Perinatal risk factors in neonatal infections

Prevalence, perinatal outcomes and factors associated with neonatal sepsis in Nigeria

OBJECTIVE

To examine the prevalence, perinatal outcomes and factors associated with neonatal sepsis in referral-level facilities across Nigeria.

DESIGN

Secondary analysis of data from the Maternal and Perinatal Database for Quality, Equity and Dignity Programme in 54 referral-level hospitals across Nigeria.

SETTING

Records covering the period from 1 September 2019 to 31 August 2020.

POPULATION

Mothers admitted for birth during the study period, and their live newborns.

METHODS

Analysis of prevalence and sociodemographic and clinical factors associated with neonatal sepsis and perinatal outcomes. Multilevel logistic regression modelling identified factors associated with neonatal sepsis.

MAIN OUTCOME MEASURES

Neonatal sepsis and perinatal outcomes.

RESULTS

The prevalence of neonatal sepsis was 16.3 (95% CI 15.3-17.2) per 1000 live births (1113/68 459) with a 10.3% (115/1113) case fatality rate. Limited education, unemployment or employment in sales/trading/manual jobs, nulliparity/grand multiparity, chronic medical disorder, lack of antenatal care (ANC) or ANC outside the birthing hospital and referral for birth increased the odds of neonatal sepsis. Birthweight of <2500 g, non-spontaneous vaginal birth, preterm birth, prolonged rupture of membranes, APGAR score of <7 at 5 min, birth asphyxia, birth trauma or jaundice were associated with neonatal sepsis. Neonates with sepsis were more frequently admitted to a neonatal intensive care unit (1037/1110, 93.4% vs 8237/67 346, 12.2%) and experienced a higher rate of death (115/1113, 10.3% vs 933/67 343, 1.4%).

CONCLUSIONS

Neonatal sepsis remains a critical challenge in neonatal care, underscored by its high prevalence and mortality rate. The identification of maternal and neonatal risk factors underscores the importance of improved access to education and employment for women and targeted interventions in antenatal and intrapartum care.

Prevalence and Factors Associated with Neonatal Sepsis in a Tertiary Hospital, North West Nigeria

Context:

Neonatal sepsis is an important cause of morbidity and mortality of newborns, especially in developing countries.

Aims:

Our study determined the prevalence of neonatal sepsis and its predisposing factors among neonates admitted in Ahmadu Bello University Teaching Hospital (ABUTH).

Settings and Design:

This was a cross-sectional descriptive study conducted in ABUTH.

Subjects and Methods:

The data were abstracted from the case notes of neonates admitted from May 2017 to May 2018. A pretested pro forma was used to abstract the data.

Statistical Analysis Used:

Odds ratios and multivariate logistic regression were used to determine the factors associated with neonatal sepsis among the study population.

Results:

The prevalence of neonatal sepsis was 37.6%. Escherichia coli was the most commonly isolated organism. Neonates 0–7 days of age were 2.8 times less likely to develop neonatal sepsis than older neonates. Babies born with an Apgar score of <6 within the 1^st min were 2.4 times more likely to develop neonatal sepsis than those whose Apgar score was higher. Neonates of mothers who had urinary tract infection during pregnancy were 2.3 times more likely to have had sepsis and those whose mothers had premature rupture of membranes were 4.6 times more likely.

Conclusions:

The prevalence of neonatal sepsis was high among the neonates studied. Neonatal and maternal factors were associated with sepsis in the neonates. These findings provide guidelines for the selection of empirical antimicrobial agents in the study site and suggest that a continued periodic evaluation is needed to anticipate the development of neonatal sepsis among neonates admitted.

Epidemiology of Early-onset Bacterial Neonatal Infections in Madagascar

BACKGROUND

Little is known about early-onset neonatal bacterial infections (EONBI) in Madagascar. Our aim was to determine their epidemiology to improve their management.

METHODS

Inborn neonates at risk for EONBI and admitted in the neonatal unit of 2 tertiary hospitals in Antananarivo, Madagascar, were included in a prospective study from April 2012 to March 2013. Using a clinical algorithm, blood culture, gastric fluid culture and C-reactive protein dosage were performed in newborns at high risk of infection, that is, peri partum fever, prematurity <35 weeks' gestation or birth weight <2000 g, or presenting with clinical signs of infection. EONBI was defined as a bacteremia occurring within the first week of life.

