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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 136-139

Distribution of microorganisms in neonatal sepsis and antimicrobial susceptibility patterns in a tertiary care hospital


Department of Microbiology, K.S. Hegde Medical Academy, Deralakatte, Mangalore, Karnataka, India

Date of Web Publication11-Nov-2014

Correspondence Address:
Sweetha Nayak
Department of Microbiology, K.S. Hegde Medical Academy, Deralakatte - 575 018, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.144304

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  Abstract 

Introduction: Neonatal sepsis is one of the leading causes of neonatal deaths in developing countries. The organisms responsible for early onset and late onset sepsis are different. Infections with multidrug-resistant organisms are also increasing in incidence. Objective: To identify the organisms causing septicemia in neonates and to determine the antimicrobial susceptibility pattern of the isolates. Materials and Methods: This prospective study was conducted by analyzing the blood cultures and the sensitivity reports of 195 newborns who were admitted to the NICU between June 2011 and May 2012 with sepsis. Results: A total number of 75 patients (38.46%) had positive blood cultures. Klebsiella pneumoniae (30.66%) was the most common organism isolated. Majority of organisms isolated were resistant to commonly used antibiotics. Maximum sensitivity was seen for Carbapenems in gram-negative bacilli, Vancomycin for gram-positive cocci. Conclusion: Multi-drug-resistant organisms were isolated from neonatal septicemia. Therefore, great caution is required in selection of antibiotics.

Keywords: Antibiotic sensitivity, early onset sepsis, neonatal sepsis


How to cite this article:
Nayak S, Rai R, Kumar VK, Sanjeev H, Pai A, Ganesh H R. Distribution of microorganisms in neonatal sepsis and antimicrobial susceptibility patterns in a tertiary care hospital . Arch Med Health Sci 2014;2:136-9

How to cite this URL:
Nayak S, Rai R, Kumar VK, Sanjeev H, Pai A, Ganesh H R. Distribution of microorganisms in neonatal sepsis and antimicrobial susceptibility patterns in a tertiary care hospital . Arch Med Health Sci [serial online] 2014 [cited 2019 Oct 15];2:136-9. Available from: http://www.amhsjournal.org/text.asp?2014/2/2/136/144304


  Introduction Top


Neonatal sepsis is defined as a disseminated disease with positive blood culture during the first month of life, and is more common in developing countries as compared with developed countries. [1]

Neonatal septicemia constitutes an important cause of morbidity and mortality in neonates in India. It is estimated that almost 20% of all neonates develop infection and approximately 1% die of serious systemic infections. [2]

Mortality rate in neonatal sepsis differs according to the type of organism involved. Klebsiella spp. and Enterococcus spp cause the highest mortality rate in neonatal sepsis. Spectrum of organisms which cause neonatal sepsis varies in different countries and sometimes changes from one center to another within the same country.

Infections with multidrug-resistant organisms are also increasing in incidence.

Serial CRP has been shown to be more useful in the diagnostic evaluation of neonates with suspected infection along with positive blood culture. [3]

Neonatal septicemia is broadly divided into early-onset sepsis (< 72 hrs) and late-onset sepsis (≥ 72 hrs-28 days). This distinction based on age is of value in presumptive identification of predominant organism. Early-onset sepsis is acquired during fetal life, delivery, or at the nursery. Group B Streptococcus, Escherichia coli, or Listeria monocytogenes happen to be the most common organism. Late-onset sepsis is most commonly caused by coagulase negative Staphylococci (CONS), Staphylococcus aureus, Escherichia coli, Klebsiella spp, and Pseudomonas aeruginosa and is usually acquired in the neonatal intensive care unit (NICU) or the community. [4]

Neonatal sepsis is more common among low birth weight infants due to their immature host defense mechanisms and invasive life support systems, which make the premature neonate particularly susceptible to overwhelming infection. [5]

