M Jeeva Sankar and colleagues call for urgent action to improve quality of care at birth and implement antimicrobial stewardship in health facilities in South Asia to reduce neonatal deaths from sepsis

https://www.bmj.com/content/bmj/364/bmj.k5314.full.pdf

Neonatal sepsis in South Asia: huge burden and spiralling antimicrobial resistance.

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 ( 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.

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

Globally, 4 million neonates die annually, with one-third of such deaths occurring as a result of infections. In 2011, there were 7.2million deaths in children below 5 years globally, and a proportion of 40% of these deaths occurred in neonates. Sepsis was reported to account for one-third of these deaths. Presently, multidrug antibiotic resistance is rapidly increasing in Neonatal Intensive Care Units (NICUs), particularly in developing countries and poses a threat to public health. The change in these organisms has been reported to vary across regions, between health facilities and even within the same facility. Continuous surveillance is required to inform antibiotic choice for neonatal sepsis management. We identified the common causative organisms of neonatal sepsis and their antibiotic susceptibility pattern in the Ho municipality. A cross sectional study was conducted in the Ho municipality from January to May, 2016. A semi-structured questionnaire was used to collect socio-demographic data from mothers of neonates with clinically suspected of sepsis. Clinical data of both mothers and neonates were extracted from case notes. A 2 ml volume of blood was also taken from neonates and dispensed into a 20 ml mixture of thioglycollate fluid broth and tryptone soy broth for culture and antibiotic susceptibility pattern determined. Out of the 150 clinically suspected neonatal sepsis cases, 91 (60.7%) were males. The Median gestational week was 38 (IQR: 36–39) and Median birthweight was 3.0 kg (IQR 2.5–3.4). The prevalence of culture positive sepsis was 17.3% of the 150 suspected cases. A total of 26 different pathogens were isolated, of which gram positive organisms had a preponderance of 18 (69%) over gram negative organisms 8 (31%). Staphylococcus epidermidis was the most common 14 (53.8%) isolate identified. There was a single isolate (4%) each of Proteus mirabilis and Escherichia coli identified. All the isolates identified showed 100% resistance to ampicillin. The prevalence of culture proven sepsis was 17.3% and Staphylococcus epidermidis was the most common isolate identified. Pathogens isolated were resistant to the first line drugs for management of neonatal sepsis. Hence, the need for a review of first line drug for empirical treatment in neonatal sepsis.

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Bacteriological profile and antibiotic susceptibility pattern of common isolates of neonatal sepsis, Ho Municipality, Ghana-2016

Despite advances in supportive care and use of antibiotics, sepsis preserves its importance due to its high mortality and morbidity for neonates. Identifying the causative agents and antibiotic resistance yearly in a neonatal intensive care unit (NICU) helps the physician to choose the most appropriate empirical therapy. In this study we aimed to evaluate positive blood cultures and antibiotic susceptibilities of newborns with proven sepsis during the years 2000-2002 in our NICU. The charts of babies with sepsis were evaluated for clinical characteristics, positive cultures and antimicrobial susceptibilities, retrospectively. Although most of the admitted patients were premature (76.5%), the frequency of proven sepsis was quite low, at 9.1% among 909 newborns. Mortality rate in sepsis was 16%. The most commonly isolated micro-organisms were coagulase-negative staphylococci (CoNS) (31.3%), fungi (19.2%), Staphylococcus aureus (13%) and Klebsiella pneumoniae (10.5%). Methicillin resistance for CoNS was 92.3% and for S. aureus was 72.7%. In the last year, a significant increase in the frequency of Klebsiella pneumoniae (8.3 vs 14.2%), CoNS (27.1 vs 37.1%), Pseudomonas aeruginosa (2.1 vs 8.6%) and fungal infections (18.8 vs 20%) was observed compared to the previous years. An initial empirical antibiotic therapy for late-onset sepsis was designed with teicoplanin + piperacillin-tazobactam/meropenem + antifungal (fluconazole or amphotericin B) as the best combination to cover this spectrum until the culture results arrive. However, this combination is only compatible with our results and may not be applied in all units. Every unit must follow the bacterial spectrum and antibacterial resistance patterns to choose their specific empirical treatment strategy for nosocomial infections.

Neonatal Nosocomial Sepsis in a Level III NICU Evaluation of the Causative Agents and Antimicrobial Susceptibilities Turk J Pediatr 48 13 18

Background: Neonatal sepsis is a common and serious problem of neonates who are admitted for intensive care. It is a leading cause of neonatal morbidity and mortality worldwide. The objective of the study was to detect the common causative microorganisms of neonatal sepsis and their antibiotic susceptibility patterns in NICU of Nobel Medical College Teaching Hospital (NMCTH).
Methods: This was a cross-sectional study conducted in a 17- bedded teaching and referral NICU of NMCTH from March to August, 2018. All neonates of clinical sepsis were enrolled in the study, blood cultures taken and were followed up till final outcome, which was discharge or death, irrespective of culture report. Descriptive statistics including percentages and frequencies was used.complications.
Results: Among the 55 neonates with diagnosis of clinical sepsis, 13(23.6%) had shown bacteria in the culture. The predominant organisms were Staphylococcus aureus and Klebsiella pneumoniae and most of them were resistant to Ampicillin and Amikacin.
Conclusions: The culture positivity rate among the neonates with clinical sepsis in the study was 23.6%. Pathogens isolated were resistant to the first line drugs for management of neonatal sepsis. Hence, the need for a review of first line drug for empirical treatment of neonatal sepsis.

Bacteriological Profile of Neonatal Sepsis in a Neonatal Intensive Care Unit of a Tertiary Care Hospital of Eastern Nepal

Neonatal Sepsis is one of the most common reasons for admission to neonatal units in developing countries. It is also a major cause of mortality in both developed and developing countries. Identification of the common bacteria and risk factors causing such infections and their susceptibility patterns will provide necessary information for timely intervention. This study was carried out to determine the bacteriological profile and associated risk factors of neonatal sepsis in Paropakar Maternity and Women's hospital. A cross-sectional prospective study was conducted among neonates suspected of neonatal sepsis. Blood culture was performed and organisms were identified and antibiotic susceptibility was carried out with standard microbiological methods. Data were analysed by using SPSS. Ver. 16 software. The positive yield of blood culture was 21%. The most common isolates were Staphylococcus epidermidis, E. coli, Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas spp. In Antibiotic susceptibility pattern Gentamycin showed the highest sensitivity to all types of isolated organisms. Vancomycin sensitivity was highest for Gram positive organism and Ciprofloxacin was most effective for Gram negative organisms isolated. Ampicillin and Amoxycillin were the least effective drug. Multiple drug resistance was observed in 77.15% of isolates. Prematurity, low birth weight and maternal pyrexia before delivery were found to be strongly associated with neonatal sepsis. Gram positive organisms were more prevalent than gram negative organisms.

K M Vaidya

Papers

Bacteriological profile and associated risk factors of neonatal sepsis in Paropakar Maternity and Women's Hospital Thapathali, Kathmandu.