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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 15
| Issue : 3 | Page : 331-334 |
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Neonatal sepsis – Microbiological spectrum, antimicrobial sensitivity, and risk factors for mortality in newborn unit of rural teaching hospital: A retrospective study
Subhash Shankar Poyekar
Department of Pediatrics, Rural Medical College, Loni, Maharashtra, India
| Date of Submission | 03-Oct-2020 |
| Date of Decision | 15-Jun-2021 |
| Date of Acceptance | 19-Jun-2021 |
| Date of Web Publication | 15-Feb-2022 |
Correspondence Address:
Subhash Shankar Poyekar
B-502, Runwal Regency, Majiwade, Thane, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mjdrdypu.mjdrdypu_558_20
Background: Neonatal sepsis (NS) is one of the leading cause of neonatal mortality. In order to decrease the morbidity and mortality associated with neonatal sepsis, treating pediatrician/neonatologist should have a keen knowledge of the existing microbiological flora and their drug-susceptibility pattern. Hence, the present study was conducted with the objective to investigate the etiological agents, pattern of antimicribial sensitivity, and risk factors for mortality in neonates with culture-proven neonatal sepsis. Methods: A retrospective/cross-sectional study was conducted over a period of 24 months in teaching Rural Hospital, Maharashtra, India. Demographic data, type of isolates, and its sensitivity pattern were recorded. Results: Of the 343 blood samples sent during the study period from neonatal intensive care unit, 84 (24.5%) samples grew organisms. Early-onset sepsis (EOS) occurred in 58.1% of cases. Of the 74 bacterial isolates, 55.4% were Gram-positive organisms and 44.6% were Gram-negative pathogen. Candida species were identified in 11.9% neonates. Staphylococcus aureus (21.6%) and coagulase-negative Staphylococcus (CONS) (21.6%) were predominant Gram-positive pathogen. Klebsiella pneumoniae was the main Gram-negative pathogen (29.7%) followed by pseudomonas (6.76%). Gram-positive organisms (Staphylococcus and CONS) showed maximum sensitivity to vancomycin and linezolid. Survival rate among neonates with culture-positive sepsis was 78.6%. Conclusions: This study highlights growing resistance to commonly used antibiotics/antifungal agents posing a great threat to neonatal survival and thereby warrants the modification of existing empirical therapy. Implementation of effective preventive strategies to combat the emergence of antibiotic resistance is urgently needed.
Keywords: Antibiotics, bacteria, multidrug resistance, neonatal sepsis, neonate
How to cite this article:
Poyekar SS. Neonatal sepsis – Microbiological spectrum, antimicrobial sensitivity, and risk factors for mortality in newborn unit of rural teaching hospital: A retrospective study. Med J DY Patil Vidyapeeth 2022;15:331-4 |
How to cite this URL:
Poyekar SS. Neonatal sepsis – Microbiological spectrum, antimicrobial sensitivity, and risk factors for mortality in newborn unit of rural teaching hospital: A retrospective study. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:331-4. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/331/337704 |
| Introduction | |  |
Neonatal Sepsis (NS) is an important cause of morbidity and mortality. It contributes to 20% of neonatal mortality in India.[1] The incidence of sepsis is 30/1000 live births in hospital-based studies, and in community-based studies, the incidence is 2.7%–17% of all live births.[2],[3]
In early-onset sepsis, organisms responsible for sepsis originate mostly from maternal genital tract. However, the organisms of late-onset sepsis are either community-acquired or nosocomial. The contributory factors for nosocomial infection are prolonged hospitalization of very low birth weight neonate, use of central lines, catheter, and respiratory support.
The clinical diagnosis of neonatal sepsis is difficult due to its nonspecific presentations. Some of the clinical indicators are hypo/hyperthermia, lethargy, refusal of feeding, poor cry, respiratory distress, bradycardia/tachycardia, poor perfusion, and hypotonia.
The gold standard for the diagnosis of NS is a positive blood culture.[4] The real challenges in the management of neonatal sepsis are increasing prevalence of multidrug resistance pathogens and scarcity of newer effective antibiotics.
More common organisms were Gram negative bacteria as reported in various studies.[5],[6] Several recent studies have reported the emergence of organisms such as coagulase negative Staphylococci (CONS) and Candida spp. as a major pathogen for neonatal sepsis.[7] Microbiological flora and their resistance pattern of a unit also changes from time to time and they differ from place to place. Regular monitoring of pattern of causative organisms and drug resistance profile will help in decision-making. Hence, the present study was planned to evaluate the causative organisms of neonatal sepsis in a newborn unit of tertiary care center and their drug-sensitivity pattern.
| Methods | | |
Study design and study population
A retrospective record-based study was conducted in the neonatal intensive care unit (NICU) of Teaching Rural Hospital, situated in the rural part of Maharashtra. Approval of Institutional Ethics Committee was obtained. Patient's case records of culture confirmed sepsis admitted to NICU during a period of 2 years from April 2017 to March 2019 were reviewed using a predefined protocol for assessment.
Inclusion criteria
- All the blood culture-positive neonatal sepsis cases admitted to NICU were included in the study.
Exclusion criteria
- Neonates with multiple congenital malformation
- Neonates with complex congenital heart disease.
One to two milliliters venous blood was collected from the study participants and sent for blood culture inoculation. The samples were processed by standard bacteriological procedure. Semi-automated BACTEC was used for the diagnosis.
