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BackgroundNeonatal sepsis is a leading cause of child mortality, and increasing antimicrobial resistance threatens progress towards the Sustainable Development Goals. Evidence to guide antibiotic treatment for sepsis in neonates and young infants from randomized controlled trials or observational studies in low- and middle-income countries (LMICs) is scarce. We aimed to describe patterns of antibiotic use, pathogens and outcomes in LMIC hospital settings globally to inform future clinical trials on the management of neonatal sepsis.Methods & FindingsHospitalised infants aged 206 different empiric antibiotic combinations were used, which were structured into 5 groups that were developed from the World Health Organisation (WHO) AWaRe classification. 25.9% (n=814) of infants started a WHO first line regimen (Group 1 -Access, penicillin-based regimen) and 13.8% (n=432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2- ‘Low’ Watch). The largest group (34.0%, n=1068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3 – ‘Medium’ Watch), 18.0% (n=566) started a carbapenem (Group 4 – ‘High’ Watch), and 1.8% (n=57) started a Reserve antibiotic (Group 5, largely colistin-based). Predictors of starting non-WHO recommended regimens included lower birth weight, longer in-hospital stay, central vascular catheter use, previous culture positive sepsis or antibiotic exposure, previous surgery and greater sepsis severity. 728/2880 (25.3%) of initial regimens in Group 1-4 were escalated, mainly to carbapenems, and usually for clinical indications (n=480; 65.9%).564 infants (17.6%) isolated a pathogen from their baseline blood culture, of which 62.9% (n=355) had a Gram-negative organism, predominantlyKlebsiella pneumoniae(n=132) andAcinetobacterspp. (n=72). These leading Gram-negatives were both mostly resistant to WHO-recommended regimens, and also resistant to carbapenems in 32.6% and 71.4% of cases respectively. MRSA accounted for 61.1% ofStaphylococcus aureus(n=54) isolates.Overall, 350/3204 infants died (11.3%; 95%CI 10.2-12.5%), with 17.7% case fatality rate among infants with a pathogen in baseline culture (95%CI 14.7-20.1%, n=99/564). Gram-negative infections accounted for 75/99 (75.8%) of pathogen-positive deaths, especiallyKlebsiella pneumoniae(n=28; 28.3%), andAcinetobacterspp. (n=24; 24.2%).ConclusionA very wide range of antibiotic regimens are now used to treat neonatal sepsis globally. There is common use of higher-level Watch antibiotics, frequent early switching and very infrequent de-escalation of therapy. Future hospital based neonatal sepsis trials will ideally need to account for the multiple regimens used as standard of care globally and include both empiric first line regimens and subsequent switching in the trial design.Author SummaryWhy was this study done?➢Increasing trends in antimicrobial resistance (AMR) disproportionately affect neonates and young infants with sepsis in LMIC settings and undermine the effectiveness of WHO-recommended antibiotics.➢Despite this, longitudinal data on antibiotic management strategies and outcomes of affected hospitalised neonates and young infants in LMIC settings are extremely limited, impeding the design of robust antibiotic trials.What did the researchers do and find?➢To our knowledge this is the first global, prospective, hospital-based observational study of clinically diagnosed neonatal sepsis across 4 continents including LMIC settings, with daily data on clinical status, antibiotic use and outcomes.➢There was a high mortality among infants with culture positive sepsis (almost 1 in 5), and a significant burden of antibiotic resistance.➢This study highlights wide variations in standard of care for sepsis in neonates and young infants with more than 200 different antibiotic combinations, significant divergence from WHO-recommended regimens, and frequent switching of antibiotics.What do these findings mean?➢These data demonstrate that patterns of routine antibiotic use are now markedly divergent from global guidance➢There is an urgent need for randomised controlled trials to address optimal empiric first and second line antibiotic treatment strategies in LMIC hospital settings with a significant AMR burden.➢Data from this study can inform the design of multicentre hospital-based neonatal antibiotic trials in LMIC settings.➢The wide range of multiple antibiotic regimens routinely used as Standard of Care (SOC) suggests the need for novel trial designs.