INTRODUCTION:

Neonatal Septicemia (NS) has been documented as a leading cause of mortality and morbidity all over the world¹. World Health Organization (WHO) reported over 4 million neonatal deaths occur each year globally; 3 million of these deaths occur in early neonatal. Mortality rate of NS has been more prevalent in developing countries which account 98% of deaths in neonates². The disease demands urgent diagnosis and treatment because of its clinical emergency³. Most of the neonatal sepsis related deaths are preventable if suspected early and treated with appropriate antibiotics.

Neonatal sepsis is broadly categorized into early and late onset sepsis depending upon the postnatal day of presentation. Early-onset neonatal sepsis (EONS) occurs within first 72 h of life, while the late-onset neonatal sepsis (LONS) occurs between 72 h to 90 days of life^4,5,6.

The bacterial agents implicated in early-onset sepsis include group B Streptococcus (GBS), Escherichia coli, coagulase-negative Staphylococcus, Haemophilus influenzae and Listeria monocytogenes^6,7,8. The organisms commonly associated with late-onset sepsis include coagulase-negative staphylococci (CONS), Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Enterobacter spp., Pseudomonas aeruginosa and Acinetobacter species^{6,7,8 9}.

The bacteriological profile for causative organisms of neonatal sepsis differs significantly between developed and developing countries^8,9. Klebsiella pneumoniae is the most common bacterial agent causing neonatal sepsis in developing countries, while group B Streptococcus and coagulase-negative staphylococci (CONS) are the common agents in developed countries^{5, 9,10}. Even among developing countries, regional variation in prevalence of the bacterial agents causing neonatal sepsis exists^11,12. The overall improvement in the neonatal survival due to newer drugs, better neonatal care and advanced life support facilities has led to a change in the spectrum of agents causing neonatal sepsis in developed countries⁶. However, there is a paucity of data on the recent trends of organisms causing neonatal sepsis in developing countries¹³.

As delay in the treatment of neonatal sepsis is associated with increased mortality, empirical therapy is the cornerstone in the management of neonatal sepsis. A combination of ampicillin or third generation cephalosporins with an aminoglycoside (gentamicin) is the commonly used empirical regimen^7,9. However, the appropriateness of this empirical therapy is being challenged in the present era of changing bacteriological profile and increasing antimicrobial resistance. Knowledge of common organisms causing neonatal sepsis in a particular area and their antibiotic sensitivity pattern should be borne in mind before setting guidelines for empirical therapy.

Hence, there is a need for surveillance to understand the trends in pathogens causing neonatal sepsis and the antibiotic susceptibility profile of those pathogens in a particular area. This study was therefore undertaken to determine the common bacterial agents associated with neonatal sepsis and their antibiotic susceptibility pattern in a tertiary care hospital in India.

MATERIAL AND METHODS:

The study was carried out prospectively in National Medical College and Teaching Hospital, Birgunj, Nepal from 1^st January, 2014 to 31^st December, 2014. A total of 215 neonates suspected cases having neonatal sepsis were included in this study. 1-2 ml of blood was drawn aseptically before starting antimicrobial treatment and inoculated directly into Brain Heart Infusion broth (BHI) in a ration of blood:BHI of 1:5. The processing of collected blood samples for culture and isolation was done by standard microbiological method¹⁴.The antimicrobial susceptibility testing was done by Kirby-Bauer disk diffusion technique recommended by Clinical Laboratory Standards Institute (CLSI) recommendations¹⁵.The various antimicrobials that were used for susceptibility testing are as follows: ofloxacine, ciprofloxacine, pepracilline, ceftriazone, amikacin,cefadroxil,imipenem,levofloxacin,cotrimoxazole,cefotaxime,cefepime,meropenem,azithromycine,gentamycin,cefepime-sulbactum manufactured by Hi-media.

