Bacteriological profile and antibiotic susceptibility of neonatal sepsis in neonatal intensive care unit of a tertiary hospital in Nepal

Beyond Early- and Late-onset Neonatal Sepsis Definitions: What are the Current Causes of Neonatal Sepsis Globally? A Systematic Review and Meta-analysis of the Evidence

Sepsis remains a leading cause of neonatal mortality, particularly in low- and lower-middle-income countries (LLMIC). In the context of rising antimicrobial resistance, the etiology of neonatal sepsis is evolving, potentially making currently-recommended empirical treatment guidelines less effective. We performed a systematic review and meta-analysis to evaluate the contemporary bacterial pathogens responsible for early-onset sepsis (EOS) and late-onset neonatal sepsis (LOS) to ascertain if historical classifications-that guide empirical therapy recommendations based on assumptions around causative pathogens-may be outdated. We analyzed 48 articles incorporating 757,427 blood and cerebrospinal fluid samples collected from 311,359 neonates across 25 countries, to evaluate 4347 significant bacteria in a random-effects meta-analysis. This revealed gram-negative bacteria were now the predominant cause of both EOS (53%, 2301/4347) and LOS (71%, 2765/3894) globally. In LLMICs, the predominant cause of EOS was Klebsiella spp. (31.7%, 95% CI: 24.1-39.7%) followed by Staphylococcus aureus (17.5%, 95% CI: 8.5 to 28.4%), in marked contrast to the Streptococcus agalactiae burden seen in high-income healthcare settings. Our results reveal clear evidence that the current definitions of EOS and LOS sepsis are outdated, particularly in LLMICs. These outdated definitions may be guiding inappropriate empirical antibiotic prescribing that inadequately covers the causative pathogens responsible for neonatal sepsis globally. Harmonizing sepsis definitions across neonates, children and adults will enable a more acurate comparison of the epidemiology of sepsis in each age group and will enhance knowledge regarding the true morbidity and mortality burden of neonatal sepsis.

Characterization of Clinical Presentation, Etiology, and Antibiotic Sensitivity Patterns in Neonatal Septicemia: A Comprehensive Analysis of Bacterial Isolates

BACKGROUND

Neonatal septicemia remains a significant healthcare challenge, particularly in resource-limited settings, with both early-onset neonatal septicemia (EONS) and late-onset neonatal septicemia (LONS) presentations contributing to morbidity and mortality. This study aimed to characterize the clinico-etiological profile and antibiotic susceptibility patterns of neonatal septicemia in a tertiary care setting in north India.

METHODOLOGY

An analytical cross-sectional study was conducted from March 2021 to February 2022, encompassing neonates admitted to the Department of Pediatrics with suspected neonatal septicemia, confirmed by positive blood cultures.

RESULTS

A total of 96 neonates were included, predominantly male (71.9%). Gram-negative bacteria constituted 61.6% of isolates, and the most common organism isolated was non-lactose fermenter group (38.4%) followed by coagulase-negative staphylococci (CoNS) (33.4%). Non-lactose fermenter group bacteria were prominent in EONS cases (44.6%), while CoNS predominated in LONS cases (51.6%). Birthplace, birth weight, and perinatal score were significantly associated with both EONS and LONS. Linezolid exhibited high efficacy against gram-positive bacteria, while ciprofloxacin and meropenem demonstrated effectiveness against various gram-negative pathogens. Methicillin-resistant Staphylococcus aureus (MRSA) strains exhibited resistance to all the antibiotics used in the study except for linezolid.

CONCLUSION

These findings underscore the importance of tailored empirical therapy guided by local epidemiological data to optimize clinical outcomes and mitigate antimicrobial resistance.

Assessment of three antibiotic combination regimens against Gram-negative bacteria causing neonatal sepsis in low- and middle-income countries

Gram-negative bacteria (GNB) are a major cause of neonatal sepsis in low- and middle-income countries (LMICs). Although the World Health Organization (WHO) reports that over 80% of these sepsis deaths could be prevented through improved treatment, the efficacy of the currently recommended first- and second-line treatment regimens for this condition is increasingly affected by high rates of drug resistance. Here we assess three well known antibiotics, fosfomycin, flomoxef and amikacin, in combination as potential antibiotic treatment regimens by investigating the drug resistance and genetic profiles of commonly isolated GNB causing neonatal sepsis in LMICs. The five most prevalent bacterial isolates in the NeoOBS study (NCT03721302) are Klebsiella pneumoniae, Acinetobacter baumannii, E. coli, Serratia marcescens and Enterobacter cloacae complex. Among these isolates, high levels of ESBL and carbapenemase encoding genes are detected along with resistance to ampicillin, gentamicin and cefotaxime, the current WHO recommended empiric regimens. The three new combinations show excellent in vitro activity against ESBL-producing K. pneumoniae and E. coli isolates. Our data should further inform and support the clinical evaluation of these three antibiotic combinations for the treatment of neonatal sepsis in areas with high rates of multidrug-resistant Gram-negative bacteria.

Reintroduction of Legacy Antibiotics in Neonatal Sepsis: The Special Role of Fosfomycin and Colistin

Neonatal sepsis is a leading cause of morbidity and mortality in neonates, particularly in low- and middle-income countries. The emergence of antimicrobial resistance is a rapidly growing global problem. A significant proportion of the pathogens that commonly cause neonatal sepsis are resistant to multiple antibiotics. Therefore, for the empirical treatment of neonatal sepsis, the repurposing of older antibiotics that are effective against multidrug-resistant pathogens is being investigated. This review aims to provide an overview of current research and experience using the repurposed antibiotics colistin and fosfomycin for the empirical treatment of neonatal sepsis. Based on current knowledge, colistin and fosfomycin may be potentially helpful for the empirical treatment of sepsis in neonates due to their efficacy against a wide range of pathogens and acceptable safety profile.

Prevalence and antibiotic resistance pattern of bacteria from sepsis suspected neonates at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

BACKGROUND

Neonatal sepsis is the major cause of neonatal mortality and morbidity, especially in low and middle-income countries. Continuous monitoring of pathogens and their antibiotic resistance pattern is crucial for managing neonatal sepsis. This study aimed to determine neonatal sepsis due to bacteria, antibiotic resistance patterns, associated risk factors and patient outcomes at St. Paul's Hospital Millennium Medical College.

METHOD

An institutional-based cross-sectional study was conducted on 400 neonates suspected of sepsis at St. Paul's Hospital Millennium Medical College from March 2020 to July 2020. A questionnaire was used to collect socio-demographic information, clinical parameters and potential risk factors from study participants. About 2ml of blood was drawn aseptically and inoculated into Tryptone Soya Broth at the patient's bedside. Bacterial identification was performed by using standard microbiological techniques. The disk diffusion method was used to determine the antibiotic susceptibility patterns of each isolated bacteria. Data entry and analysis were done using Statistical Package for Social Sciences (SPSS) version 20 software. Bivariate and multivariable logistic regressions were used to assess associated risk factors of neonatal sepsis. A p-value less than 0.05 was considered statically significant with a 95% confidence interval.

RESULTS

The overall prevalence of neonatal septicemia was 21% (84/400). Of these, 67 (79.8%) and 17 (20.2%) were gram-negative and gram-positive bacteria, respectively. Klebsiella spp, 37 (44%), E. coli 19 (21.6%) and Coagulase negative Staphylococci 13 (15.47%) were the leading cause of neonatal sepsis. Ciprofloxacin and amikacin were the most effective antibiotics for gram-negative and gram-positive bacteria. Multidrug resistance was observed in 84% of the bacterial isolates. Low birth weight and preterm were associated with neonatal septicemia (AOR = 49.90, 95% CI = 15.14-123.081, P = 0.002) and (AOR = 18.20, 95% CI = 6.835-27.541, P = 0.004) respectively.

CONCLUSION

Klebsiella spp and E. coli were frequently isolated bacteria in our study. The proportion of multidrug-resistance was significantly high. Most isolated bacteria were resistant to ampicillin, ceftazidime, cefotaxime and gentamycin, which indicates the necessity of continuous evaluation of antibiotic resistance rate.

Association between vancomycin therapeutic drug monitoring and clinical outcomes in treating neonatal sepsis

BACKGROUND

Neonatal sepsis is commonly treated with vancomycin in the neonatal intensive care unit. Therapeutic drug monitoring of vancomycin is routinely used to personalise dosing to optimise effectiveness and avoid toxicity.

OBJECTIVES

This study aimed to define a target range by evaluating associations between vancomycin trough concentrations or area under the concentration time curve over 24 hours (AUC24h) and clinical outcomes in neonates.

METHODS

Neonates, who were admitted to the neonatal intensive care unit and received intravenous vancomycin, were included in this retrospective cohort study. For evaluating effectiveness, patients who received vancomycin for < 5 days were excluded. The AUC24h was estimated based on a study-derived population pharmacokinetic model. Primary outcomes were persistent/recurrent infections and mortality within 30 days. Secondary outcomes, including acute kidney injury (AKI), were also assessed. Logistic regression and classification and regression tree analyses were performed.

RESULTS

A total of 448 patients (123 patients for effectiveness analysis) were included. A vancomycin trough > 10 mg/L was associated with 70% lower odds of persistent/recurrent infections (adjusted OR 0.30, 95% CI 0.09-0.86; P = 0.023). Patients who took more than a day to reach target range had 1.4 times higher odds of persistent/recurrent infections or death (P = 0.04). A vancomycin trough > 15 mg/L was associated with a three times higher risk of AKI (P = 0.003). An AUC24h of 420-650 mg*h/L was also associated with the lowest risk of composite outcomes (adjusted OR 0.29, 95% CI 0.08-0.86; P = 0.025).

CONCLUSION

A vancomycin trough target range of 10-15 mg/L and achievement of this target within a day of treatment initiation were associated with the most optimal clinical outcomes in treating neonatal sepsis.

A real-world cost-effectiveness study of vancomycin versus linezolid for the treatment of late-onset neonatal sepsis in the NICU in China

BACKGROUND AND OBJECTIVE

Currently, the detection rates of methicillin-resistant S. aureus (MRSA) and methicillin-resistant coagulase-negative staphylococci (MRCoNS) in the blood cultures of neonates with sepsis exceed the national average drug resistance level, and vancomycin and linezolid are the primary antibacterial drugs used for these resistant bacteria according to the results of etiological examinations. However, a comprehensive evaluation of their costs and benefits in late-onset neonatal sepsis in a neonatal intensive care unit (NICU) has not been conducted. This study aimed to compare the cost and effectiveness of vancomycin and linezolid in treating neonatal sepsis in the NICU.