In very low birth weight (VLBW) infants, invasive fungal infection is usually preceded by colonization, which may occur via vertical or horizontal transmission. In studies of VLBW infants, most fungal colonization occurs by 2 weeks of life. [6]

Candida is an opportunistic pathogen. The major factor predisposing VLBW infants to colonization and invasive infection is the ability of Candida species to adhere to skin, mucosal and catheter surfaces as commensal organisms. With damage to the skin or mucosal membranes and the diminished immune defenses of preterm infants, Candida can disseminate to the bloodstream. [5]


  Objectives Top


To identify the organisms causing septicemia in neonates and to determine the antimicrobial susceptibility pattern of the isolates.


  Materials and Methods Top


This prospective study was conducted by analyzing the blood cultures and the sensitivity reports of 195 newborns who were admitted with symptoms of sepsis to the NICU from June 2011 to May 2012. One to two ml of blood was collected from each neonate with aseptic precautions and inoculated into brain-heart infusion broth and incubated at 37 0 C for 24 hrs.

Subcultures were made at 24 hr, 48 hr, 72 hr, and on the 7th day on Blood agar and MacConkey agar. Any growth observed was identified as per standard guidelines. Antibiotic sensitivity testing was performed by Kirby-Bauer disc diffusion method and interpreted as per CLSI guidelines. Escherichia coli ATTC 25922, Staphylococcus aureus ATTC 25923, Pseudomonas aeruginosa ATTC 27853, Enterococcus faecalis ATTC 2921 were used as controls.


  Results Top


During the study period, there were 560 neonates admitted in the NICU. Among them, blood cultures were done in 195 suspected cases of neonatal sepsis. There were 121 (62.05%) male and 74 (37.95%) female neonates, with the male to female ratio of 1.63:1. The total numbers of culture-positive cases were found to be 91 with the culture positivity rate of 46.66%, and 104 (53.33%) remained sterile after 7 days of incubation. Among 91 samples with growth, 16 had growth of contaminants.

Among the 75 significant culture-positive cases, there were 47 (62.66%) male and 28 (37.33%) female neonates with the male to female ratio of 1.6:1. Out of 195 cases, those of early-onset septicemia (EOS) were 164 and late-onset septicemia (LOS) were 31. Blood culture positivity was seen in 53 cases of EOS and 22 cases of LOS. Early-onset sepsis was more common than late-onset.

It is shown in [Table 1] and [Table 2] that 46 (61.33%) of the 75 bacterial growths were gram-negative bacilli (GNB) while 21 (28.0%) were gram-positive cocci (GPC) and 8 (10.66%) were candida isolates. 30.66% of the GNB were Klebsiella pneumoniae, thus making it the predominant GNB. Acinetobacter species constituted 20%, while Escherichia coli and Pseudomonas aeruginosa made up 3% each of the GNB. Acinetobacter speciation could not be done in our laboratory set up. Staphylococcus aureus made up 15 (20%) of the GPC while coagulase-negative staphylococcus (CONS) and Enterococcus faecalis constituted 5.33%, and 2.66%, respectively.
Table 1: Distribution of bacterial isolates

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Table 2: Distribution of candida isolates

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The resistance of the isolated Klebsiella pneumoniae to ceftazidime, ceftriaxone, and cefepime were 87.0% each [Table 3]. Resistance to ampicillin was 100% and 87%, 82.6% for gentamicin and amikacin, respectively. Klebsiella pneumoniae isolates tested against imipenem showed 48% resistance. Also, the resistance against ciprofloxacin was 82.6% as shown in [Table 3].
Table 3: Resistance pattern of gram-negative isolates

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Ninety-three percent of the Staphylococcus aureus were sensitive to ciprofloxacin while 40%, 47%, and 73% were sensitive to erythromycin, clindamycin, and gentamicin, respectively. Penicillin resistance was 80%, and all isolates were sensitive to vancomycin.


