High Mortality among Premature Neonates with Positive Blood Culture Neonatal Sepsis in a Tertiary Hospital, Tanzania: A Call for Action

Phenotypic bacterial epidemiology and antimicrobial resistance profiles in neonatal sepsis at Jimma medical center, Ethiopia: Insights from prospective study

BACKGROUND

Epidemiological profiles and the rundown crisis of antimicrobial resistance from bacterial isolates in neonatal sepsis compel regular surveillance to enhance data-driven decision-making. Accordingly, this study aimed to assess the phenotypic epidemiology and antimicrobial resistance profiles of bacteria isolated from clinically suspected neonatal sepsis in Ethiopia.

METHODS

A total of 342 neonates suspected of clinical sepsis were randomly included in a prospective observational study conducted at the neonatal intensive care unit (NICU) of Jimma medical center (JMC) from May 2022 to July 2023. Blood samples were collected from each neonate and subjected to a culture test for identification of bacterial isolates and their antibiotic resistance profiles following the standardized guidelines. The laboratory results, along with relevant clinical data, were recorded using WHONET and analyzed using STATA software.

RESULTS

Out of the 342 blood samples that were analyzed, 138 samples (40.4%, 95% CI: 35.1-45.6, P<0.01) exhibited proven bacterial infection. The infection rates were notably higher in males with 85/138 (61.6%, 95% CI: 53.4-69.8, P<0.01) and neonates aged 0-3 days with 81/138 (58.7%, 95% CI: 50.5-66.9, P<0.01). The majority of the infections were attributed to Gram-negative bacteria, accounting for 101/138(73.2%, 95% CI: 65.6-80.7) cases, with 69/101(68.3%, 95% CI: 63.8-72.8) cases involving ESBL-producing strains, while Gram-positive bacteria were responsible for 26.8% (95% CI: 19.3-34.4) of the infections. The predominant isolates included Klebsiella pneumoniae (37.7%, 95% CI: 29.6-45.8), Coagulase-negative Staphylococci (CoNs) (20.3%, 95% CI: 13.6-27.0), and Acinetobacter species (11.6%, 95% CI: 6.0-17.1). Of the total cases, 43/72 (59.7%, 95% CI: 48.4-71.1, P<0.01) resulted in mortality, with 28/72 (38.9%, 95% CI: 27.70-50.1, P<0.03) deaths linked to Extended-Spectrum Beta-Lactamase (ESBL)-producing strains. Klebsiella pneumoniae displayed high resistance rates to trimethoprim-sulfamethoxazole (100%), ceftriaxone (100%), cefotaxime (98.1%), ceftazidime (90.4%), and gentamicin (84.6%). Acinetobacter species showed resistance to ampicillin (100%), cefotaxime (100%), trimethoprim-sulfamethoxazole (75%), ceftazidime (68.8%), chloramphenicol (68.8%), and ceftriaxone (68.8%). Likewise, CoNs displayed resistance to ampicillin (100%), penicillin (100%), cefotaxime (86.0%), gentamicin (57.2%), and oxacillin (32.2%). Multidrug resistance was observed in 88.4% (95% CI: 81.8-93.0) of isolates, with ESBL-producers significantly contributing (49.3%, 95% CI: 45.1-53.5). Furthermore, 23.0% (95% CI: 15.8-31.6) exhibited a prevalent resistance pattern to seven distinct antibiotic classes.

CONCLUSION

The prevalence and mortality rates of neonatal sepsis were significantly high at JMC, with a notable surge in antibiotic and multidrug resistance among bacterial strains isolated from infected neonates, specifically ESBL-producers. These resistant strains have a significant impact on infection rates and resistance profiles, highlighting the requisite for enhanced diagnostic and antimicrobial stewardship, stringent infection control, and further molecular characterization of isolates to enhance neonatal survival.

Prevalence of carbapenem-resistant gram-negative bacteria among neonates suspected for sepsis in Africa: a systematic review and meta-analysis

BACKGROUND

The emergence and rapid spread of gram-negative bacteria resistant to carbapenems among newborns is concerning on a global scale. Nonetheless, the pooled estimate of gram-negative bacteria resistant to carbapenem that cause neonatal sepsis in developing nations remains unknown. Thus, this study aimed to determine the combined prevalence of gram-negative bacteria resistant to carbapenem in African newborns who were suspected of having sepsis.