METHODS

A cost-effectiveness analysis of real-world data was carried out by retrospective study in our hospital, and the cost and effectiveness of vancomycin and linezolid were compared by establishing a decision tree model. The drug doses in the model were 0.6 g for linezolid and 0.5 g for vancomycin. The cost break down included cost of medical ward, NICU stay, intravenous infusion of vancomycin or linezolid, all monitoring tests, culture tests and drugs. The unit costs were sourced from hospital information systems. The effectiveness rates were obtained by cumulative probability analysis. One-way sensitivity analysis was used to analyze uncertain influencing factors.

RESULTS

The effectiveness rates of vancomycin and linezolid in treating neonatal sepsis in the NICU were 89.74% and 90.14%, respectively, with no significant difference. The average cost in the vancomycin group was ¥12261.43, and the average cost in the linezolid group was ¥17227.96. The incremental cost effectiveness was ¥12416.33 cost per additional neonate with treatment success in the linezolid group compared to vancomycin group at discharge. Factors that had the greatest influence on the sensitivity of the incremental cost-effectiveness ratio were the price of linezolid and the effectiveness rates.

CONCLUSIONS

The cost for treatment success of one neonate in linezolid group was ¥5449.17 more than that in vancomycin group, indicating that vancomycin was more cost-effective. Therefore, these results can provide a reference for a cost effectiveness treatment scheme for neonatal sepsis in the NICU.

Prevalence of multidrug-resistant and extensively drug-resistant phenotypes of Gram-negative bacilli isolated in clinical specimens at Centre Hospitalo-Universitaire Ibn Rochd, Morocco

Introduction

antimicrobial resistance in gram-negative bacilli is one of the major concerns in public health. We aimed to evaluate gram-negative bacilli epidemiology, antimicrobial profiles, and the resistance´s mechanism for Enterobacteriaceae isolated from specimens of hospitalized patients in wards of University Hospital Center Ibn Rochd of Casablanca, Morocco.

Methods

a prospective study of the patient's specimens, collected from December 2016 to 31st March 2017. Isolation and identification were performed using conventional biochemical tests. According to the European Committee on Antimicrobial Susceptibility Testing guidelines, antibiotic susceptibility was determined. Polymerase Chain Reaction (PCR) was used to detect β-lactamase and carabapenemase genes: CTX-M, SHV, TEM, OXA-48, NDM, and VIM among the Enterobacteriaceae.

Results

according to inclusion criteria, 38 Enterobacteriaceae, 25 Acinetobacter baumannii (A. baumannii), and 10 Pseudomonas aeruginosa (P. aeruginosa) were included during the study period; these bacteria were mainly responsible for bacteremia. Fifty-five percent of enterobacteria were extended-spectrum β-lactamase (ESBL), 42% EBSL and carbapenemase, and 3% carbapenemase, with high coresistances. Eighty-four percent of A. baumannii were XDR. All P. aeruginosa were MDR; amikacin showed the best activity (70% susceptibility). The genotypic approach revealed the presence of blaCTX-M, blaSHV, blaTEM in 68%, 22%, and 11% respectively. Of the 22 carbapenemase-producers, 41% were blaOXA-48 and 18% blaNDM; none had blaVIM. Furthermore, various genes coexistence were detected: blaCTX-M+blaOXA-48; blaCTX-M+blaNDM; blaCTX-M+blaSHV+blaOXA-48; and blaSHV+blaOXA-48.

Conclusion

findings revealed highly resistance rate among isolates. This raises the need to control antibiotics and regular screening to identify dynamics promoting resistance. Thus, we recommend developing antimicrobial stewardship programs and improving hygiene systems to prevent the nosocomial spreading of these phenotypes in our center.

Recent Advances in Monoclonal Antibody-Based Approaches in the Management of Bacterial Sepsis

Sepsis is a life-threatening condition characterized by an uncontrolled inflammatory response to an infectious agent and its antigens. Immune cell activation against the antigens causes severe distress that mediates a strong inflammatory response in vital organs. Sepsis is responsible for a high rate of morbidity and mortality in immunosuppressed patients. Monoclonal antibody (mAb)-based therapeutic strategies are now being explored as a viable therapy option for severe sepsis and septic shock. Monoclonal antibodies may provide benefits through two major strategies: (a) monoclonal antibodies targeting the pathogen and its components, and (b) mAbs targeting inflammatory signaling may directly suppress the production of inflammatory mediators. The major focus of mAb therapies has been bacterial endotoxin (lipopolysaccharide), although other surface antigens are also being investigated for mAb therapy. Several promising candidates for mAbs are undergoing clinical trials at present. Despite several failures and the investigation of novel targets, mAb therapy provides a glimmer of hope for the treatment of severe bacterial sepsis and septic shock. In this review, mAb candidates, their efficacy against controlling infection, with special emphasis on potential roadblocks, and prospects are discussed.

Reduction of antibiotic use and multi-drug resistance bacteria infection in neonates after improvement of antibiotics use strategy in a level 4 neonatal intensive care unit in southern China

The investigation on antibiotic stewardship in neonatal intensive care unit in China is scarce. This study aimed to analyze the effect of a comprehensive 2-year antibiotic stewardship in a level 4 NICU. During this baseline period from October 1st 2017 to October 1st 2019, continuation of empirical antibiotic therapy for ruled-out sepsis courses was beyond 72 h and for pneumonia was more than 7 days. Meropenem or vancomycin was used even if they were not the only bacterial sensitive antibiotics. The intervention period was from October 2nd 2019 to August 23rd 2021. Three areas for quality improvement were targeted in our center: discontinuation of antibiotic use in ruled-out sepsis within 72 h, treatment duration for culture-negative pneumonia less than 7 days, and vancomycin or meropenem was not used unless the cultured bacteria was only susceptible to them. The total antibiotic consumption decreased from 791.1 to 466.3 days of therapy per 1000 patient days from baseline to intervention period. Antibiotics were stopped within 72 h for 47.48% patients with rule-out sepsis and within 7 days for 75.70% patients with pneumonia compared with 11.56% and 37.69% during the baseline period respectively. The prevalence of multi-drug resistance bacteria decreased from 67.20 to 48.90%. The total use rate of meropenem or vancomycin decreased from 7.6 to 1.8%. Our quality improvement approach on antibiotic strategy significantly reduced antibiotic use and prevalence of multi-drug resistance bacteria in our NICU.

Assessment of flomoxef combined with amikacin in a hollow-fibre infection model for the treatment of neonatal sepsis in low- and middle-income healthcare settings

BACKGROUND

Annual mortality from neonatal sepsis is an estimated 430 000-680 000 infants globally, most of which occur in low- and middle-income countries (LMICs). The WHO currently recommends a narrow-spectrum β-lactam (e.g. ampicillin) and gentamicin as first-line empirical therapy. However, available epidemiological data demonstrate high rates of resistance to both agents. Alternative empirical regimens are needed. Flomoxef and amikacin are two off-patent antibiotics with potential for use in this setting.

OBJECTIVES

To assess the pharmacodynamics of flomoxef and amikacin in combination.

METHODS

The pharmacodynamic interaction of flomoxef and amikacin was assessed in chequerboard assays and a 16-arm dose-ranged hollow-fibre infection model (HFIM) experiment. The combination was further assessed in HFIM experiments mimicking neonatal plasma exposures of clinically relevant doses of both drugs against five Enterobacterales isolates with a range of flomoxef/amikacin MICs.

RESULTS

Flomoxef and amikacin in combination were synergistic in bacterial killing in both assays and prevention of emergence of amikacin resistance in the HFIM. In the HFIM assessing neonatal-like drug exposures, the combination killed 3/5 strains to sterility, (including 2/5 that monotherapy with either drug failed to kill) and failed to kill the 2/5 strains with flomoxef MICs of 32 mg/L.

CONCLUSIONS

We conclude that the combination of flomoxef and amikacin is synergistic and is a potentially clinically effective regimen for the empirical treatment of neonatal sepsis in LMIC settings and is therefore suitable for further assessment in a clinical trial.

Length of Hospital Stay and Its Predictors Among Neonatal Sepsis Patients: A Retrospective Follow-Up Study

INTRODUCTION

Sepsis is common among neonates, and is often fatal. Hospitalization results in severe nosocomial infections which could be resistant to antibiotics. It also incurs higher fees for medical care.

METHODS

A retrospective follow-up study, which includes 206 neonates, was conducted to assess the length of hospital stay among neonatal sepsis patients from September 2018 to September 2020 at TASH Hospital, Addis Ababa, Ethiopia. Data were collected from medical charts. Mean length of hospital stay was compared using independent sample t-tests. Risk factors for length of stay were identified using binary logistic regression analysis.

RESULTS

All neonates stayed a total of 325 days, which gives 75,512 neonate-days. Neonates who stayed more than 7 days had low mean birth weight and higher mean age at admission. Mean length of stay was higher among neonates with comorbid illness, neonates with drug therapy problems and male neonates. Even though the mean length of stay is shorter among neonates with maternal PROM and CS delivery, these maternal factors were found to be insignificant in the multivariate logistic regression.

DISCUSSION

Similar to other studies, neonates with low birth weight and comorbidity had a longer hospital stay. Neonates with maternal PROM and CS delivery had a shorter stay. But these maternal factors, identified by prior studies as risk factors for neonatal sepsis and its mortality, are not found to be predictors of prolonged hospitalization. Having neurologic features and drug therapy problems among neonates with sepsis prolonged hospital stay.

CONCLUSION

The mean length of stay varies with respect to maternal and neonatal factors. Lower birth weight, presence of neurologic features, presence of comorbidity, presence of drug therapy problems and being male are found to be predictors of a longer hospital stay among neonates with sepsis.

Clinical Laboratory Features of Microbes That Cause Neonatal Sepsis: An 8-Year Retrospective Study

Purpose

To determine the distribution and antibiotic resistance patterns among pathogens that cause neonatal sepsis (NS) and to assess trends in antibiotic resistance.

Patients and methods

A total of 864 patients with sepsis admitted to a neonatal intensive care unit (NICU) between 2014 and 2021 were enrolled. Data on neonate age and sex, pathogenic microbes, and antimicrobial susceptibility were collected. Univariate and linear regression analyses were performed to determine the differences and trends in antibiotic resistance rates.

