Neonatal sepsis in Karachi: factors determining outcome and mortality

Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital

Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.

Cost-effectiveness analysis of implementing an integrated neonatal care kit to reduce neonatal infection in rural Pakistan

OBJECTIVE

To evaluate the cost-effectiveness of distribution of the integrated neonatal care kit (iNCK) by community health workers from the healthcare payer perspective in Rahimyar Khan, Pakistan.

SETTING

Rahimyar Khan, Pakistan.

PARTICIPANTS

N/A.

INTERVENTION

Cost-utility analysis using a Markov model based on cluster randomised controlled trial (cRCT: NCT02130856) data and a literature review. We compared distribution of the iNCK to pregnant mothers to local standard of care and followed infants over a lifetime horizon.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was incremental net monetary benefit (INMB, at a cost-effectiveness threshold of US$15.50), discounted at 3%. Secondary outcomes were life years, disability-adjusted life years (DALYs) and costs.

RESULTS

At a cost-effectiveness threshold of US$15.50, distribution of the iNCK resulted in lower expected DALYs (28.7 vs 29.6 years) at lower expected cost (US$52.50 vs 55.20), translating to an INMB of US$10.22 per iNCK distributed. These results were sensitive to the baseline risk of infection, cost of the iNCK and the estimated effect of the iNCK on the relative risk of infection. At relative risks of infection below 0.79 and iNCK costs below US$25.90, the iNCK remained cost-effective compared with current local standard of care.

CONCLUSION

The distribution of the iNCK dominated the current local standard of care (ie, the iNCK is less costly and more effective than current care standards). Most of the cost-effectiveness of the iNCK was attributable to a reduction in neonatal infection.

Frequency of Early-onset Neonatal Sepsis Following Prolonged Rupture of Membranes

Introduction In developing countries, sepsis and associated mortality rates in neonatal patients is a serious concern. To improve the outcomes and mortality posed by sepsis, physicians need to know the local epidemiology of the microbial pathogens and their resistance patterns to antimicrobial agents. Therefore, our aim was to determine the frequency of early-onset neonatal sepsis (EONS) following prolonged rupture of membranes (PROM). Materials and methods After approval from the ethical review committee, this cross-sectional study was conducted at a tertiary care hospital of a developing country, and informed consent was taken from patients' parents. All neonates born to a mother with PROM after 24 weeks of gestation up to seven days of life were included. Demographic features, signs of sepsis, blood culture results, and laboratory markers of sepsis were recorded. All data were analyzed by using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Results A total of 124 patients were enrolled in the study. Seven neonates (5.6%) developed EONS and positive cultures were seen in four neonates (3.2%) with a maternal history of PROM. The organisms identified in cultures were Klebsiella pneumonia, group B streptococcus, Staphylococcus aureus, and Streptococcus species in EONS caused by prolonged PROM. Conclusions Early recognition of risk factors, recognition of clinical conditions with prompt laboratory screening for infection, and early establishment of empirical antibiotic treatment are effective preventive measures. Such approaches would be a secure and efficient strategy, particularly in developing countries.

Predictors of mortality in outborns with neonatal sepsis: A prospective observational study

Background

Neonatal sepsis-related mortalities are the outcome of a complex interaction of maternal-foetal colonisation, transplacental immunity and physical and cellular defence mechanisms of neonates.

Objective

The objective of this study was to evaluate the risk factors of mortality in outborn neonatal sepsis.

Materials and Methods

A 1-year prospective observational study was undertaken at a tertiary care centre. All referred neonates with maternal and neonatal risk factors of sepsis were enrolled. Blood culture, sepsis screen and other relevant investigations were performed.

