds, and the support systems. If we give them the tools and the time, they will use the "magnifying glass" to save lives.

Technical Summary

1. Problem Statement

Sepsis caused by drug-resistant pathogens is a leading cause of under-five mortality in low- and middle-income countries (LMICs), threatening progress toward Sustainable Development Goal (SDG) 3.2. While blood culture is the "gold standard" for diagnosing bloodstream infections and guiding antimicrobial stewardship, its utilization in routine pediatric care in Uganda remains critically low.

• Context: Despite national investments in microbiology capacity (e.g., via the Fleming Fund and National AMR Surveillance), blood cultures account for only 8.9% of bacterial isolates reported in Uganda.
• Gap: Previous data suggests a disconnect between laboratory capacity and clinical practice. It is unclear whether low utilization is due to a lack of clinician knowledge or systemic/behavioral barriers.
• Objective: To assess the extent of blood culture utilization, identify clinical and contextual determinants, and explore behavioral drivers using the Theoretical Domains Framework (TDF).

2. Methodology

The study employed a cross-sectional mixed-methods design combining retrospective quantitative data review with qualitative in-depth interviews.

• Setting: Four Regional Referral Hospitals (RRHs) representing Uganda's four regions: Jinja (Central), Mbarara (Western), Mbale (Eastern), and Arua (Northern).
• Study Population:
  • Quantitative: 384 patient records of children <5 years hospitalized with suspected sepsis (September 2024 – September 2025).
  • Qualitative: 20 clinicians (consultants, residents, medical officers, clinical officers, nurses) involved in pediatric sepsis management.
• Sampling:
  • Quantitative: Probability Proportionate to Size (PPS) sampling based on annual blood culture volumes.
  • Qualitative: Purposive sampling until data saturation was reached.
• Data Analysis:
  • Quantitative: Modified Poisson regression with robust standard errors to calculate Adjusted Prevalence Ratios (aPR) for factors associated with blood culture requests.
  • Qualitative: Thematic analysis guided by the Theoretical Domains Framework (TDF) to map behavioral determinants.
• Ethical Considerations: Approved by Makerere University School of Public Health (Ref: MakSPH-REC_506); verbal consent obtained for interviews; secondary data used for records.

3. Key Contributions

• Behavioral Framework Application: This is one of the first studies in the region to apply the Theoretical Domains Framework (TDF) to diagnostic stewardship in pediatric sepsis, moving beyond simple "knowledge deficit" explanations to explore emotional, environmental, and social drivers.
• Mixed-Methods Triangulation: The study effectively triangulates statistical utilization rates with the lived experiences of clinicians, revealing why the numbers are low despite high awareness.
• Identification of "Diagnostic Fatigue": It highlights "emotional fatigue" and "adaptive behavior" (e.g., giving up on testing due to system failures) as critical, previously under-discussed barriers in LMIC settings.

4. Key Results

A. Quantitative Findings

• Utilization Rate: Blood cultures were requested in only 28.1% (108/384) of suspected sepsis cases.
• Factors Associated with Higher Utilization:
  • Clinical Severity: Presence of WHO danger signs (aPR 1.1), Severe Acute Malnutrition (aPR 1.3), and Sickle Cell Disease (aPR 1.3).
  • Provider Cadre: Senior clinicians (Consultants: aPR 1.4; Senior House Officers/Medical Officers: aPR 1.2) were significantly more likely to order cultures than nurses.
  • Timing: Admissions during the day (aPR 1.1) and on weekdays (aPR 1.1) had higher utilization.
  • Duration: Longer hospital stays (≥8 days) were associated with higher utilization (aPR 1.1).
• Factors Associated with Lower Utilization:
  • Age: Older children (12–35 months and ≥36 months) were less likely to have cultures ordered compared to infants <12 months.
  • Prior Antibiotics: Preadmission antibiotic use significantly reduced the likelihood of a culture request (aPR 0.9).

B. Qualitative Findings (TDF Themes)

Four overarching themes emerged regarding clinician behavior:

1. Motivation Amidst Systemic Constraints: Clinicians recognize blood culture as the "gold standard" but feel helpless when results are delayed (2–3 days) or never returned, leading to a loss of morale.
2. Environmental and Institutional Barriers: Recurrent stock-outs of bottles/reagents, power outages, understaffing, and delayed sample transport are primary drivers of non-utilization.
3. Mentorship and Teamwork: Active mentorship and feedback loops (e.g., monthly AMR reports) significantly improved adherence. When mentorship stopped, practice regressed.
4. Emotional Fatigue and Adaptive Behavior: Clinicians experience frustration and "diagnostic fatigue" due to repeated system failures. This leads to adaptive behaviors where they stop ordering tests they perceive as futile, even if they know they should.

5. Significance and Implications

• Systemic vs. Knowledge Gap: The study concludes that low utilization is not primarily due to a lack of clinician knowledge (awareness is high) but is driven by health system fragility, inefficient workflows, and emotional exhaustion.
• Policy Recommendations:
  • Infrastructure: Ensure uninterrupted supply chains for consumables and 24-hour laboratory coverage.
  • Workflow Integration: Implement clinical decision support tools (checklists, electronic prompts) to standardize ordering regardless of severity.
  • Behavioral Reinforcement: Institutionalize mentorship programs, regular feedback loops between labs and clinicians, and recognition systems to combat emotional fatigue.
• Global Health Impact: Improving diagnostic stewardship in pediatric sepsis is critical for curbing Antimicrobial Resistance (AMR) and achieving SDG 3.2 (reducing neonatal/child mortality).

Conclusion: Sustainable improvement in pediatric sepsis management in Uganda requires a shift from isolated infrastructure investments to integrated interventions that address structural barriers, workflow efficiency, and the psychosocial well-being of healthcare providers.