Results

The overall incidence rate of NS was 4.59 cases per 1000 live births. Of these cases, 255 (29.5%) were early-onset neonatal sepsis (EONS) and 609 (70.5%) were late-onset neonatal sepsis (LONS). A total of 670 (70.5%) gram-positive cocci and 171 (19.8%) gram-negative bacilli were identified. Among the 552 coagulase-negative Staphylococcus (CoNS) strains, the rate of oxacillin resistance was 70.6%, but no strains were resistant to linezolid, vancomycin or tigecycline. Among the antibiotic resistance patterns of the top three gram-negative pathogens, K. pneumoniae showed the highest rates of resistance, with resistance rates of 37.9% and 39.4% to ertapenem and imipenem, respectively, while E. coli and Enterobacter cloacae showed high levels of susceptibility to both. With regard to the trends in resistance among important pathogens, the rates of resistance to rifampicin, ciprofloxacin, levofloxacin, moxifloxacin and clindamycin by Staphylococcus epidermidis significantly decreased (p<0.05) during the study period. E. coli strains exhibited a significant increase in ceftriaxone resistance during the study period (p<0.05).

Conclusion

CoNS was the main microbe that caused NS, followed by E. coli. The bacterial isolates showed varying levels of resistance to the antimicrobial drugs tested. Thus, periodic surveillance in hospital settings to monitor changes in pathogens and antibiotic resistance is important.

Neonatal Sepsis in a Resource-Limited Setting: Causative Microorganisms and Antimicrobial Susceptibility Profile

Background

Empiric treatment of suspected neonatal sepsis must be based on data on setting-specific causative pathogens and their respective susceptibilities to antimicrobials, as well as universal treatment guidelines. This approach will ensure better therapeutic outcomes and reduce mortality.

Objectives

The objectives of this study were to determine the bacteriological profile and antibiotic susceptibility pattern of isolated microorganisms responsible for neonatal sepsis in a regional hospital in Ghana.

Methods

This was a retrospective study that assessed causative microorganisms and antimicrobial susceptibility profiles of neonates suspected of sepsis at the Greater Accra Regional Hospital from January 2018 to December 2019. Blood culture was done using a fully automated BACTEC 9240 blood culture system. Bacteria isolates were identified by Gram staining and conventional biochemical methods. Antimicrobial susceptibility testing was done by Kirby–Bauer's disc diffusion method, and interpretations were carried out according to clinical and laboratory standards. Culture and antibiotic sensitivity reports were obtained and the data subsequently analyzed.

Results

Of 2514 blood samples collected from neonates suspected of neonatal sepsis, 528 (21.0%) of the samples were found to be culture-positive. The majority of these positive cultures were from male neonates (68.9%). A total of 11 different pathogens were isolated, of which Gram-positive organisms had a preponderance of 72.0% over Gram-negative organisms (28.0%). Staphylococcus epidermidis was the most common pathogen identified, accounting for 60.0% of isolates. The most prevalent Gram-negative bacteria were Klebsiella spp. (13.6%). Most Gram-positive microorganisms showed sensitivity to amikacin, meropenem, vancomycin, and piperacillin/tazobactam. Gram-positive isolates were found to be resistant to ampicillin and penicillin, but moderately susceptible to flucloxacillin. Most Gram-negative isolates were sensitive to meropenem.

Conclusion

The prevalence of culture-proven sepsis was 21.0%. The most prevalent Gram-negative bacteria were Klebsiella spp. As there is some level of antibiotic resistance observed in the current study, it is necessary for routine microbial analysis of samples and their antibiogram.

A high percentage of hospital-acquired neonatal bacteraemia but rare resistance to standard antibiotic regimens

AIM

We examined community and hospital-acquired bacteraemia, namely bloodstream infections or meningitis, and looked at the clinical features and outcomes of cases.

METHODS

The study comprised infants under 3 months of age, who were admitted to a tertiary referral centre in northern Israel with bacteraemia from 2010-2019. Causative pathogens, antibiotic susceptibility and mortality were retrospectively recorded.

RESULTS

We identified 314 infants, 325 episodes of bacteraemia and 344 pathogens. Meningitis was identified in 22 (7.0%) infants. Hospital-acquired bacteraemia accounted for 84.8% of the 325 episodes. Coagulase-negative staphylococci (33.9%) was the most prevalent pathogen in the hospital-acquired cases, while Escherichia coli (37.2%) dominated the community-acquired cases. The susceptibility of Gram-negative early-onset sepsis cases to ampicillin-gentamicin or ampicillin-cefotaxime was 96% and 94.7% for hospital-acquired cases and 91.7% and 88% for community-acquired cases, respectively. Susceptibility to piperacillin-tazobactam or amikacin in late-onset sepsis were 92.8% and 98%, respectively, in hospital-acquired cases. The 30-day mortality was 5.7% in infants with hospital-acquired cases. Risk factors were Arab ethnicity (p < 0.028), haemodynamic instability (<0.001) and Gram-negative sepsis (0.043).

CONCLUSION

Most cases of bacteraemia were acquired during hospitalisation and these accounted for the majority of the deaths. Resistance to standard antibiotic regimens was rare.

Antibiogram of Urinary Tract Infections and Sepsis among Infants in Neonatal Intensive Care Unit

Neonatal infections including sepsis and urinary tract infections are considered among the leading causes of mortality in neonatal intensive care units (NICU). Thus, use of empiric antibiotics is very important in infected neonates and the success of this practice is mainly reliant on the availability of an up-to-date antibiogram for currently used antibiotic drugs. In this study, we aim to determine the bacteriological profile and antibiotic susceptibility pattern of bacteria isolated from blood or/and urine cultures belonging to patients at the NICU. A total of 54 urine samples were collected in the period between January 2015 and December 2019. Data of infants with positive urine and blood bacterial isolates were gathered retrospectively. The most commonly isolated bacteria from urine observed were K. pneumoniae (44%) and E. coli (39%), while Acinetobacter baumannii (33%) and K. pneumoniae (22%) predominated in neonatal blood samples. The majority of uropathogens and blood isolates exhibited low resistance to imipenem and tigecycline, respectively. These antibiotics would be recommended for future use as empirical treatment in neonates with urinary tract infections and/or sepsis. This investigation highlights the importance of surveillance studies to manage and ensure the effectiveness of treatment plan for critically ill infants.

Flomoxef and fosfomycin in combination for the treatment of neonatal sepsis in the setting of highly prevalent antimicrobial resistance

BACKGROUND

Neonatal sepsis is a serious bacterial infection of neonates, globally killing up to 680 000 babies annually. It is frequently complicated by antimicrobial resistance, particularly in low- and middle-income country (LMIC) settings with widespread resistance to the WHO's recommended empirical regimen of ampicillin and gentamicin.

OBJECTIVES

We assessed the utility of flomoxef and fosfomycin as a potential alternative empirical regimen for neonatal sepsis in these settings.

METHODS

We studied the combination in a 16-arm dose-ranged hollow-fibre infection model (HFIM) experiment and chequerboard assays. We further assessed the combination using clinically relevant regimens in the HFIM with six Enterobacterales strains with a range of flomoxef/fosfomycin MICs.

RESULTS

Pharmacokinetic/pharmacodynamic modelling of the HFIM experimental output, along with data from chequerboard assays, indicated synergy of this regimen in terms of bacterial killing and prevention of emergence of fosfomycin resistance. Flomoxef monotherapy was sufficient to kill 3/3 strains with flomoxef MICs ≤0.5 mg/L to sterility. Three of three strains with flomoxef MICs ≥8 mg/L were not killed by fosfomycin or flomoxef monotherapy; 2/3 of these were killed with the combination of the two agents.

CONCLUSIONS

These data suggest that flomoxef/fosfomycin could be an efficacious and synergistic regimen for the empirical treatment of neonatal sepsis in LMIC settings with prevalent antimicrobial resistance. Our HFIM results warrant further assessment of the flomoxef/fosfomycin combination in clinical trials.

Bacteriological Profile and Antibiotic Susceptibility Pattern of Neonatal Septicemia and Associated Factors of ICU Hospitalization Days

Purpose

To evaluate the microorganisms involved in neonatal septicemia and its antibiotic susceptibility pattern and to further investigate the factors associated with the length of intensive care unit (ICU) stay in neonatal septicemia.

Patients and Methods

A total of 297 infants with septicemia at neonatal ICU (NICU), Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology from 2016 to 2020 were enrolled. Identification of bacterial species was done using the standard positive blood culture. Data included demographics, signs at time of septicemia, laboratory values, patient sources, complications, microbiologic characteristics, and the duration of ICU stay. Univariate and multivariate gamma regression analyses were applied to determine the variables associated with ICU stay.

Results

The result demonstrated that the main causative pathogens of neonatal septicemia in our hospital were Gram-positive bacteria, among which Staphylococcus epidermidis (100 isolates, 47.17%) was the main conditional pathogens; Escherichia coli (27 isolates, 49.09%) was most frequently isolated among Gram-negative pathogens. Gram-positive bacteria had higher susceptibility to vancomycin, tigecycline and linezolid. Escherichia coli was susceptive to piperacillin (27/27, 100.00%), cefotetan (27/27, 100.00%), meropenem and imipenem (27/27, 100.00%). Streptococcus agalactiae (95% CI: 0.140–0.539), for patients who were transferred from other hospital (95% CI: 0.016 to 0.354), septicemia during hospitalization (95% CI: 0.411 to 0.825), the use of antibacterial drug during pregnancy (95% CI: 0.362 to 2.136), feeding intolerance (95% CI: 0.127 to 0.437), bradycardia (95% CI: 0.196 to 0.838), septicemia newborns have complications (95% CI: 0.063 to 0.291), the onset age (95% CI: 0.006 to 0.023), TRIPS score (95% CI: 0.005 to 0.016), and CRP level (95% CI: 0.002 to 0.005) were related to prolonged ICU stay days.

Conclusion

This study summarized common pathogens and associated drug sensitivity, and factors influencing ICU stay length. Prevention and control policy in the NICU should be strengthened.

Clinical Characteristics and Death Risk Factors of Severe Sepsis in Children

Sepsis is a systemic inflammatory response syndrome caused by viral infection. The circulatory dysfunction caused by sepsis is also called septic shock or septic shock. The main characteristics are rapid onset, rapid changes, and involvement. Multiple organs in the body make diagnosis difficult, which seriously threatens the survival of patients. As many as one million people worldwide die every year because of SIRS, it is also the leading cause of death among children in hospital ICUs. This article is aimed at studying the clinical characteristics of severe sepsis in children and the risk factors for death. Based on the analysis of the pathogenesis of sepsis and the treatment of septic shock, 65 cases of children with PICU sepsis admitted to a hospital were selected. Data, to study its clinical characteristics and risk factors for death. The results of the study showed that despite the interaction among the removal factors of the three indexes of serum lactic acid value, PCIS level, and the number of organs involved in MODS, they are still related to the mortality of children with severe sepsis.