RESULTS AND DISCUSSION:

215 blood samples collected from neonates suspected of neonatal sepsis, the prevalence was found to be 42.79% (92/215). Among the samples, 68.37% (147/215) were male and 31.62% (68/215) were female. The numbers of positive neonatal sepsis cases were slightly more (43.53%) frequent than the females (41.17%). The results were depicted in Figure 1.

Figure 1: Sex wise distribution of total neonatal sepsis cases

Among the study population 193 (89.8%) were aged less than 7 days (early onset septicemia) and 22 (10.3%) were aged more than 7 days (late onset septicemia) neonatal suspected septicemia included among which 81 (42%) were shown culture positive in aged less than 7 days (early onset septicemia) and 11 (50%) were in aged more than 7 days (late onset septicemia) as shown in Figure 2.

Figure 2: Culture positivity and onset of septicemia

Out of 92 bacterial pathogens, Gram positive organisms 76 (82.6%) predominated over gram negative organisms 15 (16.4%). The common isolates in gram positive organisms were Staphylococcus aureus 66 (86.9%), Enterococci sp 9 (11.9%), Streoptococcus sp 1 (1.3%). Similarly in gram negative organisms were Klebsiella pneumoniae 9 (60%), E.coli 2 (13.3%), Acinetobacter 2 (13.3%) and Pseudomonas aeruginosa 2 (13.3%). All isolated organisms including are gram positive and gram negative shown in Figure 3.

Figure 3: Isolated organisms and their numbers

Gram positive isolates (Staphylococcus aureus, Streptococcus sp, Enterocococcus.sp) shown resistant against Penicillin(P), Ampicillin (AMP) and Meropenem (MRP) but only Streptococcus sp showed complete sensitivity towards Ceftazidime (CAT), Cephalexin (CN), Cefixime (CFM), Ofloxacine (OF), Imipenem (IPM), Levfloxacin (LE) and Azithromycin (AZM). Among all gram negative isolates (Klebsiella pneumoniae, Escherichia coli, Acinetobacter, Pseudomonas aeroginosa). Klebsiella pneumoniae shown resistant against all antibiotics and Escherichia coli, Acinetobacter, Pseudomonas aeroginosa shown fully sensitive towards Cefepime sulbactum (CPMS) and Levfloxacin (LE). E.coli given resistant against Ofloxacine(OF),Ceftriazone (CTR),Cefadroxil (CFR) and Cotrimixazole (COT) as well as all Acinetobacter given against Of loxacine(OF), Amikacin (AK) while half (50%) Acinetobacter shown resistant against Ciprofloxacin (CIP), Ceftriazone (CTR), Cefadroxil (CFR). All Pseudomonas aeroginosa showed resistant against Ofloxacine(OF), Amikacin (AK) and Cefadroxil (CFR) and half of this shown resistant towards Ciprofloxacin (CIP), Ceftriazone (CTR), Piperaciline (PI) and Imipenem (IPM) shown in Table 1.

Table 1: Antibiotic Profile of Isolated Organisms

Antibiotics	*Staphylococcus aureus* (n=66)	*Streptococcus* sp (n=1)	*Enterococcus* sp (n=9)	*Klebseilla pneumoniae* (n=9)	*Escherichia coli* (n=2)	*Acinetobacter* sp (n=2)	*Pseudomonas aeruginosa* (n=2)
P	60.6	100	66.6	-	-	-	-
CAT	40.9	0	22.2	-	-	-	-
CN	25.7	0	11.11	-	-	-	-
CFM	12.1	0	44.4	-	-	-	-
AMP	77.2	100	77.7	-	-	-	-
CPMS	-	-		77.7	0	0	0
OF	16.6	0	22.2	77.7	100	100	100
CIP	-	-	-	22.2	0	50	50
PI	-	-	-	22.2	0	0	50
AK	-	-	-	22.2	0	100	100
CTR	21.2	100	0	77.7	100	50	50
CFR	-	-	-	77.7	100	50	100
IPM	68.1	0	77.7	44.4	0	0	50
LE	10.6	0	11.1	11.1	0	0	0
COT	-	-	-	44.4	100	50	50
CTX	-	-	-	33.3	0	100	50
CPM	-	-	-	77.7	100	100	100
MRP	83.3	100	55.5	66.6	100	100	50
AZM	13.6	0	33.3	88.8	100	100	100
GEN	-	-	-	88.8	100	50	50