Results

The mortality rate of neonatal sepsis among outborns was 38.24%. The common presentations of these neonates were respiratory distress, lethargy and hypothermia. On univariate analysis, significant risk factors for mortality included male sex (P = 0.05), weight on admission <1500 g (P < 0.001), hypothermia (P = 0.003), respiratory distress (P = 0.04), cyanosis (P = 0.001), convulsions (P = 0.02), prolonged capillary refill time (P < 0.001), thrombocytopenia (P < 0.001), abnormal radiological finding (P = 0.01), cerebrospinal fluid cellularity (P = 0.002) and positive C-reactive protein (P < 0.001). Maternal factors such as hypertension in pregnancy (P = 0.001) and antepartum haemorrhage (P = 0.03) were associated with statistically significant mortality. Gestational age (odds ratio [OR]: 0.49, confidence interval [CI]: 0.26-0.90, P = 0.02), weight on admission (OR: 1.57, CI: 1.08-2.27, P = 0.01), age at admission (OR: 0.89, CI: 0.78-0.99, P = 0.04), distance travelled with neonate (OR: 1.01, CI: 1.00-1.01, P = 0.003), duration of hospital stay (OR: 0.69, CI: 0.63-0.74, P < 0.001), hypothermia (OR: 1.87, CI: 1.01-3.42, P = 0.04), convulsion (OR: 2.88, CI: 1.33-6.20, P = 0.007), cyanosis (OR: 2.39, CI: 1.07-5.35, P = 0.03) and prolonged capillary refill time (OR: 3.34, CI: 1.78-6.24, P < 0.001) were the independent predictors of mortality in neonatal sepsis.

Conclusion

Gestational age; birth weight; long distance travelled with neonate and presentation with hypothermia, cyanosis, convulsions and prolonged capillary refill time were the independent risk factors for mortality in neonatal sepsis among outborns.

Etiology of early onset neonatal sepsis in neonatal intensive care unit - Mansoura, Egypt

INTRODUCTION

This study was conducted to find out the bacterial causes of early onset neonatal sepsis and their susceptibility pattern for different classes of antibiotics in neonates admitted to neonatal intensive care unit (NICU) of Mansoura-Egypt.

METHODS

A descriptive cross-sectional study was conducted. All admitted newborns to our study were infants at <72 hours of age with clinical features of sepsis or product of an in-house delivery at Mansoura University Hospital with risk factors for neonatal sepsis. Identification of Gram-negative isolates was confirmed by API 20E kits (bioMerieux). Antibiotic susceptibility was performed by Kirby-Bauer disc diffusion method. Bacteria resistant to ≥3 antimicrobial classes were counted as multidrug resistant.

RESULTS

One hundred eighty eight babies were admitted to our study. Positive blood culture was reported in 34.6% of newborn infants with prevalence of 4.02/1,000 live births. The most common isolated bacteria in early onset neonatal sepsis were coagulase negative staphylococci followed by Klebsiella pneumoniae and Serratia marcescens. The Gram-positive bacteria showed high resistance to ampicillin 93.9% while all the isolates were susceptible to vancomycin. The isolated Gram-negative bacteria were highly resistant to ampicillin [96.9%], amoxicillin-clavulanic acid [90.6%], cefotaxime [84.4%] and ceftazidime [84.4%]. Best sensitivity among all isolates was observed to imipenem. Multidrug resistance was observed among 45.5% of the Gram-positive and 68.8% of Gram-negative isolates.

CONCLUSION

Appropriate identification of the source of infection and initiation of an effective management can reduce both mortality and morbidity associated with neonatal sepsis. The challenge is to initiate immediate empirical antibiotic therapy according to a strictly implemented updated antibiotic policy based on an individualized community established antimicrobial sensitivity pattern of microorganisms causing early onset neonatal sepsis.

Effect of emollient therapy on clinical outcomes in preterm neonates in Pakistan: a randomised controlled trial

IMPORTANCE

Newborn oil massage, a traditional community practice, could potentially benefit thermoregulation and skin barrier function, and prevent serious infections, morbidity and mortality in high-risk preterm infants, but has only been evaluated in limited studies in low income settings.

OBJECTIVES

To assess the efficacy of topical coconut oil applications among a cohort of hospital-born preterm infants.

DESIGN

A prospective, individually randomised controlled clinical trial.

SETTING

Nursery and neonatal intensive care unit at Aga Khan University Hospital, Pakistan.

PARTICIPANTS

Of 270 eligible neonates, a consecutive cohort of 258 hospital-born preterm infants (gestational age ≥26 weeks and ≤37 weeks).

INTERVENTION

Twice daily topical application of coconut oil by nurses from birth until discharge and continued thereafter by mothers at home until completion of the 28th day of life.

PRIMARY OUTCOME MEASURES

Incidence of hospital-acquired bloodstream infections.

SECONDARY OUTCOME MEASURES

Weight gain, skin condition and neonatal mortality.