Risk Factors and Clinical Characteristics of Neonatal Acute Respiratory Distress Syndrome Caused by Early Onset Sepsis

PURPOSE

To identify risk factors associated with the development of acute respiratory distress syndrome (ARDS) in infants with early onset sepsis (EOS) and to describe the clinical features.

METHODS

A retrospective study was conducted at the Children's Hospital of Chongqing Medical University between January 2000 and October 2020. The infants were divided into ARDS and non-ARDS groups. Clinical characteristics and risk factors were compared between the two groups.

RESULTS

Two hundred fifty infants (58 with ARDS) were included. Smaller gestational age, lower birth weight (LBW), lower serum albumin level, a higher rate of preterm birth, premature rupture of membranes, antenatal steroid exposure, and lower Apgar score were associated with an increased development of ARDS by univariate analysis (P < 0.05). LBW (β = -0.001, P = 0.000, OR: 0.999, 95% CI: 0.998-0.999) and low serum albumin levels (β = -0.063, P = 0.022, OR: 0.939, 95% CI: 0.889-0.991) were identified as independent risk factors for the development of ARDS by logistic regression analysis. A higher frequency of complications, including persistent pulmonary hypertension, intraventricular hemorrhage, pulmonary hemorrhage, septic shock, and bronchopulmonary dysplasia, was found in the ARDS group (P < 0.05). The rate of mortality was higher for those in the ARDS group than for those in the non-ARDS group (46.6% vs. 15.6%, χ² = 24.205, P = 0.000).

CONCLUSION

Acute respiratory distress syndrome (ARDS) in EOS could lead to a higher frequency of complications and mortality. The risk factors for the development of ARDS were LBW and low serum albumin levels.

Efficacy of empiric antibiotic treatment of late-onset neonatal sepsis caused by Enterobacteriaceae: A Systematic Review

Neonatal sepsis is a serious condition, where an adequate empiric antibiotic treatment is crucial. The objective of this systematic review is to assess whether the World Health Organisation's recommended treatment regime remains applicable for late-onset neonatal sepsis caused by Enterobacteriaceae, in the time of increased antimicrobial resistance. PubMed was searched for articles from 2009 to 2020. A total of 49 articles were eligible for inclusion. The review was carried out in accordance with PRISMA guidelines. For Klebsiella spp. 100%, 68%, and 63% of the studies found sensitivity to ampicillin, gentamicin, and third generation cephalosporin in <50% of the isolates. For Escherichia coli the corresponding values were 88%, 50%, and 42% respectively, whilst for Enterobacter spp. 100%, 70% and 94% of the studies found <50% sensitivity to these antibiotics. Overall, there is low sensitivity to all agents in the WHO's recommended empiric treatment regimes (WHO recommends ampicillin plus gentamicin as first line treatment and third generation cephalosporin as second line treatment). A revised guideline for empiric antibiotic treatment of neonatal sepsis is urgently needed due to increased threat of antimicrobial resistant Enterobacteriaceae causing neonatal sepsis.

Massive Pleural Effusion as a Rare Manifestation in Severe Neonatal Sepsis

BACKGROUND: Neonatal sepsis can be severe and has mortality rate. The pleural effusion is a rare sign of severe sepsis in newborn and only few studies that reported it. CASE PRESENTATION: We report a case of newborn who referred to our hospital because of dependent mechanical ventilator and severe sepsis. We found a massive pleural effusion and did the pleural drainage. After the drainage, the baby was extubate and discharge well with no signs of respiratory distress. CONCLUSION: Massive pleural effusion might be considered as a cause of dependent ventilator in severe neonatal sepsis.

Bacterial and fungal profile, drug resistance pattern and associated factors of isolates recovered from blood samples of patients referred to Ethiopian Public Health Institute: cross-sectional study

Background

Blood stream infections are serious infections that usually induce prolongation of hospital stay, morbidity and mortality in several countries including Ethiopia. The aim of this study was to determine bacterial and fungal profile, their drug resistance patterns, and risk factors associated with blood stream infections.

Methods

A cross sectional study design was conducted from February 23 to June 23, 2020 at Ethiopian public health. A structured questionnaire was used to collect data on socio-demographic factors and clinical conditions. Blood specimens were analyzed using standard microbiological techniques. Antimicrobial susceptibility tests were performed using Kirby–Bauer disc diffusion technique and Vitek compact 2. Simple and multiple logistic regressions were used to assess the potential risk factors.

Results

A total of 175 pathogens isolated from 346 blood specimens. Of these, 60% Gram-negative bacteria, 30.86% Gram-positive bacteria and 9.14% fungal isolates were identified. Burkholderia cepacia and Coagulase negative staphylococcus were the predominant pathogen among Gram-negative and Gram-positive bacteria respectively. Among fungus, Candida krusei (56.25%) was the most predominant isolate. The highest proportions of antibacterial resistance were observed among 3rd generation cephalosporin and penicillin. Most fungal isolates expressed resistance to fluconazole. Sex (P = 0.007), age (P < 0.001) and use of invasive medical devices (P = 0.003) were identified as risk factors for bacterial blood stream infections.

Conclusion

The study showed high prevalence of blood stream infection was due to B. cepacia and non-C. albicans spp. This finding alarming ongoing investigation of blood stream infection is important for recognizing future potential preventive strategies including environmental hygiene and management of comorbid medical diseases to reduce the problem.

Maternal IgA2 Recognizes Similar Fractions of Colostrum and Fecal Neonatal Microbiota

Microbiota acquired during labor and through the first days of life contributes to the newborn’s immune maturation and development. Mother provides probiotics and prebiotics factors through colostrum and maternal milk to shape the first neonatal microbiota. Previous works have reported that immunoglobulin A (IgA) secreted in colostrum is coating a fraction of maternal microbiota. Thus, to better characterize this IgA-microbiota association, we used flow cytometry coupled with 16S rRNA gene sequencing (IgA-Seq) in human colostrum and neonatal feces. We identified IgA bound bacteria (IgA+) and characterized their diversity and composition shared in colostrum fractions and neonatal fecal bacteria. We found that IgA2 is mainly associated with Bifidobacterium, Pseudomonas, Lactobacillus, and Paracoccus, among other genera shared in colostrum and neonatal fecal samples. We found that metabolic pathways related to epithelial adhesion and carbohydrate consumption are enriched within the IgA2+ fecal microbiota. The association of IgA2 with specific bacteria could be explained because these antibodies recognize common antigens expressed on the surface of these bacterial genera. Our data suggest a preferential targeting of commensal bacteria by IgA2, revealing a possible function of maternal IgA2 in the shaping of the fecal microbial composition in the neonate during the first days of life.

Resistance Patterns of Gram-Negative Bacteria Recovered from Clinical Specimens of Intensive Care Patients

Intensive care units are complex environments favoring high resistance in microorganisms. This study evaluated the resistance and the distribution dynamics of resistant Gram-negative bacteria (GNB) in patients admitted to intensive care units. This retrospective, record-based, cross-sectional study analyzed all of the antibiograms of patients admitted to the ICUs. The BD Phoenix system (BD Diagnostics, Sparks, MD, USA) was used for bacterial identification and antimicrobial testing. Clinical and Laboratory Standard Institute recommendations were used for antimicrobial testing. Frequencies and percentages of multidrug and pan-drug resistance were calculated. A total of 570 bacterial growths were observed, out of which 437 (76.7%) were of GNB. K. pneumoniae (21.0%), P. aeruginosa (11.8%), and Staphylococcus aureus (13.2%) were the most frequent disease-causing bacteria in intensive care patients. Resistance rates of 73.2% and 70.1% were observed for third- and fourth-generation cephalosporins, respectively, while 48.2% carbapenem and > 65% fluoroquinolones resistance rates were observed. Amikacin was the most effective antibiotic, with a sensitivity rate of 69.5%. A total of 372 (85.1%) of GNB were multidrug resistant. The majority of infections in intensive care patients are caused by multidrug-resistant (MDR) Gram-negative bacteria. Female gender and advancing age are factors favoring MDR. Enhanced surveillance and strengthening of the antimicrobial stewardship program are warranted.

Clinical Profile of Neonates Admitted with Sepsis to Neonatal Intensive Care Unit of Jimma Medical Center, A Tertiary Hospital in Ethiopia

Background

Globally, over 3 million newborn die each year, one million of these attributed to infections. The objective of this study was to determine the etiologies and clinical characteristics of sepsis in neonates admitted to intensive care unit of a tertiary hospital in Ethiopia.

Methods

A longitudinal hospital based cohort study was conducted from April 1 to October 31, 2018 at the neonatal intensive care unit of Jimma Medical Center, southwest Ethiopia. Diagnosis of sepsis was established using the World Health Organization's case definition. Structured questionnaires and case specific recording formats were used to capture the relevant data. Venous blood and cerebrospinal fluid from neonates suspected to have sepsis were collected.

Results

Out of 304 neonates enrolled in the study, 195 (64.1%) had clinical evidence for sepsis, majority (84.1%; 164/195) of them having early onset neonatal sepsis. The three most frequent presenting signs and symptoms were fast breathing (64.6%; 122/195), fever (48.1%; 91/195) and altered feeding (39.0%; 76/195). Etiologic agents were detected from the blood culture of 61.2% (115/195) neonates. Bacterial pathogens contributed for 94.8% (109/115); the rest being fungal etiologies. Coagulase negative staphylococci (25.7%; 28/109), Staphylococcus aureus (22.1%; 24/109) and Klebsiella species (16.5%; 18/109) were the most commonly isolated bacteria.

Conclusion

Majority of the neonates had early onset neonatal sepsis. The major etiologies isolated in our study markedly deviate from the usual organisms causing neonatal sepsis. Multicentre study and continuous surveillance are essential to tackle the current challenge to reduce neonatal mortality due to sepsis in Ethiopia.

A High Distribution of Resistant Pathogens among Critically Ill Neonates from Secondary Referral Hospital of Indonesia

Background

The spread of resistant pathogens among critically ill neonates has increased in recent years. Therefore, information about the antimicrobial profile and its susceptibility over time helps to select the most appropriate therapy. The study assesses the distribution of resistant pathogens and its susceptibility among neonates' patients.

Methods

Eight hundred and eight suspected neonatal infected from January 2011 to December 2019 were recruited anonymously in our retrospective, observational analysis. The study was conducted in the secondary-care level NICU which located on the western border of Jakarta, Indonesia. The MDROs definition was define by Centre for Disease Prevention and Control (CDC) criteria and standardized international terminology. Microbial identification and susceptibility testing were carried out following standard protocols.