RESULTS

Among 307 neonates, 75 (24.4%) had an EONBI caused by 1 (n = 59) or 2 (n = 16) bacteria (91 isolates). Gram-negative bacteria were predominant (n = 62, 82.7%), including Enterobacter cloacae (n = 26), Klebsiella pneumoniae (n = 14), Escherichia coli (n = 7) and Proteus mirabilis (n = 2). Group B Streptococcus, Acinetobacter baumanii and Enterococcus sp. represented 3.6%, 8.2% and 12.1% of the isolates, respectively. All E. cloacae and 12/14 (85.7%) K. pneumoniae were extended-spectrum β-lactamase producers. At all, 41/91 (45.1%) bacteria were multidrug-resistant (MDR) and 34/75 (45.3%) newborns had an EONBI caused by an MDR bacteria. Neonatal asphyxia was the only factor associated with multidrug resistance (odds ratio: 4.52; CI: 1.20-16.94; P = 0.025). The EONBI-related mortality (n = 20/75, 26.7%) rose up to 38.2% (n = 13/34) in case of MDR bacteria.

CONCLUSIONS

The epidemiology of EONBIs in Madagascar is comparable to that found in many low-income countries. Prevention, including improvement of hygiene during resuscitation for neonatal asphyxia, is likely to be more effective in reducing EONBI-related morbidity and mortality than using new antibiotics to counter resistance.

Risk Factors for Neonatal Sepsis in Public Hospitals of Mekelle City, North Ethiopia, 2015: Unmatched Case Control Study

OBJECTIVES

Neonatal sepsis is a leading cause of neonatal morbidity and mortality, particularly in the developing countries. Delays in the identification and treatment of neonatal sepsis are among the main contributors to the high mortality. The aim of this study was to determine the risk factors of neonatal sepsis in public hospitals of Mekelle City, Tigray Region, North Ethiopia, 2015.

METHODS

A hospital based case control study was done in public hospitals of Mekelle City, Tigray region. Cases were neonates who had sepsis with their index mothers and controls were neonates who hadn't had sepsis with their index mothers. Hematologic findings were used to diagnose sepsis once the neonates were being clinically suspected. Cases and controls were selected using the systematic sampling technique. Data were entered using Epi info version 7 and then analyzed using SPSS window 20. The binary logistic regression model was used to test the association between dependent and independent variables and multivariable logistic regression was used to identify the associated risk factors to neonatal sepsis.

FINDINGS

A total of 78 cases and 156 controls were included in this study. More than three quarters (76.8%) of cases had early onset sepsis. The multivariable logistic regression analysis showed that the possible risk factors of neonatal sepsis in this study were; history of maternal urinary tract infection or sexually transmitted infection [AOR = 5. 23; 95% CI (1.82, 15.04)], prolonged rupture of membrane [AOR = 7. 43; 95% CI (2.04, 27.1)], Place of delivery; health center delivery [AOR = 5. 7; 95% CI (1.71, 19.03)], intrapartum fever [AOR = 6. 1 95% CI (1.29, 28.31)], APGAR score <7 at 5th minute [AOR = 68. 9; 95% CI (3.63, 1308)] and not crying immediately at birth [AOR = 124. 0; 95% CI (6.5, 2379)].

CONCLUSION

Both maternal and neonatal factors had contributed to the risk of neonatal sepsis. Strengthening of the existing risk based prevention strategies as well as improvement of institutional delivery practices are crucial.

Predictive values for procalcitonin in the diagnosis of neonatal sepsis

BACKGROUND

Early diagnosis of neonatal sepsis followed by appropriate treatment decreases mortality and morbidity in infants. The aim of this study is to assess the role of procalcitonin (PCT) as a marker in the early diagnosis of neonatal sepsis.