RESULTS

23% of the enrolled neonates developed clinically suspected sepsis while 14% developed blood culture proven infection. The unadjusted hazard for developing hospital-acquired infection in the control group was 4.7 (95% CI 1.8 to 12.4) compared with the intervention group. After adjusting for gestational age, birth weight, duration of intubation and duration of hospitalisation for possible confounding, the hazard for hospital-acquired infection in the control group was 6.0 (95% CI 2.3 to 16) compared with the intervention group. The rate of hospital-acquired infections in the control and intervention groups was 219.1 and 39.5 per 1000 patient-days, respectively. Mean weight gain was 11.3 g/day higher (95% CI 8.1 to 14.6, p<0.0001) and average skin condition was significantly better in the intervention group when compared with controls. There was no significant impact on duration of hospitalisation or neonatal mortality. No adverse effects such as local irritation or local infection were observed among newborns receiving coconut oil applications.

CONCLUSIONS

Topical emollient therapy was effective in maintaining skin integrity and reducing the risk of bloodstream infection in preterm infants in a tertiary hospital setting in Pakistan. The effectiveness of this approach in primary care settings needs to be further explored.

TRIAL REGISTRATION NUMBER

NCT01396642.

Types of Bacteria associated with Neonatal Sepsis in Al-Thawra University Hospital, Sana'a, Yemen, and their Antimicrobial Profile

OBJECTIVES

This study was undertaken to investigate the organisms causing sepsis in the Neonatal Unit at Al-Thawra Hospital, Sana'a, Yemen, determine their resistance to antibiotics, and recommend policy for empirical treatment.

METHODS

A total of 158 neonates having one or more signs of sepsis, and aged from 0 to 28 days, were enrolled in this study. A blood sample was taken from each subject, cultured, and then antibacterial susceptibility tests were performed for isolates.

RESULTS

90 (57%) cases yielded positive cultures. Early-onset sepsis showed higher positive culture results (61.7%) than late-onset sepsis (32%). Significant positive culture results were found among the group with birth weight 0.9-2 Kg (78.6%). Gram negative bacteria constituted 97.8% of the total isolates, of which Klebsiella pneumoniae was the predominant pathogen (36.7%), followed by Pseudomonas species (30.0%). The commonest symptoms among the cases were respiratory distress (72.2%), jaundice (62.2%), cyanosis (51.1%), and lethargy (47.8%); the mortality rate was 27.8%. All Gram negative bacterial isolates were sensitive to imipenem and some isolates were sensitive to fourth-generation cephalosporins, but most isolates were highly resistant to the majority of other antibiotics tested.

CONCLUSION

Gram negative organisms were the most frequent causative agents of bacterial sepsis, which is a significant cause of mortality and morbidity in the newborn, and particularly in those of very low birth weight. It can also be concluded that imipenem and fourth-generation cephalosporins can be used for empirical treatment of bacterial sepsis.

Effect of case management on neonatal mortality due to sepsis and pneumonia

Background

Each year almost one million newborns die from infections, mostly in low-income countries. Timely case management would save many lives but the relative mortality effect of varying strategies is unknown. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST).

Methods

We conducted systematic searches of multiple databases to identify relevant studies with mortality data. Standardized abstraction tables were used and study quality assessed by adapted GRADE criteria. Meta-analyses were undertaken where appropriate. For interventions with biological plausibility but low quality evidence, a Delphi process was undertaken to estimate effectiveness.

Results

Searches of 2876 titles identified 7 studies. Among these, 4 evaluated oral antibiotics for neonatal pneumonia in non-randomised, concurrently controlled designs. Meta-analysis suggested reductions in all-cause neonatal mortality (RR 0.75 95% CI 0.64- 0.89; 4 studies) and neonatal pneumonia-specific mortality (RR 0.58 95% CI 0.41- 0.82; 3 studies). Two studies (1 RCT, 1 observational study), evaluated community-based neonatal care packages including injectable antibiotics and reported mortality reductions of 44% (RR= 0.56, 95% CI 0.41-0.77) and 34% (RR =0.66, 95% CI 0.47-0.93), but the interpretation of these results is complicated by co-interventions. A third, clinic-based, study reported a case-fatality ratio of 3.3% among neonates treated with injectable antibiotics as outpatients. No studies were identified evaluating injectable antibiotics alone for neonatal pneumonia. Delphi consensus (median from 20 respondents) effects on sepsis-specific mortality were 30% reduction for oral antibiotics, 65% for injectable antibiotics and 75% for injectable antibiotics on pneumonia-specific mortality. No trials were identified assessing effect of hospital management for neonatal infections and Delphi consensus suggested 80%, and 90% reductions for sepsis and pneumonia-specific mortality respectively.