Results

Culture positivity was found in 132 (16.3%) with dominating MDR-Gram negative bacteria 47 (61.8%). The most common pathogens were extended-spectrum β-lactamase and multidrug-resistant Acinetobacter 18 (38.3%), respectively. There were coagulase negative staphylococci 29 (38.2%) among MDROs. Most of the Gram negative bacteria were highly susceptible to the combination of cefoperazone/sulbactam (79.6%), amikacin (88.7%), and tigecycline (77.1%). Staphylococcus aureus had a good susceptibility to almost all classes' antibiotics. Candida isolates showed 100.0% susceptibility to all antifungal classes.

Conclusions

Our study highlighted the microbial profile along with its susceptibility among neonatal patients that able to provide necessary information for antimicrobial guidelines and policies for effective infectious case management.

Potential Antibiotics for the Treatment of Neonatal Sepsis Caused by Multidrug-Resistant Bacteria

Neonatal sepsis causes up to an estimated 680,000 deaths annually worldwide, predominantly in low- and middle-income countries (LMICs). A significant and growing proportion of bacteria causing neonatal sepsis are resistant to multiple antibiotics, including the World Health Organization-recommended empiric neonatal sepsis regimen of ampicillin/gentamicin. The Global Antibiotic Research and Development Partnership is aiming to develop alternative empiric antibiotic regimens that fulfil several criteria: (1) affordable in LMIC settings; (2) activity against neonatal bacterial pathogens, including extended-spectrum β-lactamase producers, gentamicin-resistant Gram-negative bacteria, and methicillin-resistant Staphylococcus aureus (MRSA); (3) a licence for neonatal use or extensive experience of use in neonates; and (4) minimal toxicities. In this review, we identify five antibiotics that fulfil these criteria: amikacin, tobramycin, fosfomycin, flomoxef, and cefepime. We describe the available characteristics of each in terms of mechanism of action, resistance mechanisms, clinical pharmacokinetics, pharmacodynamics, and toxicity profile. We also identify some knowledge gaps: (1) the neonatal pharmacokinetics of cefepime is reliant on relatively small and limited datasets, and the pharmacokinetics of flomoxef are also reliant on data from a limited demographic range and (2) for all reviewed agents, the pharmacodynamic index and target has not been definitively established for both bactericidal effect and emergence of resistance, with many assumed to have an identical index/target to similar class molecules. These five agents have the potential to be used in novel combination empiric regimens for neonatal sepsis. However, the data gaps need addressing by pharmacokinetic trials and pharmacodynamic characterisation.

Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis

BACKGROUND

Neonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms, which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries. We therefore completed a systematic review and meta-analysis of available data from all low- and lower-middle-income countries (LLMICs) since 2010, with a focus on regional differences in Gram-negative infections and AMR.

METHODS AND FINDINGS

All studies published from 1 January 2010 to 21 April 2021 about microbiologically confirmed bloodstream infections or meningitis in neonates and AMR in LLMICs were assessed for eligibility. Small case series, studies with a small number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. We included 88 studies (4 cohort studies, 3 randomised controlled studies, and 81 cross-sectional studies) comprising 10,458 Gram-negative isolates from 19 LLMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 55% to 65%). Klebsiella spp. was the most common, with a pooled proportion of 38% of Gram-negative sepsis (95% CI 33% to 43%). Regional differences were observed, with higher proportions of Acinetobacter spp. in Asia and Klebsiella spp. in Africa. Resistance to aminoglycosides and third-generation cephalosporins ranged from 42% to 69% and from 59% to 84%, respectively. Study limitations include significant heterogeneity among included studies, exclusion of upper-middle-income countries, and potential sampling bias, with the majority of studies from tertiary hospital settings, which may overestimate the burden caused by Gram-negative bacteria.

CONCLUSIONS

Gram-negative bacteria are an important cause of neonatal sepsis in LLMICs and are associated with significant rates of resistance to WHO-recommended first- and second-line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required.

High Burden of Bloodstream Infections Associated With Antimicrobial Resistance and Mortality in the Neonatal Intensive Care Unit in Pune, India

BACKGROUND

Antimicrobial resistance (AMR) is a growing threat to newborns in low- and middle-income countries (LMIC).

METHODS

We performed a prospective cohort study in 3 tertiary neonatal intensive care units (NICUs) in Pune, India, to describe the epidemiology of neonatal bloodstream infections (BSIs). All neonates admitted to the NICU were enrolled. The primary outcome was BSI, defined as positive blood culture. Early-onset BSI was defined as BSI on day of life (DOL) 0-2 and late-onset BSI on DOL 3 or later.

RESULTS

From 1 May 2017 until 30 April 2018, 4073 neonates were enrolled. Among at-risk neonates, 55 (1.6%) developed early-onset BSI and 176 (5.5%) developed late-onset BSI. The majority of BSIs were caused by gram-negative bacteria (GNB; 58%); among GNB, 61 (45%) were resistant to carbapenems. Klebsiella spp. (n = 53, 23%) were the most common cause of BSI. Compared with neonates without BSI, all-cause mortality was higher among neonates with early-onset BSI (31% vs 10%, P < .001) and late-onset BSI (24% vs 7%, P < .001). Non-low-birth-weight neonates with late-onset BSI had the greatest excess in mortality (22% vs 3%, P < .001).

CONCLUSIONS

In our cohort, neonatal BSIs were most commonly caused by GNB, with a high prevalence of AMR, and were associated with high mortality, even in term neonates. Effective interventions are urgently needed to reduce the burden of BSI and death due to AMR GNB in hospitalized neonates in LMIC.

Prevalence and risk factors for antimicrobial resistance among newborns with gram-negative sepsis

INTRODUCTION

Newborn sepsis accounts for more than a third of neonatal deaths globally and one in five neonatal deaths in Ethiopia. The first-line treatment recommended by WHO is the combination of gentamicin with ampicillin or benzylpenicillin. Gram-negative bacteria (GNB) are increasingly resistant to previously effective antibiotics.

OBJECTIVES

Our goal was to estimate the prevalence of antibiotic-resistant gram-negative bacteremia and identify risk factors for antibiotic resistance, among newborns with GNB sepsis.

METHODS

At a tertiary hospital in Ethiopia, we enrolled a cohort pregnant women and their newborns, between March and December 2017. Newborns who were followed up until 60 days of life for clinical signs of sepsis. Among the newborns with clinical signs of sepsis, blood samples were cultured; bacterial species were identified and tested for antibiotic susceptibility. We described the prevalence of antibiotic resistance, identified newborn, maternal, and environmental factors associated with multidrug resistance (MDR), and combined resistance to ampicillin and gentamicin (AmpGen), using multivariable regression.

RESULTS

Of the 119 newborns with gram-negative bacteremia, 80 (67%) were born preterm and 82 (70%) had early-onset sepsis. The most prevalent gram-negative species were Klebsiella pneumoniae 94 (79%) followed by Escherichia coli 10 (8%). Ampicillin resistance was found in 113 cases (95%), cefotaxime 104 (87%), gentamicin 101 (85%), AmpGen 101 (85%), piperacillin-tazobactam 47 (39%), amikacin 10 (8.4%), and Imipenem 1 (0.8%). Prevalence of MDR was 88% (n = 105). Low birthweight and late-onset sepsis (LOS) were associated with higher risks of AmpGen-resistant infections. All-cause mortality was higher among newborns treated with ineffective antibiotics.

CONCLUSION

There was significant resistance to current first-line antibiotics and cephalosporins. Additional data are needed from primary care and community settings. Amikacin and piperacillin-tazobactam had lower rates of resistance; however, context-specific assessments of their potential adverse effects, their local availability, and cost-effectiveness would be necessary before selecting a new first-line regimen to help guide clinical decision-making.

Invasive Klebsiella pneumoniae Infections in Community-Settings and Healthcare Settings

Objective

To assess clinical characteristics, outcomes and antimicrobial resistance of invasive Klebsiella pneumoniae (KP) infections in Chinese pediatric patients in hospital and community settings.

Methods

This retrospective study was conducted in the nine tertiary hospitals during 2016–2018. The 324 pediatric inpatients who had KP isolated from blood and cerebrospinal fluid and had complete medical records reviewed were included. We analyzed the risk factors, outcomes and antimicrobial resistance pattern of KP-infected patients based on comparison between healthcare-associated KP infections (HAI) and community-acquired infections.

Results

Of the 324 enrolled patients, 275 (84.9%) were clinically defined as HAI, including 175 (63.6%) neonates and 100 (36.4%) aged >28 days. The overall prevalence of CRKP was 38.2% (43.4% in HAI verse 8.7% in CAI, P <0.05). Prematurity (odds ratio (OR): 37.07, 95% CI: 8.29–165.84), hematologic malignancies (OR: 15.52, 95% CI: 1.89–127.14) and invasive mechanical ventilation (OR: 13.09, 95% CI: 1.66–103.56) were independent risk factors for HAI. Patients from rural area (OR: 1.94, 95% CI: 1.12–3.35), invasive mechanical ventilation (OR: 2.33, 95% CI: 1.25–4.33), antibiotic therapy prior to admission (OR: 2.33, 95% CI: 1.25–4.33) and prior hospital stay in the past 30 days (OR: 3.46, 95% CI: 1.87–6.41) were associated with healthcare-associated CRKP infections. Organ dysfunction was independently correlated with poor outcomes (OR: 2.92, 95% CI: 1.23–6.95).

Conclusion

Pediatric invasive KP infections and high prevalence of CRKP infections largely occurred in healthcare settings in China. The adequate and intensified infection control measures should be focused on high-risk hematologic patients, neonatal patients and intubated patients.

Use of Meropenem in a Tertiary Pediatric Hospital in Costa Rica and Its Role in the Era of Antimicrobial Stewardship

Background

Understanding antibiotic profiles and their resistance patterns can improve hospital quality care and optimize clinical outcomes. This paper characterizes the use of meropenem in the National Children’s Hospital of Caja Costarricense del Seguro Social (CCSS) in Costa Rica, and its role in antibiotic stewardship.

Methods

This is a retrospective observational study from hospitalized patients under 13 years of age that received meropenem as part of their treatment. Patients were identified through medical and pharmacy records. Data was summarized using frequencies and percentages for categorical variables, means and standard deviations for normally distributed continuous variables, and medians with interquartile ranges (IQR) for non-normally distributed continuous variables.

Results

A total of 181 of the 309 selected patients met inclusion criteria. Median age was 21 months (IQR: 4.0-79.0). Mean length of stay was 31 days (16.0-58.0). The most frequent diagnosis was septic shock (29%). 87% of patients received at least one antibiotic prior to receiving meropenem; 71% of patients received a second antibiotic simultaneously with meropenem. In 113 (62%) cases, meropenem was prescribed as empirical therapy. The most frequent isolate was extended-spectrum ß-lactamase Escherichia coli (24%). 74% of patients who received meropenem as targeted therapy had a favorable outcome.

