Neonatal sepsis in rural India: timing, microbiology and antibiotic resistance in a population-based prospective study in the community setting

Late onset neonatal sepsis: Can plasma gelsolin be a promising diagnostic marker?

Plasma gelsolin (pGSN) correlates with clinical improvement in septic patients. We aimed to investigate pGSN levels as a diagnostic and prognostic marker of neonatal late-onset-sepsis (LOS). A case-control study was done on 184 neonates (92 with LOS and 92 controls). All participants were subjected to detailed history taking, full clinical evaluation, sepsis workup, and pGSN enzyme-linked immunosorbent-assay measurement. We detected significantly lower pGSN level among cases compared to controls (90.63 ± 20.64 vs 451.83 ± 209.59). It was significantly related to the severity of sepsis and mortality, with significantly lower values among cases with septic shock and multiorgan failure and non-survivors. Follow-up pGSN significantly increased after sepsis improvement in survivors compared to admission values. pGSN might be a reliable diagnostic and prognostic marker for LOS.

World Health Organization Danger Signs to predict bacterial sepsis in young infants: A pragmatic cohort study

Bacterial sepsis is generally a major concern in ill infants. To help triaging decisions by front-line health workers in these situations, the World Health Organization (WHO) has developed danger signs (DS). The objective of this study was to evaluate the extent to which nine DS predict bacterial sepsis in young infants presenting with suspected sepsis in a low-income country setting. The study pragmatically evaluated nine DS in infants younger than 3 months with suspected sepsis in a regional hospital in Lilongwe, Malawi, between June 2018 and April 2020. Main outcomes were positive blood or cerebrospinal fluid (CSF) cultures for neonatal pathogens, and mortality. Among 401 infants (gestational age [mean ± SD]: 37.1±3.3 weeks, birth weight 2865±785 grams), 41 had positive blood or CSF cultures for a neonatal pathogen. In-hospital mortality occurred in 9.7% of infants overall (N = 39/401), of which 61.5% (24/39) occurred within 48 hours of admission. Mortality was higher in infants with bacterial sepsis compared to other infants (22.0% [9/41] versus 8.3% [30/360]; p = 0.005). All DS were associated with mortality except for temperature instability and tachypnea, whereas none of the DS were significantly associated with bacterial sepsis, except for "unable to feed" (OR 2.25; 95%CI: 1.17-4.44; p = 0.017). The number of DS predicted mortality (OR: 1.75; 95%CI: 1.43-2.17; p<0.001; AUC: 0.756), but was marginally associated with positive cultures with a neonatal pathogen (OR 1.22; 95%CI: 1.00-1.49; p = 0.046; AUC: 0.743). The association between number of DS and mortality remained significant after adjusting for admission weight, the only statistically significant co-variable (OR 1.75 [95% CI: 1.39-2.23]; p<0.001). Considering all positive cultures including potential bacterial contaminants resulted a non-significant association between number of DS and sepsis (OR 1.09 [95% CI: 0.93-1.28]; p = 0.273). In conclusion, this study shows that DS were strongly associated with death, but were marginally associated with culture-positive pathogen sepsis in a regional hospital setting. These data imply that the incidence of bacterial sepsis and attributable mortality in infants in LMIC settings may be inaccurately estimated based on clinical signs alone.

Incidence and risk factors of neonatal bacterial infections: a community-based cohort from Madagascar (2018-2021)

BACKGROUND

Few studies on neonatal severe bacterial infection are available in LMICs. Data are needed in these countries to prioritize interventions and decrease neonatal infections which are a primary cause of neonatal mortality. The BIRDY project (Bacterial Infections and Antimicrobial Drug Resistant among Young Children) was initially conducted in Madagascar, Senegal and Cambodia (BIRDY 1, 2012-2018), and continued in Madagascar only (BIRDY 2, 2018-2021). We present here the BIRDY 2 project whose objectives were (1) to estimate the incidence of neonatal severe bacterial infections and compare these findings with those obtained in BIRDY 1, (2) to identify determinants associated with severe bacterial infection and (3) to specify the antibiotic resistance pattern of bacteria in newborns.