Conclusion

Oral antibiotics administered in the community are effective for neonatal pneumonia mortality reduction based on a meta-analysis, but expert opinion suggests much higher impact from injectable antibiotics in the community or primary care level and even higher for facility-based care. Despite feasibility and low cost, these interventions are not widely available in many low income countries.

Funding

This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.

Predictors of mortality in neonatal septicemia in an underresourced setting

OBJECTIVE

To determine the predictors of mortality in neonatal septicemia.

METHOD

The records of babies with culture-proven septicemia managed in a Nigerian newborn unit between 2006 and 2008 were studied using bivariate and multivariate analysis.

RESULTS

Out of 174 babies with septicemia, 56 (32.2%) died. Outborn babies, babies with estimated gestational age (EGA) less than 32 weeks, weight less than 1.5 kg, temperature less than 38 degrees C, respiratory distress, abdominal distension, poor skin color, hypoglycemia, and infection with gram-negative pathogens were significantly associated with death by bivariate analysis. Multivariate analysis of these risk factors confirmed that EGA less than 32 weeks (odds ratio [OR], 5.5), respiratory distress (OR, 3.4), abdominal distension (OR, 2.7), poor skin color (OR, 3.3), and hypoglycemia (OR, 5.2) had significant independent contributions to the occurrence of death among babies with culture-proven septicemia.

CONCLUSION

Most of the identified predictors of mortality are modifiable and can be used to draw up a screening tool to determine the clinical severity among septic babies.

Pathophysiology and treatment of septic shock in neonates

Neonatal septic shock is a devastating condition associated with high morbidity and mortality. Definitions for the sepsis continuum and treatment algorithms specific for premature neonates are needed to improve studies of septic shock and assess benefit from clinical interventions. Unique features of the immature immune system and pathophysiologic responses to sepsis, particularly those of extremely preterm infants, necessitate that clinical trials consider them as a separate group. Keen clinical suspicion and knowledge of risk factors will help to identify those neonates at greatest risk for development of septic shock. Genomic and proteomic approaches, particularly those that use very small sample volumes, will increase our understanding of the pathophysiology and direct the development of novel agents for prevention and treatment of severe sepsis and shock in the neonate. Although at present antimicrobial therapy and supportive care remain the foundation of treatment, in the future immunomodulatory agents are likely to improve outcomes for this vulnerable population.

Risk Factors of Neonatal Sepsis: A Preliminary Study in Dr. Soetomo Hospital

The risk factors of developing neonatal sepsis could be caused by maternal and neonatal risk factors. Objective to determine the characteristics and risk factors for neonatal sepsis. Study design was case control study. The data of neonates were taken from the medical record. Neonates who were admitted in neonatal care unit of Dr. Soetomo hospital were included at January 2010 to February 2010, and divided into 2 groups, one group was sepsis cases and other group was non sepsis cases as a control. The risk factors that associated with sepsis were studied. Chi square and logistic regression analysis were used to analyze the data. 97 patients were includedand 31were sepsis cases and non sepsis case were 66. The risk factors that significantly cause sepsis are low birth weight (p=0.001 OR 2.75, 95% CI 1.454–5.200) , prematurity (p=0.000, OR 4.073, 95% CI 2.180–7.609), meconeal amniotic fluid (p=0.029, OR 2.535,95% CI 1.225–5.245) and C-section (p=0.032, OR 1.895, 95% CI 1.087–3.303). The significant risk factors of the neonatal sepsis arelow birth weight, prematurity, meconeal amniotic fluid, and caesarian section

Serious community-acquired neonatal infections in rural Southeast Asia (Bohol Island, Philippines)

OBJECTIVE

To determine the bacterial etiology, clinical presentation and risk factors for outcome of serious community-acquired infections in young infants.

STUDY DESIGN

Infants younger than 60 days, admitted for severe pneumonia or suspected sepsis/meningitis were prospectively evaluated using complete blood count, blood culture, chest radiograph, cerebrospinal fluid (CSF) culture in suspected meningitis. chi2 or Fisher's exact test and stepwise logistic regression were used for analysis.