Conclusions

Meropenem can be used as monotherapy for complicated, multi-drug resistant, gram negative, bacterial infections, due to its susceptibility profile, convenient dosing schedule, and minimum adverse effects. However, it should be restricted to cases where no other drug is available in order to safeguard its value.

Amikacin Combined with Fosfomycin for Treatment of Neonatal Sepsis in the Setting of Highly Prevalent Antimicrobial Resistance

Antimicrobial resistance (particularly through extended-spectrum β-lactamase and aminoglycoside-modifying enzyme production) in neonatal sepsis is a global problem, particularly in low- and middle-income countries, with significant mortality rates. High rates of resistance are reported for the current WHO-recommended first-line antibiotic regimen for neonatal sepsis, i.e., ampicillin and gentamicin. We assessed the utility of fosfomycin and amikacin as a potential alternative regimen to be used in settings of increasingly prevalent antimicrobial resistance. The combination was studied in a 16-arm dose-ranged hollow-fiber infection model (HFIM) experiment. The combination of amikacin and fosfomycin enhanced bactericidal activity and prevented the emergence of resistance, compared to monotherapy with either antibiotic. Modeling of the experimental quantitative outputs and data from checkerboard assays indicated synergy. We further assessed the combination regimen at clinically relevant doses in the HFIM with nine Enterobacterales strains with high fosfomycin and amikacin MICs and demonstrated successful kill to sterilization for 6/9 strains. From these data, we propose a novel combination breakpoint threshold for microbiological success for this antimicrobial combination against Enterobacterales strains, i.e., MIC_F × MIC_A < 256 (where MIC_F and MIC_A are the fosfomycin and amikacin MICs, respectively). Monte Carlo simulations predict that a standard fosfomycin-amikacin neonatal regimen would achieve >99% probability of pharmacodynamic success for strains with MICs below this threshold. We conclude that the combination of fosfomycin with amikacin is a viable regimen for the empirical treatment of neonatal sepsis and is suitable for further clinical assessment in a randomized controlled trial.

A Systemic Review and Meta-analysis of the Leading Pathogens Causing Neonatal Sepsis in Developing Countries

Background

Neonatal sepsis is one of the major public health problems globally, particularly, in developing countries. Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli are the common pathogens for neonatal sepsis in developing countries. However, the pooled estimate of common pathogens causing neonatal sepsis in developing countries is still unknown. Therefore, this study is aimed at computing the pooled proportion of the leading cause of pathogens for neonatal sepsis in developing countries.

Methods

We strictly followed the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines to report this systematic review and meta-analysis. PubMed, Cochrane Library, Web of Science, CINAHL, Science Direct, and other search engines such as Google Scholar, Africa Journals Online, and Hinari were used to obtain studies related to the leading cause of pathogens for neonatal sepsis in developing countries. The search was done from October 1 to December 30, 2018, by considering both published and gray literature. Studies were evaluated based on the PRISMA guideline checklist by using their titles, abstracts, and full texts. Studies were extracted using Microsoft Excel spreadsheets, and STATA software version 14 was used to analyze data. Heterogeneity between studies was checked based on Cochran's Q-test and the corresponding I² statistic test.

Results

The pooled prevalence of the leading cause of pathogens of neonatal sepsis in developing countries were Klebsiella (26.36%), Staphylococcus aureus (23.22%), Coagulase-negative Staphylococcus (23.22%), and Escherichia coli (15.30%). Common pathogens were varied across regions; for instance, pooled isolated Coagulase-negative Staphylococcus was 25.98% in Africa, 16.62% in Asia, and 36.71% in Latin America, and Klebsiella was 29.80% in Africa, 23.21% in Asia, and 22.00% in Latin America. Also, Staphylococcus aureus was 27.87% in Africa and 18.28% in Asia, and Escherichia coli was 22.97% in Asia and 9.43% in Africa.

Conclusions

This study highlights that the more prevalent common isolated pathogens in developing countries were Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli, Klebsiella, and Staphylococcus aureus pathogens were predominantly high in Africa as compared to other Asian and Latin American countries. At the same time, Coagulase-negative Staphylococcus was more prevalent in Latin America compared to other regions. Escherichia coli is more dominant in Asia as compared to Africa and Latin America.

Antimicrobial Resistance among Neonates with Bacterial Sepsis and Their Clinical Outcomes in a Tertiary Hospital in Kathmandu Valley, Nepal

Globally, antibiotic resistance in bacteria isolated from neonatal sepsis is increasing. In this cross-sectional study conducted at a medical college teaching hospital in Nepal, we assessed the antibiotic resistance levels in bacteria cultured from neonates with sepsis and their in-hospital treatment outcomes. We extracted data of neonates with sepsis admitted for in-patient care from June 2018 to December 2019 by reviewing hospital records of the neonatal intensive care unit and microbiology department. A total of 308 neonates with sepsis were admitted of which, blood bacterial culture antibiotic sensitivity reports were available for 298 neonates. Twenty neonates (7%) had bacteriologic culture-confirmed neonatal sepsis. The most common bacterial species isolated were Staphylococcus aureus (8), followed by coagulase-negative Staphylococcus (5). Most of these bacteria were resistant to at least one first-line antibiotic used to manage neonatal sepsis. Overall, there were 7 (2%) deaths among the 308 neonates (none of them from the bacterial culture-positive group), and 53 (17%) neonates had left the hospital against medical advice (LAMA). Improving hospital procedures to isolate bacteria in neonates with sepsis, undertaking measures to prevent the spread of antibiotic-resistant bacteria, and addressing LAMA's reasons are urgently needed.

Detailed nursing intervention on neonatal septicemia can improve the clinical symptoms of children and reduce the inflammatory reaction

OBJECTIVE

To explore the application effect of detailed nursing intervention in neonatal septicemia.

METHODS

Altogether 60 neonates of neonatal septicemia admitted to our hospital from November 2019 to October 2020 were selected as the research participants, and all the children have received routine treatment, among which 30 neonates received routine nursing intervention as the regular group, and the remaining 30 received detailed nursing intervention as the detail group. The clinical effects, improvement of clinical symptoms, length of stay, and guardian satisfaction were compared, and the levels of serum inflammatory factors (TNF-α, IL-6 and IL-17) and immune function indicators (CD4+, CD8+) before and after nursing intervention were detected.

RESULTS

The total effective rate in the detail group was higher than that in the regular group (P < 0.05). Compared with the regular group, the temperature stabilization time, blood culture turning negative time, improvement time of milk rejection and hospital stay in the detail group were significantly shortened (P < 0.05). The guardian satisfaction score in the detail group was higher than that in the regular group (P < 0.05). After nursing, the levels of TNF-α, IL-6 and IL-17 decreased in both groups, and the levels of these three in the detail group were lower than those in the regular group (P < 0.05). After nursing, CD4+/CD8+ of children in both groups increased, and CD4+/CD8+ in the detail group and regular group were higher than those in the regular group (P < 0.05).

CONCLUSION

The adoption of detailed nursing modes in the treatment of neonatal septicemia can further improve the treatment effect, shorten the hospital stay and the improvement time of clinical symptoms, reduce the incidence of complications, improve the nursing satisfaction of guardians, reduce the inflammation of the body and improve the immune function of the body.

Bacteriological and antibiotic profile of infection among infants in the post-neonatal period at a tertiary care hospital in South India

Purpose

Severe bacterial infection is a major cause of neonatal morbidity and mortality worldwide. Geographical-based demographic laboratory and clinical data are required to get a conclusion about the bacterial infection and their antibiotic susceptibility for the empiric antibiotic treatment in infants who presented with suspected infection. This study was aimed to find the most prevalent bacterial infection and antibiotic sensitivity among infants in the post-neonatal period presented at a tertiary care centre in South India.

Design/methodology/approach

A cross-sectional study was designed among infants (29 days to 1 year old) presented with suspected infection in the paediatric department. Infants with positive culture report were analysed for the bacteriological and antibiotic profile from the medical records. Antibiotic sensitivity was determined for the isolated bacteria according to standard procedure and data statically analysed.

Findings

Total of 218 samples (138 male and 80 female) were analysed. Most of the samples (171/218, 78.4%) were throat swab (p = 0.0247). Only one sample was cerebrospinal fluid from case of meningitis. Sample from upper RTI was major (162/218, 74.3%) with male dominance followed by stool samples from cases of diarrhoea (22/218, 10.0%). Staphylococcus aureus was the major organism identified in 46/171 (26.9 %) throat swabs. The most sensitive antibiotic against bacteria isolated from throat swab and CSF was gentamicin and cloxacillin. Netilmicin and piperacillin plus tazobactam were the sensitive antibiotics against bacteria isolated from stool, ear secretion and urine samples.

Originality/value

Upper RTI was the prevalent bacterial infection followed by diarrhoea in infants in the post-neonatal period. Klebsiella pneumoniae was the common organism identified in the overall report followed by E. coli and S. aureus. Community-based awareness should be provided to follow good hygiene regularly in child care. Furthermore, avoid delay in seeking treatment and provide the medicine prescribed at the right time and in the right dose to limit the morbidity and bacterial resistance.

López E, Álvarez R, Aung MS, Kobayashi N, Quiñones D. Characterization of Neonatal Infections by Gram-Negative Bacilli and Associated Risk Factors, Havana, Cuba

Infections represent an important problem in neonates because of the high mortality. An increase in neonatal infections has been found in Cuban hospitals in recent years. The aim of this study was to provide evidence on the clinical and microbiological behavior of Gram-negative bacilli that cause neonatal infections in hospitals of Havana, Cuba. It was carried out as a descriptive cross-sectional investigation from September 2017 to July 2018 in The Tropical Medicine Institute "Pedro Kouri" (IPK). Sixty-one Gram-negative bacilli isolated from neonates with infections in six Gyneco-Obstetric and Pediatric Hospitals of Havana were analyzed for their species and antimicrobial susceptibility. Late-onset infections were more common than early-onset ones and included urinary tract infection in the community (87%) and sepsis in hospitals (63.3%). Catheter use (47%) and prolonged stay (38%) were the most frequent risk factors. Species of major pathogens were Escherichia coli (47%) and Klebsiella spp. (26%). The isolated Gram-negative bacilli showed high resistance rates to third-generation cephalosporins, ciprofloxacin and gentamicin, while being more susceptible to carbapenems, fosfomycin, colistin and amikacin. The present study revealed the clinical impact of Gram-negative bacilli in neonatology units in hospitals of Havana. Evaluation of antimicrobial susceptibilities to the isolates from neonates is necessary for selection of appropriate empirical therapy and promotion of the rational antibiotic use.