Antimicrobial susceptibility testing was also performed and categorized as sensitive or resistant.
For each neonate, information including gestational age, gender, weight, maternal, and perinatal history was recorded. Clinical examination findings at the time of enrollment, report of blood culture with sensitivity pattern, and outcome were also recorded. Data were entered into the personal computer. Data analysis, including descriptive statistics was done by using the SSPS version 16 (SSPS Inc. Chicago). Conclusions were drawn from the tabulated results.
| Results | | |
A total of 343 neonates were admitted with the diagnosis of clinical sepsis, of which 84 (24.5%) were culture proven. From those with culture confirmed neonates with neonatal sepsis, 48 (57.14%) were male, 57 (67.86%) were preterm babies, 70 (83.33%) were low-birth-weight babies, and 16 (19%) were small for gestational age babies.
The distribution of participants according to isolated organism and age of presentation is shown in [Table 1],[Table 2],[Table 3],[Table 4]. It was observed that bacterial isolation rate was more in neonates with Early onset septicemia (EOS) as compared to neonates with late-onset septicemia (LOS) which was statistically significant. | Table 2: Number of study subjects according to isolated organisms and onset of NS
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 | Table 3: Sensitivity pattern of isolated Gram + ve and Gram – ve organisms to differ ent antibiotics
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| Discussion | | |
Neonatal mortality is the major contributor for under-five mortality in developing countries. Early neonatal deaths are caused by prematurity and neonatal sepsis. Although bacteria are the most common agents implicated for neonatal sepsis, it is also caused by Candida species. Low proportion of the blood cultures from neonates with clinical sepsis come positive for pathogenic organisms.
During the study period of 2 years, 84 inborn neonates with septicemia confirmed by blood culture were included. Of which, 48 (57.14%) were male, 57 (67.86%) were preterm, 70 (83.33%) were low birth weight, and 55 (65.48%) were born of spontaneous vaginal delivery. Most of the cases either being LBW or preterm. Similar observation has been reported.[8],[9],[10]
Early-onset sepsis (58.1%) was more common than LOS(41.9%) in neonates with sepsis caused by bacterial pathogen. A similar observation was observed.[11] The EOS occurs due to ascending infection from infected birth canal and immaturity of immunological responses in the first few days of life.
In the present study, blood culture positivity was 24.5% (84 out of 343) neonates, which is comparable with studies from North India and Maharashtra.[12],[13] Gram-positive bacteria were the most commonly isolated organisms causing neonatal sepsis in this study; which is in congruent with the study reports from developing countries[14],[15] In most of the studies, Gram-negative organisms were major pathogen for neonatal septicemia.[5],[6],[16],[17] Candida spp. were identified in 10 (11.9%) neonates. Similar observation has been reported.[8]
Ampicillin and gentamycin are being used in our set up as empirical therapy. Unfortunately, most identified bacteria were resistant to Ampicillin. Similar observation has been reported.[18] The demonstrated high rate of antimicrobial resistance may be due to over-utilization of empiric therapy with these antibiotics for most other common neonatal problems.
Klebsiella pneumonia was found to be the predominant pathogen (29.73%) followed by Staphylococcus aureus  and CoNS accounting for (21.62%) cases each. Similar observation has been reported.[19] K. pneumoniae was reported as a predominant pathogen by Mane et al.[20] from India. Predominance of K. pneumonia as the causative agent of neonatal sepsis may be due to the selective pressure of using antimicrobial agents; so that resistant organisms tend to colonize and proliferate in the neonates. Meropenem was having higher sensitivity for K. pneumoniae.
The next common pathogen was S. aureus. It has been reported by Karthikeyan and Premkumar.[21] Gram-positive isolates showed a high degree of sensitivity to Vancomycin. Similar observation has been reported.[22] These findings have implications for therapy and infection control.
Since, K. pneumonia and S. aureus can survive in the environment for a relatively long time and fairly widely distributed in the hospital environment; they have the potential for being transmitted from the environment to the patients through practices that breach infection control measures.
Other organisms showed variable susceptibility patterns. Higher sensitivity for Meropenem and Aminoglycosides exhibited by most of the Gram-negative isolates and Gram-positive isolates. This could be explained by the use of these antibiotics as later options. Similar observation has been reported by Prabhu et al.[23]
Out of 84 culture-proven neonates, 18 (21.43%) death occurred during the study period. Gram-negative organisms responsible for death in neonates with culture proven NS, were Klebsiella (43.75%), followed by P. aeruginosa (12.5%) and Escherichia More Details Coli. Gram-positive organisms responsible for death in neonates with culture proven NS, were S. aureus and CONS. Birth weight <1000 Gm, lower gestational age, EOS, shorter stay in NICU, and sepsis due to Gram-negative organisms were the risk factors for mortality.
| Conclusions | | |
S. aureus, CoNS, and Klebsiella spp. were the leading pathogen of neonatal sepsis. The present study highlights growing resistance to commonly used antimicrobials. It reemphasizes the need to follow strict policy to use available antibiotics rationally. An effective infection-control program, regular antibiotic-susceptibility surveillance and evaluation, and periodic review of the antibiotic policy of the hospital may help to reduce the rates of acquiring nosocomial infections and development of bacterial resistance.
Acknowledgment
I acknowledge the help and support provided by the HOD and staff of Department of Microbiology Rural Medical College, Loni.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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