METHODS

The BIRDY 2 study was a prospective community-based mother and child cohort, both in urban and semi-rural areas. All pregnant women in the study areas were identified and enrolled. Their newborns were actively and passively followed-up from birth to 3 months. Data on clinical symptoms developed by the children and laboratory results of all clinical samples investigated were collected. A Cox proportional hazards model was performed to identify risk factors associated with possible severe bacterial infection.

FINDINGS

A total of 53 possible severe bacterial infection and 6 confirmed severe bacterial infection episodes were identified among the 511 neonates followed-up, with more than half occurring in the first 3 days. For the first month period, the incidence of confirmed severe bacterial infection was 11.7 per 1,000 live births indicating a 1.3 -fold decrease compared to BIRDY 1 in Madagascar (p = 0.50) and the incidence of possible severe bacterial infection was 76.3, indicating a 2.6-fold decrease compared to BIRDY 1 in Madagascar (p < 0.001). The 6 severe bacterial infection confirmed by blood culture included 5 Enterobacterales and one Enterococcus faecium. The 5 Enterobacterales were extended-spectrum β-lactamases (ESBL) producers and were resistant to quinolones and gentamicin. Enterococcus faecium was sensitive to vancomycin but resistant to amoxicillin and to gentamicin. These pathogns were classified as multidrug-resistant bacteria and were resistant to antibiotics recommended in WHO guidelines for neonatal sepsis. However, they remained susceptible to carbapenem. Fetid amniotic fluid, need for resuscitation at birth and low birth weight were associated with early onset possible severe bacterial infection.

CONCLUSION

Our results suggest that the incidence of severe bacterial infection is still high in the community of Madagascar, even if it seems lower when compared to BIRDY 1 estimates, and that existing neonatal sepsis treatment guidelines may no longer be appropriate in Madagascar. These results motivate to further strengthen actions for the prevention, early diagnosis and case management during the first 3 days of life.

The functional repertoire of AmpR in the AmpC β-lactamase high expression and decreasing β-lactam and aminoglycosides resistance in ESBL Citrobacter freundii

Citrobacter freundii is characterized by AmpC β-lactamases that develop resistance to β-lactam antibiotics. The production of extended-spectrum β-lactamase (ESBL) is substantially high in Escherichia coli, C. freundii, Enterobacter cloacae, and Serratia marcescens, but infrequently explored in C. freundii. The present investigation characterized the ESBL C. freundii and delineated the genes involved in decrease in antibiotics resistance. We used the VITEK-2 system and Analytical Profile Index (API) kit to characterize and identify the Citrobacter isolates. The mRNA level of AmpC and AmpR was determined by RT-qPCR, and gel-shift assay was performed to evaluate protein-DNA binding. Here, a total of 26 Citrobacter strains were isolated from COVID-19 patients that showed varying degrees of antibiotic resistance. We examined and characterized the multidrug resistant C. freundii that showed ESBL production. The RT-qPCR analysis revealed that the AmpC mRNA expression is significantly high followed by a high level of AmpR. We sequenced the AmpC and AmpR genes that revealed the AmpR has four novel mutations in comparison to the reference genome namely; Thr64Ile, Arg86Ser, Asp135Val, and Ile183Leu while AmpC remained intact. The ΔAmpR mutant analysis revealed that the AmpR positively regulates oxidative stress response and decreases β-lactam and aminoglycosides resistance. The AmpC and AmpR high expression was associated with resistance to tazobactam, ampicillin, gentamicin, nitrofurantoin, and cephalosporins whereas AmpR deletion reduced β-lactam and aminoglycosides resistance. We conclude that AmpR is a positive regulator of AmpC that stimulates β-lactamases which inactivate multiple antibiotics.

Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS)

BACKGROUND

There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design.

METHODS AND FINDINGS

Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability.

CONCLUSION

Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT03721302).