Bloodstream infection remains a major cause of morbidity and prolonged hospital stay in children¹⁶. In neonates and infants, it is a life-threatening emergency, and therefore identifying the common bacteria and their susceptibility patterns will provide information necessary for timely intervention^17,18. In this study, neonatal sepsis was more frequent in among male neonates (43.53%) than female neonates (41.17%).This may be due to presence of single X chromosome in male than double chromosome found in female¹⁹. The increased numbers of male cases in present study may be gender bias in presentation to hospital for care, place of study, samples and other factors²⁰.

In this study, early onset sepsis cases were found to be higher than late onset sepsis. This is supported by several other studies, early onset was noted in 95%, while late onset only 5% ²¹.The early and late onset sepsis in Al- Shifa Hospital was 81.2% (91) and 18.8% ²². The early onset septicemia occurred to 16 infants (47.06%) and late onset septicemia occurred in 18 cases (52.94%) ²³. The increased early onset sepsis might be due to the fact that they have not been given prophylactic drugs, prematurity and low birth weight of neonates.

In this present study, the most common causative agents of neonatal sepsis was Staphylococcus aureus (86.9%) followed by Klebsiella pneumoniae (60%), Enterococci sp (11.9%) and others. Staphylococcus aureus as most common pathogen of neonatal sepsis has also been reported by other investigators from Nepal^{24,25,26,27,28}.However, our finding was highest as compared to the findings reported by others from Nepal which ranged from 16.7% to 50%^{24,25,26,27,28}. The prevalence in neonatal septicemia due to the fact that Staphylococcus aureus is common hospital acquired organisms and there is high transmission to neonates from health care workers and relatives²⁹.It has been reported that Klebsiella pneumoniae was more prominent because it is known that Gram negative organisms are dominant flora in pregnant females increasing the probability of these organisms gaining access to nurseries and causing infection³⁰.

Drug resistance of microorganisms causing neonatal sepsis is a rapidly emerging, potentially a disastrous problem. The situation is worse in developing countries because of lack of legislation, over the counter sale of antibiotics, poor sanitary conditions, lack of surveillance of the standards of maternity homes and the practices of traditional birth attendants. Staphylococcus aureus and Enterococci sp shown resistant to all antibiotics that has been used but streptococcus sp shown both sensitivity as well as resistant against antibiotics to be used. Regarding the gram negative isolates, Klebsiella pneumoniae was the most resistant pathogen among Gram-negative rods. Findings of this study are in accordance with the previous studies showing more than 70% of K. pneumoniae and E. coli resistant to various antibiotics in India and Pakistani hospital^31,32. WHO also have reported the high incidence of AMR against against common pathogens including (K. pneumoniae, E. coli, E. cloacae and S. aureus) in NS. Various other studies have also highlighted the frequently isolated pathogens including S. aureus and CoNS as mentioned by various workers^{13, 34}.

CONCLUSION:

Neonatal sepsis is common in our setting and has high mortality; convulsion, lethargy, inability to feed and significantly contributed by positive blood culture with multi-resistant gram negative and positive bacteria. Guidelines for management of neonatal sepsis in developing countries are needed so that morbidity and mortality of sepsis due to highly prevalent multi-resistant gram negative bacteria and MRSA can be reduced.

THE CONFLICT OF INTEREST:

Authors does not have any conflict of interest.

ACKNOWLEDGEMENT:

We are grateful to our chairman Prof. Dr.Jainudin Ansari for his kind co-operation to complete our research.

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Received on 09.01.2018 Modified on 15.03.2018

Research J. Pharm. and Tech 2018; 11(6): 2238-2242.

DOI: 10.5958/0974-360X.2018.00414.6