  Discussion Top


Sepsis is one of the main causes of neonatal morbidity and mortality. Nosocomial sepsis frequency and microorganism profiles vary widely from center to center and from country to country. The frequency of infections in NICUs varies from 6% to 25% in the United States and from 8% to 10% in Europe. [7] There has been a wide variation in the growth positivity in India; a higher isolation rate of 52.63% was reported by Murty et al., probably due to a low sample size. [8] In this study, blood culture positivity rate in neonatal septicemia cases is 46.66%, which is much higher, and similar results were found by Kumhar GD et al., I roy et al., and Kairavi. J. Desai et al. [9],[10] For the effective management of neonatal septicemia cases, study of the bacteriological profile with their antibiotic pattern plays a significant role.

There was a male preponderance in this study. This is similar to the previous studies carried out by various authors who hypothesized that incidence of septicemia was higher in males ranging from 59%-82% due to the presence of factors regulating the synthesis of gamma globulin on X chromosome. [11]

We found in our study that early-onset sepsis (EOS) was more common than late-onset sepsis (LOS), which is compatible with the reports from the other developing countries. In our study, early-onset septicemia (EOS) was seen in 84.10% cases of neonatal septicemia, which was also seen by Movahedian AH et al. and A.K Mane, N.V. Nagdeo et al. [12] We obtained Klebsiella spp and S. aureus as most common cause of EOS as seen in other studies. [13]

In our study, gram-negative bacteria (61.33%) were the principle pathogens, which caused septicemia. Similar results were reported by Roy I, Jain A et al. [9],[14] Similar preponderance of the gram-negative rods has been reported in other studies conducted in Pakistan. [15],[16] This is in contrast to the studies from abroad where gram-positive cocci including Staphylococcus aureus, coagulase-negative staphylococci, and group B streptococci are the predominant agents. [17],[18]

Klebsiella pneumonia and Staphylococcus aureus were the predominant isolates. Klebsiella and Staphylococcus aureus can survive in the environment for a relatively long time and fairly widely distributed in the hospital environment, and, therefore, have the potential for being transmitted from the environment to the patients through practices that breach infection control measures. This emphasizes the need for the establishment of effective and functional infection control programs in hospitals.

The most significant finding of this study was almost 80% of the Klebsiella isolates were resistant to commonly used antibiotics, especially gentamicin and the second and third generation cephalosporins. Screening for ESBL showed most of the Klebsiella isolates to be extended spectrum beta-lactamase (ESBL) producers. Antibiotic sensitivity testing of gram-negative bacteria showed high resistance to multiple drugs while imipenem is still the best for infections with multidrug-resistant gram-negative organism. [12]

We isolated 14.3% isolates of Staphylococcus aureus in the present study. Our results also matched the reports of Narang A et al. [14] Gram-positive bacteria responded very well to vancomycin.

This situation is serious as these are the last line antibiotics available with us. If we continue using these, resistance will obviously emerge against these as well. To prevent, we should stress more upon preventive measures, so that minimum of our neonates develop sepsis. These preventive measures should focus on recognition of high-risk infant, strict asepsis during labor. [19]


  Conclusion Top


Multi-drug-resistant organisms were isolated from septicemia in neonates. Therefore, great caution is required in selection of antibiotic therapy. Strict infection control in neonatal units, hand washing along with regular surveillance of neonatal sepsis is required in order to bring about changes in risk factors and antibiotic susceptibility patterns.