RESULTS

Thirty-four of 767 enrolled infants had a positive blood or CSF culture. Gram-negative bacteria were more frequent than Gram positive: overall (P=0.004), in those below 7 days of age (P=0.002) and among home deliveries (P=0.012). Case fatality rates were higher among infants below 1 week old (OR 4.14, P<0.001), those with dense (OR 2.92, P<0.001) or diffuse radiographic infiltrates (OR 2.79, P=0.003).

CONCLUSIONS

Gram-negative enteric bacteria are the predominant causes of community-acquired infections in Filipino infants below 2 months old. Age below 7 days and radiographic pneumonia predicted death.

Serious bacterial infections in newborn infants in developing countries

PURPOSE OF REVIEW

The overwhelming majority of the world's annual 4 million neonatal deaths occur in developing countries. This review therefore briefly addresses the burden, aetiology, prevention and management of serious neonatal bacterial infections in low-income settings.

RECENT FINDINGS

Bacterial infection is the biggest cause of neonatal admissions to hospitals, and probably the biggest cause of morbidity in the community, but its burden is unclear. The commonest serious infections involve bacteraemia, meningitis and respiratory infection, and case fatality rates may be as high as 45%. Key pathogens are Escherichia coli, Klebsiella species, Staphylococcus aureus and Streptococcus pyogenes. The incidence of neonatal infections with group B streptococcus is highly variable, as is the spectrum of antimicrobial resistance.

SUMMARY

Current areas of research include the rectification of micronutrient deficiencies, neonatal skin care, appropriate breastfeeding recommendations, cleansing of the birth canal, and simplified methods of diagnosis of infection. Operational activities include the control of neonatal tetanus, the diagnosis and treatment of sexually transmitted infections, integrated strategies for improving pregnancy, childbirth and neonatal survival, community-based management of acute respiratory infections, and community-based management of neonatal sepsis.

Multidrug resistant neonatal sepsis in Peshawar, Pakistan

OBJECTIVE

To investigate the spectrum of organisms causing neonatal sepsis in Peshawar, Pakistan and to assess their sensitivity to various groups of drugs.

METHODS

Blood taken from newborn babies admitted to the special care baby unit at the Khyber Teaching Hospital with a clinical diagnosis of neonatal sepsis was cultured. The data obtained from October 1997 to December 2000 were analysed and the results tabulated.

RESULTS

A total of 1598 blood cultures were taken; 1003 were positive (positivity rate 62.8%). Escherichia coli was the most common organism found (36.6%), followed by Staphylococcus aureus (29.5%), Pseudomonas (22.4%), Klebsiella (7.6%), and Proteus (3.8%). No group B streptococcus was grown. Listeria monocytogenes was found in one cerebrospinal fluid culture. E coli and Pseudomonas showed a high degree of resistance to commonly used antibiotics (ampicillin, augmentin, and gentamicin), a moderate degree of resistance to cephalosporin (cefotaxime, ceftzidime, and ceftrioxone), and low resistance to drugs not used for newborn babies (ofloxacin, ciprofloxacin, and enoxabid). S aureus showed a low resistance to all three groups of antibiotics.

CONCLUSION

Neonatal sepsis remains one of the leading causes of neonatal admission, morbidity, and mortality in developing countries. Gram negative organisms are the major cause of neonatal sepsis in Peshawar. Such organisms have developed multidrug resistance, and management of patients infected with them is becoming a problem in developing countries.

Clinico-bacteriological study of neonatal septicemia in Hubli

Septicemia is a leading cause of neonatal morbidity and mortality in India. In a study of 242 infants with septicemia conducted between March 1996 & June 1997 at Hubli, Karnataka, 43.39% infants had 'very early onset' sepsis (VOS), 40.08%, had 'early onset' sepsis (EOS), and 16.53% 'late onset' sepsis (LOS). 54.55% neonates had birth weight below 2000 g and 39.67% were born before 37 weeks of gestation. The cardiorespiratory signs and jaundice were the most frequent clinical features. The blood culture positivity rate was 64.87%. Klebsiella species was the commonest causative pathogen found and multidrug resistance was frequent. The overall mortality rate was 47.52% and the case fatality rate in LOS was higher than in VOS and EOS (p < 0.001). The mortality was significantly higher in neonates with lower birth weight and lower gestational age (p < 0.001). The study underlines the importance of monitoring the various features of neonatal septicemia, as well as the drug resistance of the pathogens from the nurseries.