METHODS

We present a cross sectional study where 35 neonates with early onset sepsis (admitted to the Neonatal Intensive Care Units at El-Minia Children University Hospital from August 2012 to August 2013) were included in the study. Another 35 healthy neonates with no clinical or biological data of infection were included as a control group. Subjects were subjected to a thorough history taking and routine laboratory investigations. Serum PCT and C-reactive protein (CRP) levels were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Mean levels of PCT and CRP in neonates with sepsis were significantly higher than in the control group (p=0.0001). There was a moderate, but significant, positive correlation between PCT and C-reactive protein (p=0.001, r=0.55) and an insignificant correlation between procalcitonin and total leukocytic count among the neonates with sepsis (p=0.2, r=0.2). In addition, procalcitonin had high sensitivity, specificity, a high positive predictive value, and a high negative predictive value (80%, 85.7%, 84.8%, and 81.1% respectively). Procalcitonin showed higher sensitivity when compared to CRP.

CONCLUSION

Procalcitonin is a sensitive, independent, and useful biomarker in comparison to CRP in early diagnosis of neonatal sepsis.

Care-seeking behavior and out-of-pocket expenditure for sick newborns among urban poor in Lucknow, northern India: a prospective follow-up study

Background

The state of Uttar Pradesh, India accounts for one-quarter of India's neonatal deaths and 8 percent of those worldwide. More than half (52%) of these deaths occur due to infections. In order to achieve Millennium Development Goal-4 of reducing child mortality by two-thirds by the year 2015, it is important to study factors which affect neonatal health. In Uttar Pradesh there is meager data for spending on health care in general and neonates in particular.

Methods

The study was conducted at an urban Reproductive and Child Health (RCH) center and a District hospital. Neonates were enrolled within 48 hours of birth and were followed-up once at 6 weeks ± 15 days at the OPD of the respective hospitals or at home. This study assessed (1) distribution of neonatal illnesses and different health providers sought (2) distribution of out-of-pocket expenditures by type of illness and type of health provider sought (3) socio-economic distribution of neonatal illnesses, care-seeking behavior and out-of-pocket expenditures. Per-protocol analysis was performed.

Results

Five hundred and ten neonates were enrolled and 481(94.4%) were followed-up. Parents of 50.3% (242/481) neonates reported at least one symptom of illness. Of these 22.3% (107/481) neonates had illnesses with at least one reported Integrated Management of Neonatal and Childhood Illnesses (IMNCI) danger sign. Among IMNCI illnesses, point prevalence of septicemia was 6.2% and pneumonia was 5.2% while among non-IMNCI illnesses point prevalence of upper respiratory infection was 9.5%, and diarrhea was 7%. Community based non-government dispensers (NGDs) were leading health providers (37.6%). Mean monthly income of families was 2804 Indian Rupees (INR) (range: 800 to 14000; n = 510), where US$ 1 = 42 INR. Mean out-of-pocket expenditure on neonatal illness was 547.5 INR (range: 1 to 15000; n = 202) and mean out-of-pocket expenditure for hospitalization was 4993 INR (range: 41 to 15000; n = 17). All hospitalizations were for IMNCI illnesses. Neonates from lower income strata were less likely to receive any medical care (p < 0.0001) and were also less likely to be seen by a Government provider (p = 0.03).

Conclusion

Since more than half of the neonates have morbidity and out-of-pocket expenditure on neonatal illnesses often exceeds the family income of the lower strata of the low income group in the community, there is a need to either introduce health insurance scheme or subsidize health care for them. Also, since NGDs, half of which could be unqualified are leading health providers, qualified medical care-seeking for sick newborns should be promoted in urban Lucknow.

Hospital-acquired neonatal infections in developing countries

Hospital-born babies in developing countries are at increased risk of neonatal infections because of poor intrapartum and postnatal infection-control practices. We reviewed data from developing countries on rates of neonatal infections among hospital-born babies, range of pathogens, antimicrobial resistance, and infection-control interventions. Reported rates of neonatal infections were 3-20 times higher than those reported for hospital-born babies in industrialised countries. Klebsiella pneumoniae, other gram-negative rods (Escherichia coli, Pseudomonas spp, Acinetobacter spp), and Staphylococcus aureus were the major pathogens among 11,471 bloodstream isolates reported. These infections can often present soon after birth. About 70% would not be covered by an empiric regimen of ampicillin and gentamicin, and many might be untreatable in resource-constrained environments. The associated morbidity, mortality, costs, and adverse effect on future health-seeking behaviour by communities pose barriers to improvement of neonatal outcomes in developing countries. Low-cost, "bundled" interventions using systems quality improvement approaches for improved infection control are possible, but should be supported by evidence in developing country settings.

Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence

BACKGROUND

Infant and under-5 childhood mortality rates in developing countries have declined significantly in the past 2 to 3 decades. However, 2 critical indicators, maternal and newborn mortality, have hardly changed. World leaders at the United Nations Millennium Summit in September 2000 agreed on a critical goal to reduce deaths of children <5 years by two thirds, but this may be unattainable without halving newborn deaths, which now comprise 40% of all under-5 deaths. Greater emphasis on wide-scale implementation of proven, cost-effective measures is required to save women's and newborns' lives. Approximately 99% of neonatal deaths take place in developing countries, mostly in homes and communities. A comprehensive review of the evidence base for impact of interventions on neonatal health and survival in developing-country communities has not been reported.

OBJECTIVE

This review of community-based antenatal, intrapartum, and postnatal intervention trials in developing countries aimed to identify (1) key behaviors and interventions for which the weight of evidence is sufficient to recommend their inclusion in community-based neonatal care programs and (2) key gaps in knowledge and priority areas for future research and program learning.

METHODS

Available published and unpublished data on the impact of community-based strategies and interventions on perinatal and neonatal health status outcomes were reviewed. Evidence was summarized systematically and categorized into 4 levels of evidence based on study size, location, design, and reported impact, particularly on perinatal or neonatal mortality. The evidence was placed in the context of biological plausibility of the intervention; evidence from relevant developed-country studies; health care program experience in implementation; and recommendations from the World Health Organization and other leading agencies.

RESULTS

A paucity of community-based data was found from developing-country studies on health status impact for many interventions currently being considered for inclusion in neonatal health programs. However, review of the evidence and consideration of the broader context of knowledge, experience, and recommendations regarding these interventions enabled us to categorize them according to the strength of the evidence base and confidence regarding their inclusion now in programs. This article identifies a package of priority interventions to include in programs and formulates research priorities for advancing the state of the art in neonatal health care.

CONCLUSIONS

This review emphasizes some new findings while recommending an integrated approach to safe motherhood and newborn health. The results of this study provide a foundation for policies and programs related to maternal and newborn health and emphasizes the importance of health systems research and evaluation of interventions. The review offers compelling support for using research to identify the most effective measures to save newborn lives. It also may facilitate dialogue with policy makers about the importance of investing in neonatal health.

Chorioamnionitis, not epidural analgesia, is associated with maternal fever during labour

PURPOSE

Maternal fever is associated with chorioamnionitis and has been linked to labour epidural analgesia (LEA). The purpose of this study was to determine possible associations between LEA and chorioamnionitis, maternal fever, operative delivery rate, and neonatal outcome.

METHODS

Data from 14,073 patients were entered into a database over a two-year period. From this database, 62 nulliparous parturients with clinical chorioamnionitis (amnionitis), but without LEA were identified (Group I). Two other groups who received LEA were matched for parity and gestation: Group II - LEA with concomitant amnionitis (n=50) and, Group III - LEA without concomitant amnionitis (n=201). The diagnosis of chorioamnionitis was confirmed by histologic examination. Results are expressed as mean +/- SD and analyzed at P <0.05 using ANOVA or Chi-square.

RESULTS

No differences were noted among the groups in the operative delivery rate or Apgar scores at five minutes. The percentage of patients with maternal fever during labour (38.0 degrees C) with amnionitis was significantly less in Group III compared to the other groups (100% in both Groups I and II vs 1.0% in Group III; P=0.000). Likewise, Group III had a lower percentage of neonates with Apgar scores <7 at one minute (35.5% in Group I, 20.0% in Group II, 17.4% in Group III; P=0.010). The percentage of histologic chorioamnionitis was significantly higher in both amnionitis groups compared to Group III (67.7% in Group I, 56.0% in Group II, 4.0% in Group III; P=0.000).

CONCLUSION

LEA without chorioamnionitis is not associated with maternal fever (38.0 degrees C), increased operative delivery rates or low Apgar scores.