Availability, Prices and Affordability of Antibiotics Stocked by Informal Providers in Rural India: A Cross-Sectional Survey

Providers without formal training deliver healthcare and antibiotics across rural India, but little is known about the antibiotics that they stock. We conducted a cross-sectional survey of such informal providers (IPs) in two districts of West Bengal, and assessed the availability of the antibiotics, as well as their sales volumes, retail prices, percentage markups for IPs and affordability. Of the 196 IPs that stocked antibiotics, 85% stocked tablets, 74% stocked syrups/suspensions/drops and 18% stocked injections. Across all the IPs, 42 antibiotic active ingredients were stocked, which comprised 278 branded generics from 74 manufacturers. The top five active ingredients that were stocked were amoxicillin potassium clavulanate (52% of the IPs), cefixime (39%), amoxicillin (33%), azithromycin (25%) and ciprofloxacin (21%). By the WHO's AWaRe classification, 71% of the IPs stocked an ACCESS antibiotic and 84% stocked a WATCH antibiotic. The median prices were in line with the government ceiling prices, but with substantial variation between the lowest and highest priced brands. The most affordable among the top five tablets were ciprofloxacin, azithromycin, cefixime and amoxicillin (US$ 0.8, 0.9, 1.9 and 1.9 per course), and the most affordable among the syrups/suspensions/drops were azithromycin and ofloxacin (US$ 1.7 and 4.5 per course, respectively), which are mostly WATCH antibiotics. IPs are a key source of healthcare and antibiotics in rural communities; practical interventions that target IPs need to balance restricting WATCH antibiotics and expanding the basket of affordable ACCESS antibiotics.

Treatment of MRSA infections in India: Clinical insights from a Delphi analysis

PURPOSE

International and Indian guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections are available, but the local guidelines are not MRSA-specific. This study aimed to provide clinical insights for the treatment of MRSA infections in India.

METHODS

We used a three-step modified Delphi method to obtain insights. Ten experts comprising infectious disease specialists, microbiologists, pulmonologists, and critical care experts agreed to participate in the analysis. In round 1, a total of 161 statements were circulated to the panel and the experts were asked to 'agree' or 'disagree' by responding 'yes' or 'no' to each statement and provide comments. The same process was used for 73 statements in round 2. Direct interaction with the experts was carried out in round 3 wherein 35 statements were discussed. At least 80% of the experts had to agree for a statement to reach concordance.

RESULTS

Eighty-eight statements in round 1, thirty-eight statements in round 2, and eight statements in round 3 reached concordance and were accepted without modification. The final document comprised 152 statements on the management of various syndromes associated with MRSA such as skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections.

CONCLUSIONS

This analysis will assist clinicians in India to choose an appropriate course of action for MRSA infections.

Comparison of efficacy of a 7-day versus a 14-day course of intravenous antibiotics in the treatment of uncomplicated neonatal bacterial sepsis: study protocol of a randomized controlled non-inferiority trial

BACKGROUND

Neonatal sepsis is a global public health problem. There is no consensus regarding the optimum duration of antibiotics for culture-proven neonatal sepsis. Published randomized controlled trials (RCTs) comparing shorter versus longer courses of antibiotics provide low-quality evidence with serious risk of bias. We hypothesized that among neonates with uncomplicated culture-proven sepsis, antibiotic duration of 7 days is not inferior to 14 days.

METHODS

This is a multi-centric, parallel-group, stratified, block-randomized, active-controlled, non-inferiority trial with outcome assessment blinded. Stratification is by center and birth weight. Neonates weighing ≥1000 g at birth, with blood-culture-proven sepsis (barring Staphylococcus aureus and fungi), without conditions warranting > 14 days antibiotics, and who clinically remit, are enrolled in the RCT on day 7 of administration of sensitive antibiotics. They are randomly allocated to no further antibiotics (intervention arm: total 7 days) or 7 more days of the same antibiotics (control arm: total 14 days). Allocation is concealed by opaque, sealed envelopes. The primary outcome is "definite or probable relapse" within 21 days after antibiotic completion. Secondary outcomes include definite and probable relapses at various timepoints until day 35 post-randomization, secondary infections, and adverse events. The neonatologist adjudicating probable relapses and lab personnel are blinded. Three hundred fifty subjects will be recruited in each arm, assuming a non-inferiority margin of 7%, one-sided alpha error 5%, and power of 90%. Analysis will be per protocol and by intention-to-treat. An independent Data Safety Monitoring Board monitors adverse events and will perform one interim analysis when 50% of expected primary outcomes have occurred or 50% of subjects have completed follow-up, whichever is earlier. O'Brien-Fleming criteria will be used to stop for mid-term benefit and Pocock's to stop for mid-term harm. A priori subgroup analyses are planned by birth weight categories, gram-stain status of pathogens, and radiological pneumonia.