 
  References Top

1.Aletayeb SM, Khosravi AD, Dehdashtian M, Kompani F, Mortazavi SM, Aramesh MR. Identification of bacterial agents and antimicrobial susceptibility of neonatal sepsis: A 54-month study in a tertiary hospital. Afr J Microbiol Res 2011;5:528-31.  Back to cited text no. 1
    
2.Mane AK, Nagdeo NV, Thombare VR. Study of neonatal septicemia in a tertiary care hospital in rural Nagpur. J Recent Adv Appl Sci 2010;25:19-24.  Back to cited text no. 2
    
3.Nuntnarumi P, Pinkaew O, Kitiwanwanich S. Bacterial Profile of Sepsis in a Neonatal Unit. J Med Assoc Thai 2002;851151-8.  Back to cited text no. 3
    
4.Shrestha NJ, Subedi KU, Rai GK. Bacteriological Profile of Neonatal Sepsis: A Hospital Based Study. J Nepal Paediatr Soc 2011;31:1-5.  Back to cited text no. 4
    
5.Kaufman D, Fairchild KD. Clinical microbiology of bacterial and fungal sepsis in very-low-birth-weight infants. Clin Microbiol Rev 2004;17:638-80.  Back to cited text no. 5
    
6.Baley JE, Kliegman RM. Disseminated fungal infections in very low-birth-weight infants: Clinical manifestations and epidemiology. Pediatrics 1984;73144-52.  Back to cited text no. 6
    
7.Korpela JK, Campbell J, Singh N. Health care associated infections. In: Mhairi MG, Mullett MD, Seshia MM, editors. Avery's Neonatology: Pathophysiology and Management of the Newborn. Philadelphia: Lippincott Williams Wilkins; 2005. p. 1356-83.  Back to cited text no. 7
    
8.Movahedian AH, Moniri R, Mosayebi Z. Bacterial culture of neonatal Sepsis. Iran J Publ Health 2006;33:84-9.  Back to cited text no. 8
    
9.Roy A, Jain M, Kumar M, Agarwal SK. Bacteriology of neonatal septicemia in a tertiary care hospital of northern India. Indian J Med Microbiol 2002;20:156-9.  Back to cited text no. 9
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10.Desai KJ, Malek S. Neonatal Septicemia: Bacterial isolates and their antibiotics susceptibility patterns. National Journal of Integrated Research in edicine 2010;1:12-5.  Back to cited text no. 10
    
11.Schreiber JR, Berger M. Intravenous immune globulin therapy for sepsis in premature neonates. J Pediatr 1992;121:401-4.  Back to cited text no. 11
    
12.Gladstone IM, Ehrenkranz RA, Edberg SC, Baltimore RS. A ten year review of neonatal sepsis and comparison with the previous fifty year experience. Pediatr Infect Dis J 1990;9:819-25.  Back to cited text no. 12
    
13.Jain A, Roy I, Gupta M, Kumar M, Agarwal SK. Prevalence of extended-spectrum β-lactamase-producing Gram-negative bacteria in septicaemic neonates in a tertiary care hospital. J Medical Microbiol 2003;52:421-5.  Back to cited text no. 13
    
14.Narang A, Rao R, Bhakoo ON. Neonatal necrotizing enterocolitis: A clinical study. Indian Pediatr 1993;30:1417-22.  Back to cited text no. 14
    
15.Bhutta ZA, Naqvi SH, Muzaffar T. Neonatal sepsis in Pakistan. Acta Paediatr Scand 1991;80:596-601.  Back to cited text no. 15
    
16.Khan IA, Akram DS. Neonatal sepsis - etiological study. J Pak Med Assoc 1987;37:327-30.  Back to cited text no. 16
    
17.Ako-Nai AK, Adejuyigbe EA, Ajayi FM, Onipede AO. The bacteriology of neonatal septicaemia in lle-Ife, Nigeria. J Trop Pediatr 1999;45:146-51.  Back to cited text no. 17
    
18.Kaushik SL, Parmar VR, Grover N, Grover PS, Kaushik R. Neonatal sepsis in hospital born babies. J Commun Dis 1998;30:147-52.  Back to cited text no. 18
    
19.Bhutta ZA, Yusuf K. Early onset neonatal sepsis in Pakistan: A case control study of risk factors in birth cohort. Am J Perinatal l997;14:577-81.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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