Sepsis profile and outcome of preterm neonates admitted to neonatal intensive care unit of Cairo University Hospital

Background

This study demonstrates the experience of the neonatal intensive care unit (NICU) of a tertiary referral center in Egypt in management of prematures with neonatal sepsis. This retrospective study included preterm neonates admitted to NICU with clinical and/or laboratory diagnosis of sepsis. Blood culture was done followed by antimicrobial susceptibility testing for positive cases. Neonates with sepsis were classified into early onset sepsis (EOS) and late onset sepsis (LOS). Hematological scoring system (HSS) for detection of sepsis was calculated.

Results

The study included 153 cases of neonatal sepsis; 63 (41.2%) EOS and 90 (58.8%) LOS. The majority of the neonates had very low or moderately low birth weight (90.9%). All neonates received first-line antibiotics in the form of ampicillin-sulbactam, and gentamicin. Second-line antibiotics were administered to 133 neonates (86.9%) as vancomycin and imipenem-cilastatin. Mortalities were more common among EOS group (p < 0.017). Positive blood cultures were detected in 61 neonates (39.8%) with a total number of 66 cultures. The most commonly encountered organisms were Klebsiella MDR and CoNS (31.8% each). Klebsiella MDR was the most predominant organism in EOS (28.9%), while CoNS was the most predominant in LOS (39.2%) The detected organisms were divided into 3 families; Enterobacteriaceae, non-fermenters, and Gram-positive family. There 3 families were 100% resistant to ampicillin. The highest sensitivity in Enterobacteriaceae and Non-fermenters was for colistin and polymyxin-B. An HSS of 3–8 had a sensitivity and specificity of 62.3% and 57.6%, respectively for diagnosis of culture-proven sepsis.

Conclusion

Neonatal sepsis was encountered in 21.5% of admitted preterm neonates; LOS was more common (58.8%). Mortality was 51.6%. Klebsiella MDR and CoNS were the most commonly encountered organisms in both EOS and LOS. The isolated families were 100% resistant to ampicillin. The hematological scoring system (HSS) showed limited sensitivity for detection of sepsis.

Neonatal sepsis in a tertiary unit in South Africa

BACKGROUND

Antimicrobial resistance (AMR) has emerged as a global threat to healthcare resulting in an increase in morbidity and mortality. Neonatal sepsis is ranked as the third highest cause of neonatal demise globally, in which AMR accounted for 31.0% of deaths. AMR in neonates has been poorly characterised in Durban, South Africa. Thus, the resultant effect of AMR on empiric regimens for neonatal sepsis is uncertain in this setting. Therefore, this study analysed the aetiology and antimicrobial susceptibility patterns of bloodstream infections within the neonatal intensive care unit at a tertiary hospital in Durban, with the aim of establishing an effective empiric regimen for the unit.

METHODS

A retrospective data review on positive blood cultures from the neonatal intensive care unit at Inkosi Albert Luthuli Central Hospital was conducted. Three time periods were analysed: 2014, 2016 and 2018. Culture data from neonates aged 0-30 days were included and repeat cultures were de-duplicated. The frequency of common organisms and their antimicrobial susceptibilities were analysed. Fischer's exact test was used for subgroup analysis. Poisson and logistic regressions were used to assess significant trends in organisms and antimicrobial susceptibilities over time.

RESULTS

Late-onset sepsis (86.8%) predominated over early-onset sepsis (13.2%). A preponderance of gram-positive organisms (68.7%) over gram-negatives (26.8%) and fungi (4.5%) was detected. Common pathogens included coagulase-negative staphylococci (53.5%), Klebsiella pneumoniae (11.6%), enterococci (9.3%), and Acinetobacter baumannii (7.7%). Despite the small contribution of fungi to the microbial profile, fluconazole-resistant Candida parapsilosis predominated within that group. High rates of resistance to first- and second-line antibiotics were also noted among gram-positive and gram-negative organisms. Multidrug resistant organisms included extended-spectrum beta-lactamase (ESBL) K. pneumoniae (7.6%) and extensively-drug resistant A. baumannii (7.0%). However, a statistically significant decrease in ESBL-producing organisms was documented during the entire study period (p = 0.005).

CONCLUSIONS

It was determined that first-line antimicrobials, advocated by the World Health Organization for treatment of neonatal sepsis, proved ineffective in this unit due to high levels of AMR. Therefore, this study advises that meropenem with or without vancomycin provides optimal empiric cover. Amphotericin B is advocated for empiric antifungal therapy. Ongoing surveillance is necessary.

Treatment outcomes, antibiotic use and its resistance pattern among neonatal sepsis patients attending Bahawal Victoria Hospital, Pakistan

BACKGROUND

Sepsis is one of the major causes of neonatal mortality in Pakistan. This study aimed to investigate the treatment outcomes, antibiotic use and its resistance pattern among neonatal sepsis patients attending a tertiary care hospital in Pakistan. We also aimed to identify the factors affecting mortality in neonatal sepsis patients.

METHODS

A descriptive, cross-sectional study was conducted in the pediatric wards of the Bahawal Victoria Hospital, Bahawalpur, Pakistan. All eligible neonatal sepsis patients who were registered at the study site from January 1, 2019 to June 30, 2019 were included in the study. The data collection form included information on patient's characteristics, antibiotic use and its sensitivity pattern, laboratory and microbiological data, and final treatment outcomes. Treatment outcomes included, discharged (with treatment success), leave against medical advice (LAMA), discharged on request (DOR) and death. Multivariable binary logistic regression analysis was used to find the independent factors associated with death. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Among the total 586 patients, 398 (67.9%) were male, 328 (56%) were preterm, 415 (70.8%) were diagnosed with early onset sepsis, 299 (51%) were born with low birth weight. Most of the patients (n = 484, 82.6%) were treated with amikacin+cefotaxime at the start of treatment. Culture was positive in 52 (8.9%) patients and the most commonly identified bacteria included, Klebsiella species (n = 19, 36.5%) followed by E. coli (n = 15, 28.5%) and Staphylococcus aureus (n = 8, 15.4%). The identified bacterial isolates showed high level of resistance against the antibiotics initiated at the start of the treatment, while resistance against piperacillin+tazobactam, imipenem, vancomycin and linezolid was very low. Just under half of the patients (n = 280, 47.8%) successfully completed the treatment (i.e., discharged with treatment success), while 123 (21%) patients died during treatment. In multivariable binary logistic regression, the factors which still remained significantly associated with neonatal death included, preterm delivery (AOR 9.59; 95% CI 4.41, 20.84), sub-optimal birth weight (AOR 5.13; 95% CI 2.19, 12.04), early onset sepsis (AOR 2.99; 95% CI 1.39, 6.41) and length of hospital stay (AOR 0.76; 95% CI 0.67, 0.88).

CONCLUSION

The mortality rate associated with sepsis was high in our study cohort. The bacterial isolates showed high level of resistance against the antibiotics started as the empiric therapy. Rational use of antibiotics can decrease the adverse outcomes in neonatal sepsis patients.

Bacteraemia and antibiotic sensitivity in a tertiary neonatal intensive care unit

BACKGROUND

Neonatal sepsis is an important cause of mortality and morbidity in neonatal intensive care populations worldwide. Data on rates of bacteraemia and antibiotic resistance patterns are limited, particularly in the developing world.

METHODS

We retrospectively reviewed positive blood cultures obtained in the neonatal intensive care unit between 01 January 2015 and 31 December 2015. All neonates, either born at the tertiary hospital or transferred from referral units, regardless of diagnosis, who had a positive blood culture were included.

RESULTS

There were 702 admissions during the study period and 437 positive cultures. Male patients made up 55.1% (65/118), and the gender was unknown for 11.0% (13/118). Late onset sepsis accounted for 85.7% (102/119) and early onset sepsis, 14.3% (17/119). Of the 119 organisms cultured, 76 (63.8%) were Gram-negative, 35 (29.4%) were Gram-positive and 8 (6.7%) were Candida species. Klebsiella was the most common genus at 42% (50/119). Of the clinically relevant organisms recovered, 37.0% (44/119) were susceptible to the empiric first-line regimen of penicillin and gentamycin. Furthermore, 69.7% (53/76) of the Gram-negative organisms produced extended-spectrum beta-lactamases.

CONCLUSION

The majority of organisms cultured were considered contaminants and were not clinically relevant. Improvements in culture collection processes are needed. The majority of organisms considered clinically relevant were resistant to the first-line antibiotic regimen. To improve the likelihood of clinical success, empiric antibiotic regimens should be based on local data, if possible.

Clinical Symptoms, Pathogen Spectrum, Risk Factors and Antibiogram of Suspected Neonatal Sepsis Cases in Tertiary Care Hospital of Southern Part of Nepal: A Descriptive Cross-sectional Study

INTRODUCTION

Neonatal mortality rate is highest in sub-Saharan Africa and Southern Asia region. The present study is undertaken to find out prevalence of neonatal sepsis, recognize bacterial pathogens, neonatal risk factors, major symptoms, and their antibiotic sensitivity pattern in neonates in tertiary care hospital in southern Nepal.

METHODS

A descriptive cross-sectional study was carried out in a tertiary care hospital from 2nd January 2017 to 20th February 2018 after approval (Ref: 125/2016-17). The sample size was calculated and convenience sampling was done. Data were collected from hospital records and microbiology laboratory and analyzed by Statistical Package for Social Sciences.

RESULTS

Out of 1200 clinically suspected cases, early-onset neonatal sepsis was seen in 290 (79.89%). A positive culture was seen in 363 (30.25%) where maximum bacterial growth was found in 254 (69.98%) males. Preterm gestational age was seen in 265 (73%), low birth weight 284 (78.23%), a vaginal delivery mode in 279 (76.90%), and delivery in hospital in 232 (63.91%). Likewise, Staphylococcus aureus in 229 (63.08%) was found maximum followed by Klebsiella pneumoniae in 48(13.22%). The major symptom observed was Respiratory distress in 245 (20.41%) while culture positive was seen in poor cry in 94 (53.10%). Mainly effective antibiotics against Gram-positive and gram-negative organisms were Linezolid in 250 (94%) and Imipenem in 46 (90.19%), whereas Penicillin-G in 254 (99.21%) and Ampicillin in 38 (94.74%) found resistance towards organisms respectively.

CONCLUSIONS

The high prevalence of neonatal sepsis in our study reflects a huge challenge to reduce the neonatal mortality rate to 12 by 2030 of Sustainable Development Goals. Bacterial isolates exhibited higher resistance towards commonly used antibiotics.