DISCUSSION

This trial will provide evidence to guide practice regarding optimum duration of antibiotics for culture-proven neonatal bacterial sepsis. If a 7-day regime is proved to be non-inferior to a 14-day regime, it is likely to reduce hospital stay, costs, adverse effects of drugs, and nosocomial infections.

TRIAL REGISTRATION

Clinical Trials Registry India CTRI/2017/09/009743 . Registered on 13 September 2017.

Epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary hospital in Northern India

AIMS AND OBJECTIVES

To study the epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary care teaching hospital in Northern India.

MATERIALS AND METHODS

Neonates (n = 406) with blood culture positive sepsis were enrolled prospectively over a period of 1 year (February 2018-January 2019). Demographic details, clinical features, microbiological profile, antibiotic sensitivity pattern, treatment, and outcome were recorded.

RESULTS

The mean (±SD) age at presentation was 2.4 (±0.6) days and 2/3rd were males. The mean (±SD) gestation was 35.5 (±3.4) weeks, birth weight was 2215 (±219) g, and 42.4% were preterm. The proportion of neonates with early and late onset sepsis were 69% and 31%, respectively. Predominant isolates were Gram-negative (46.5%), Gram-positive (27.6%) organisms, and yeast (25.9%). Klebsiella pneumoniae (46.5%), Acinetobacter baumannii (17.5%), and Escherichia coli (8%) were common Gram-negative; and coagulase negative Staphylococcus (CONS) (70%), Staphylococcus aureus (13.4%), and Enterococcus (12.5%) were common Gram-positive organisms. Among Gram-negative organisms, the antibiotic sensitivity pattern was ciprofloxacin 45%, cephalosporins 15-40%, aminoglycosides 20-42%, piperacillin-tazobactam 49%, carbapenems 34-51%, tetracyclines 55-70%, doxycycline 55%, chloramphenicol 42%, and colistin 98%; and among Gram-positive organisms were methicillin 30%, clindamycin 52%, vancomycin 100%, teicoplanin 98%, and linezolid 99%. The survival rate was 60.3%. The neonates with Gram-negative sepsis had higher requirement of oxygen, mechanical ventilation, and vasoactive drugs; had more complications; and lower survival (50.3% vs. 72.3%, p= .003) when compared to Gram-positive sepsis.

CONCLUSIONS

Gram-negative organisms were commonest cause of neonatal sepsis, had low sensitivity to commonly used antibiotics, and associated with poor outcome.

Bacterial Etiology of Neonatal Sepsis, Antibiotic Susceptibility Profile, and Associated Factors at Burdwan Medical College, Burdwan, West Bengal, India

Objective Neonatal sepsis remains to be a major cause of neonatal mortality and morbidity in developing countries like India. This study was aimed to identify the bacterial isolates and study antimicrobial profile among admitted babies with neonatal sepsis.

Methods A cross-sectional retrospective study was conducted in the sick neonatal wards and neonatal intensive care unit of Burdwan Medical College from March 2017 to February 2018. A total of 299 neonates suspected of neonatal sepsis was evaluated. Diagnosis of neonatal sepsis was made through positive blood culture. Positive samples were subcultured on specific media like blood, chocolate agar, nutrient, Muller–Hinton agar, and MacConkey plates, and the organisms were identified by gram staining and biochemical reactions. Antibiotic susceptibility was tested by Kirby–Bauer disc diffusion method.