METHODS

All studies published from January 1, 2010, up to December 30, 2023, from PubMed, Science Direct, Scopus electronic databases, and the Google Scholar search engine were researched. Isolates tested for carbapenem from neonates with sepsis, English language papers conducted in Africa, and cross-sectional and cohort studies papers were included. Using PRISMA guidelines, we systematically reviewed and meta-analyzed studies that assessed the prevalence of carbapenem-resistant gram-negative bacteria. The "Joanna Briggs Institute" was used critically to evaluate the quality of the included studies. The data analysis was carried out using STATA™ version 17. Heterogeneity across the studies was evaluated using Q and I 2 tests. The subgroup analysis was done and, funnel plot and Egger's regression test were used to detect publication bias. A sensitivity analysis was conducted.

RESULTS

All 36 studies were included in the meta-analysis and systematic review. The pooled prevalence of carbapenem resistance in Africa was 30.34% (95% CI 22.03-38.64%). The pooled estimate of gram-negative bacteria resistant to imipenem, and meropenem was 35.57% (95% CI 0.67-70.54%) and 34.35% (95% CI 20.04% - 48.67%), respectively. A. baumannii and Pseudomonas spp. had pooled prevalence of 45.9% (95% CI 33.1-58.7%) and 43.0% (95% CI 23.0-62.4%), respectively. Similarly, Pseudomonas spp. and A. baumannii also exhibited strong meropenem resistance, with a pooled prevalence of 29.2% (95% CI 4.8-53.5%) and 36.7% (95% CI 20.1-53.3%), respectively. E. coli and K. pneumoniae were the two most common isolates.

CONCLUSION

There should be urgent antimicrobial stewardship practices, strengthened surveillance systems and effective treatment for neonates with sepsis. There was remarkable variation in resistance across the continent.

Bacterial Aetiology of Neonatal Sepsis and Antimicrobial Resistance Pattern at the Regional Referral Hospital, Dar es Salam, Tanzania; A Call to Strengthening Antibiotic Stewardship Program

The diagnosis of neonatal sepsis in lower-income countries is mainly based on clinical presentation. The practice necessitates empirical treatment with limited aetiology and antibiotic susceptibility profile knowledge, prompting the emergence and spread of antimicrobial resistance. We conducted a cross-sectional study to determine the aetiology of neonatal sepsis and antimicrobial resistance patterns. We recruited 658 neonates admitted to the neonatal ward with signs and symptoms of sepsis and performed 639 automated blood cultures and antimicrobial susceptibility testing. Around 72% of the samples were culture positive; Gram-positive bacteria were predominantly isolated, contributing to 81%. Coagulase-negative Staphylococci were the most isolates, followed by Streptococcus agalactiae. Overall, antibiotic resistance among Gram-positive pathogens ranged from 23% (Chloramphenicol) to 93% (Penicillin) and from 24.7% (amikacin) to 91% (ampicillin) for Gram-negative bacteria. Moreover, about 69% of Gram-positive and 75% of Gram-negative bacteria were multidrug-resistant (MDR). We observed about 70% overall proportion of MDR strains, non-significantly more in Gram-negative than Gram-positive pathogens (p = 0.334). In conclusion, the pathogen causing neonatal sepsis in our setting exhibited a high resistance rate to commonly used antibiotics. The high rate of MDR pathogens calls for strengthening antibiotic stewardship programs.

Predictors of Death in Patients with Neonatal Sepsis in a Peruvian Hospital

Reducing neonatal mortality is a global challenge. This study’s objective was to determine the predictors of mortality in patients with neonatal sepsis. The study was a retrospective cohort study in a Peruvian hospital from January 2014 to April 2022. Neonates diagnosed with sepsis were included. To find predictors of mortality, we used Cox proportional regression models. We evaluated 288 neonates with sepsis; the median birth weight and hospitalization time were 3270 g and seven days, respectively. During follow-up, 18.4% did not survive, and the most common complications were jaundice (35.42%), respiratory distress syndrome (29.51%), and septic shock (12.5%). The most isolated bacteria were Klebsiella pneumoniae. The risk factors associated with higher mortality were prematurity (aHR = 13.92; 95% CI: 1.71−113.51), platelets <150,000 (aHR = 3.64; 1.22−10.88), creatinine greater than 1.10 (aHR = 3.03; 1.09−8.45), septic shock (aHR = 4.41; 2.23−8.74), and admission to IMV (aHR = 5.61; 1.86−16.88), On the other hand, breastfeeding was associated with a lower risk of death (aHR = 0.25; 0.13−0.48). In conclusion, we report a high incidence of death and identify clinical (prematurity, septic shock, admission to IMV) and laboratory characteristics (elevated creatinine and thrombocytopenia) associated with higher mortality in patients with neonatal sepsis. Breastfeeding was a factor associated with survival in these patients.