Changing trends in the bacteriological profiles and antibiotic susceptibility in neonatal sepsis at a tertiary children's hospital of China

BACKGROUND

Sepsis is a major cause of neonatal morbidity and mortality in developing countries, and early-onset sepsis has poor outcomes. The causative bacteria vary depending on the geographical location of the hospital. This study aimed to determine the changing trends of causative bacteria and antibiotic susceptibility in the past decade.

METHODS

This study retrospectively analyzed the blood culture of positive cases of early-onset sepsis admitted to the neonatal intensive care unit of our hospital between 2009 and 2018. The cases were divided into two phases, i.e., phase I (2009 to 2013) and phase II (2014 to 2018). Changing trends in the bacteriological profiles and antibiotic susceptibility were recorded and analyzed.

RESULTS

A total of 1,479 causative bacteria were detected. Gram-positive bacteria were isolated in 74.92% of the cases, and coagulase-negative Staphylococci (CoNS) (63.22%) was identified as the common isolate. Klebsiella pneumoniae (10.01%) followed by Escherichia coli (8.72%) were the dominant Gram-negative bacteria. Comparative analysis showed a significant reduction in CoNS. Among Gram-negative bacteria, K. pneumoniae was initially predominant but was replaced by E. coli in phase II. Gram-positive bacteria showed relatively high susceptibility to aminoglycosides and quinolones. K. pneumoniae exhibited higher resistance to cephalosporin compared with E. coli. Reduced sensitivity against the first- and second-generation antibiotics was observed in phase II.

CONCLUSIONS

The etiological profile of neonatal sepsis (NS) has undergone a significant change in the last decade. Antibiotic resistance has increased, and continuous surveillance for antibiotic susceptibility is required to ensure efficient therapeutic outcomes.

Study of Antibiotic Susceptibility among Bacterial Isolates in Neonatal Intensive Care Unit of a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction:

Neonatal sepsis is a major cause of neonatal morbidity and mortality worldwide, especially in developing countries like Nepal. Antibiotic resistance among microorganisms poses new challenges in the treatment of neonatal sepsis. The present study is conducted with the objectives of determining clinico-bacteriological profile and antibiotic susceptibility among isolated bacteria in a neonatal intensive care unit.

Methods:

A descriptive cross-sectional study was conducted from January 1, 2017, to December 31, 2019, in the neonatal intensive care unit of a tertiary care hospital after obtaining ethical clearance from Institutional Review Committee (Ref: 2020-064). The sample size was calculated and 77 neonates with culture-proven sepsis were included in the study. The antibiotic susceptibility tests of the isolates were done by Kirby-Bauer disc diffusion method. Data entry was done in Statistical Packages for the Social Sciences version 20.

Results:

Of the 841 specimens (blood, cerebrospinal fluid, urine, tracheal aspirate and pus) processed for culture, bacteria were isolated in 84 (10.0%) specimens. Among the 84, gram-negative bacilli were the predominant isolates 76 (90.5%); of which Acinetobacter baumannii was the most common 27 (32.1%). Both the Gram-negative and the Gram-positive bacteria showed high resistance to Penicillin and Cephalosporins. Gram-negative bacteria showed maximum sensitivity to Colistin, Carbapenems, Tigecycline and Fluoroquinolones. Gram-positive bacteria showed maximum susceptibility to Amikacin, Vancomycin and Carbapenems.

Conclusions:

Judicious use of antibiotics based on the updated knowledge of prevalent organisms in the local hospital setting and their antibiotic sensitivity pattern is of utmost importance for the effective treatment of neonatal sepsis.

Risk factors and etiology of neonatal sepsis after hospital delivery: A case-control study in a tertiary care hospital of Rajshahi, Bangladesh

BACKGROUND

Sepsis is one of the major causes of neonatal death worldwide as well as in Bangladesh. The objective of the present study was to identify the risk factors and causative organisms of neonatal sepsis after delivery in a tertiary care hospital, Bangladesh.

METHODS

This was a case-control study conducted in the neonatal ward of Rajshahi Medical College Hospital (RMCH), a 1000-bed tertiary hospital situated in Rajshahi, Bangladesh. Neonates diagnosed as neonatal sepsis by clinical and laboratory parameters were included as cases in this study. Admitted neonates unsuspected or undiagnosed for sepsis were considered as controls. Maternal and neonatal information and their laboratory reports were collected and analyzed. Both bivariate and multiple logistic regression models were used to identify the risk factors of neonatal sepsis.

RESULTS

A total of 91 cases and 193 controls were included in the study. Maternal history of urinary tract infection (UTI) during the third trimester of pregnancy (aOR 2.75, 95% CI: 1.04-7.23, p <0.05), premature birth (aOR 2.77, 95% CI: 1.08-7.13, p <0.05) and APGAR score <7 at five minutes (aOR 2.58, 95% CI: 1.04-6.39, p <0.05) were associated with onset of neonatal sepsis in multiple logistic regression model. All these factors were also associated with developing early-onset neonatal sepsis, while maternal UTI and male sex of neonates were associated with developing late-onset neonatal sepsis. Escherichia coli (40.7%), Staphylococcus aureus (27.5%), and Klebsiella pneumoniae (18.7%) were the commonly isolated organisms causing neonatal sepsis. All these organisms were highly resistant to common antibiotics like amoxicillin, cephalosporins, aminoglycosides and quinolones. Carbapenemase group of drugs along with amikacin, nitrofurantoin and linezolid were the most sensitive drugs.

CONCLUSIONS

Strengthening the existing facility for antenatal screening for early diagnosis and treatment of maternal infection during pregnancy as well as identifying high-risk pregnancy for adequate perinatal management is necessary to prevent neonatal sepsis-related morbidity and mortality. Rational use of antibiotics according to local epidemiology and culture and sensitivity reports may minimize the increasing hazards of antibiotic resistance.

The usefulness of C-reactive protein as a biomarker in predicting neonatal sepsis in a sub-Saharan African region

Objective

The early diagnosis of neonatal sepsis remains a challenge for physicians. The initiation or/and discontinuation of the empirical antibiotic therapy at neonates with sepsis is a dilemma due to the lack of definitive diagnosis and the fear of misdiagnosing a case with its serious outcomes, which can follow up. Therefore, this study aimed to assess the usefulness of C-reactive protein (CRP) as an inflammatory biomarker in the prediction of the neonatal sepsis diagnosis in Butembo, the Democratic Republic of the Congo, in sub-Saharan Africa. Blood culture and quantitative CRP measurements were performed for each neonate. Receiver operating characteristics (ROC) analyses were done in the assessment of CRP accuracy in diagnosing neonatal sepsis.

Results

Of the 228 neonates screened for sepsis, 69 (30.3%) had a positive blood culture. Of the 228 neonates with suspected sepsis, 94 (41.2%) had a positive CRP. Among the 69 cases with positive blood culture, CRP identified 66 cases. The sensitivity, specificity, positive and negative predictive values of CRP were 95.7%, 82.4%, 70.2%, and 97.8%, respectively. The area under the curve (AUC) for the CRP ROC analysis was 0.948. CRP showed its usefulness in the diagnosis of neonatal sepsis.

Literature review on the distribution characteristics and antimicrobial resistance of bacterial pathogens in neonatal sepsis

Purpose: Neonatal sepsis (NS) has no specific clinical manifestations and blood culture analysis requires a long period of time. Knowledge of prevalent bacterial isolates and their antibiotic susceptibility is crucial when choosing an empirical therapy to decrease morbidity and mortality. This literature review summarizes the distribution characteristics and antimicrobial resistance of bacterial pathogens associated with bloodstream infections in Chinese neonates, and thus serves as a reference for pediatricians.Methods: The full-text journal database, CNKI, was searched using the key words "neonatal", "sepsis", and "bacterial pathogen" to retrieve relevant literature published from 2016 up to April 2018. The following data were extracted from the selected papers: title, pathogen collection time, care unit name, province (city), distribution of bacterial pathogens among bloodstream infections, and antimicrobial resistance of major pathogens.Results: A total of 86 articles were searched, of which 30 complied with the study requirements and thus were included in the review; all were retrospective studies. The articles covered a total of 4098 bacterial strains from 24 cities (2494 Gram-positive bacteria, 1429 Gram-negative bacteria, 176 fungi). Among the Gram-positive bacteria, the four pathogens with the highest detection rates were coagulase-negative staphylococci (CoNS) (40.23%), Streptococci (6.81%), Enterococci (6.10%), and Staphylococcus aureus (S. aureus) (5.15%); among the Gram-negative bacteria, Klebsiella (14.52%), Escherichia coli (12.12%), Enterobacter cloacae (1.90%), and Pseudomonas (1.41%) had the highest detection rates. The detection rate of Candida and other fungi was 4.29%. Among the pathogens with high clinical detection rates, S. epidermidis and S. aureus are highly resistant to both erythromycin and penicillin. Antibacterial drugs with high efficacy for both S. epidermidis and S. aureus include vancomycin, ciprofloxacin, gentamicin, linezolid, rifampicin, and tetracycline. Klebsiella pneumoniae and Escherichia coli are highly resistant to ampicillin, but there are drugs with high efficacy for both, including imipenem, piperacillin/tazobactam, aminoglycosides (gentamicin, amikacin), and quinolones (levofloxacin, ciprofloxacin). In contrast to the drug resistance data reported by the China Antimicrobial Resistance Surveillance System (CARSS) in 2017, the detection rate of methicillin-resistant S. aureus (MRSA) and methicillin-resistant coagulase-negative staphylococci (MRCoNS) in the blood cultures of neonates with sepsis exceeded the national average drug resistance level (p < .01). The resistance rate of K. pneumoniae to third-generation cephalosporins was higher than the national average drug resistance level (p < .01), but this organism was most sensitive to carbapenems (carbapenem resistance refers to resistance to any of imipenem, meropenem, or ertapenem). The resistance of Escherichia coli to quinolones was better than the national average level (p < .01).Conclusions: Medical care-related infections in neonatal intensive care units (NICUs) were more often caused by CoNS than by S. aureus and Gram-negative bacteria. Vancomycin remains the preferred drug for treating confirmed infections, because most isolated CoNS are resistant to β-lactam drugs including penicillin. For Gram-negative enteric bacteria, aminoglycoside and carbapenem were sufficient for treatment. Compared to the CARSS data on bacterial resistance, the data in this review on the resistance of pathogens causing NS were not favorable. The next goal in antibiotic management in NICUs must be to develop strategies to reduce the use of antibiotics.