Results Overall, 118 blood cultures out of 299 patients (39.46%) were bacteria-positive. Of these, 31.3% cases had early-onset septicemia (EOS), while 68.6% had late-onset septicemia (LOS). The prevalence of sepsis was higher in males (55.9%), preterm babies (58.47%), and low birth weight neonates (37.29%). The highest bacterial strains isolated were Klebsiella spp. (33.8%) followed by Staphylococcus aureus (25.8%), Escherichia coli (22.8%), coagulase-negative Staphylococcus (12.5%), Pseudomonas spp. (2.5%), Enterococcus spp. (1.6%), Acinetobacter spp. (0.8%), and Burkholderia spp. (0.8%). Resistance is high among the gram-negative bacteria, like Enterobacter and Pseudomonas, for piperacillin–tazobactam and cephalosporins but they are mostly sensitive to meropenem, colistin, and levofloxacin. Gram-positive bacteria, like S. aureus, are mostly resistant to amoxicillin–clavulanic acid but highly sensitive to linezolid, vancomycin, azithromycin, and teicoplanin.

Conclusion K. spp. and S. aureus are the most common isolates in our study. The level of resistance among the organisms toward conventional antibiotics like amoxicillin, cephalosporins, and piperacillin–tazobactum is alarmingly high. This warrants formulation of a hospital-specific guideline for antibiotic use and periodic review of the same.

A Systemic Review and Meta-analysis of the Leading Pathogens Causing Neonatal Sepsis in Developing Countries

Background

Neonatal sepsis is one of the major public health problems globally, particularly, in developing countries. Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli are the common pathogens for neonatal sepsis in developing countries. However, the pooled estimate of common pathogens causing neonatal sepsis in developing countries is still unknown. Therefore, this study is aimed at computing the pooled proportion of the leading cause of pathogens for neonatal sepsis in developing countries.

Methods

We strictly followed the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines to report this systematic review and meta-analysis. PubMed, Cochrane Library, Web of Science, CINAHL, Science Direct, and other search engines such as Google Scholar, Africa Journals Online, and Hinari were used to obtain studies related to the leading cause of pathogens for neonatal sepsis in developing countries. The search was done from October 1 to December 30, 2018, by considering both published and gray literature. Studies were evaluated based on the PRISMA guideline checklist by using their titles, abstracts, and full texts. Studies were extracted using Microsoft Excel spreadsheets, and STATA software version 14 was used to analyze data. Heterogeneity between studies was checked based on Cochran's Q-test and the corresponding I² statistic test.

Results

The pooled prevalence of the leading cause of pathogens of neonatal sepsis in developing countries were Klebsiella (26.36%), Staphylococcus aureus (23.22%), Coagulase-negative Staphylococcus (23.22%), and Escherichia coli (15.30%). Common pathogens were varied across regions; for instance, pooled isolated Coagulase-negative Staphylococcus was 25.98% in Africa, 16.62% in Asia, and 36.71% in Latin America, and Klebsiella was 29.80% in Africa, 23.21% in Asia, and 22.00% in Latin America. Also, Staphylococcus aureus was 27.87% in Africa and 18.28% in Asia, and Escherichia coli was 22.97% in Asia and 9.43% in Africa.

Conclusions

This study highlights that the more prevalent common isolated pathogens in developing countries were Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli, Klebsiella, and Staphylococcus aureus pathogens were predominantly high in Africa as compared to other Asian and Latin American countries. At the same time, Coagulase-negative Staphylococcus was more prevalent in Latin America compared to other regions. Escherichia coli is more dominant in Asia as compared to Africa and Latin America.

Bacteriological and antibiotic profile of infection among infants in the post-neonatal period at a tertiary care hospital in South India

Purpose

Severe bacterial infection is a major cause of neonatal morbidity and mortality worldwide. Geographical-based demographic laboratory and clinical data are required to get a conclusion about the bacterial infection and their antibiotic susceptibility for the empiric antibiotic treatment in infants who presented with suspected infection. This study was aimed to find the most prevalent bacterial infection and antibiotic sensitivity among infants in the post-neonatal period presented at a tertiary care centre in South India.

Design/methodology/approach

A cross-sectional study was designed among infants (29 days to 1 year old) presented with suspected infection in the paediatric department. Infants with positive culture report were analysed for the bacteriological and antibiotic profile from the medical records. Antibiotic sensitivity was determined for the isolated bacteria according to standard procedure and data statically analysed.

Findings

Total of 218 samples (138 male and 80 female) were analysed. Most of the samples (171/218, 78.4%) were throat swab (p = 0.0247). Only one sample was cerebrospinal fluid from case of meningitis. Sample from upper RTI was major (162/218, 74.3%) with male dominance followed by stool samples from cases of diarrhoea (22/218, 10.0%). Staphylococcus aureus was the major organism identified in 46/171 (26.9 %) throat swabs. The most sensitive antibiotic against bacteria isolated from throat swab and CSF was gentamicin and cloxacillin. Netilmicin and piperacillin plus tazobactam were the sensitive antibiotics against bacteria isolated from stool, ear secretion and urine samples.

Originality/value

Upper RTI was the prevalent bacterial infection followed by diarrhoea in infants in the post-neonatal period. Klebsiella pneumoniae was the common organism identified in the overall report followed by E. coli and S. aureus. Community-based awareness should be provided to follow good hygiene regularly in child care. Furthermore, avoid delay in seeking treatment and provide the medicine prescribed at the right time and in the right dose to limit the morbidity and bacterial resistance.

Increasing Resistance to Reserve Antibiotics: The Experience of a Tertiary Level Neonatal Intensive Care Unit

BACKGROUND

Blood stream infections are considered as a major cause of morbidity and mortality in neonates. Recent trend shows increasing resistance to commonly used antibiotics.

AIMS AND OBJECTIVES

The aim of this study is to find the antibiotic susceptibility pattern of various bacteria from blood samples in neonates and associated risk factors.

METHODS

All consecutive cases of intramural neonatal sepsis were enrolled for >12 months. Before starting or changing antibiotic, blood sample under all aseptic precautions was taken for culture. Clinical and demographic details were recorded to analyze risk factors for sepsis. Antibiotic sensitivity tests were done as per CLSI 2019 guidelines.

RESULTS

Of the 898 participants, 107 showed culture positivity. Klebsiella pneumoniae (25.2%) and Coagulase-negative Staphylococcus (23.3%). The blood culture positivity rate was 11.9%. Approximately 79% of isolates were multidrug-resistant: extended-spectrum beta-lactamase 90%, carbapenemase-resistant Enterobacteriaceae 27.7% and MRSA 43%. The risk factors found to be associated with sepsis were period of gestation ≤37 weeks, meconium-stained liquor, birth weight <1500 g, mechanical ventilation, partial exchange transfusion, duration of antibiotics for >10 days and duration of both NICU stay and hospital stay for >10 days. The case fatality rate (CFR) was more due to K. pneumoniae (19.2%) and the relative risk of death was 2.53 in culture-positive cases with an attributable risk of 60% and the population attributable risk of 15.4%.

CONCLUSION

Increase in antibiotic resistance organisms can lead to an increase in the neonatal CFR, so regular surveillance is needed.

Global incidence and mortality of neonatal sepsis: a systematic review and meta-analysis

BACKGROUND

Neonates are at major risk of sepsis, but data on neonatal sepsis incidence are scarce. We aimed to assess the incidence and mortality of neonatal sepsis worldwide.

METHODS

We performed a systematic review and meta-analysis. 13 databases were searched for the period January 1979-May 2019, updating the search of a previous systematic review and extending it in order to increase data inputs from low-income and middle-income countries (LMICs). We included studies on the population-level neonatal sepsis incidence that used a clinical sepsis definition, such as the 2005 consensus definition, or relevant ICD codes. We performed a random-effects meta-analysis on neonatal sepsis incidence and mortality, stratified according to sepsis onset, birth weight, prematurity, study setting, WHO region and World Bank income level.

RESULTS

The search yielded 4737 publications, of which 26 were included. They accounted for 2 797 879 live births and 29 608 sepsis cases in 14 countries, most of which were middle-income countries. Random-effects estimator for neonatal sepsis incidence in the overall time frame was 2824 (95% CI 1892 to 4194) cases per 100 000 live births, of which an estimated 17.6% 9 (95% CI 10.3% to 28.6%) died. In the last decade (2009-2018), the incidence was 3930 (95% CI 1937 to 7812) per 100 000 live births based on four studies from LMICs. In the overall time frame, estimated incidence and mortality was higher in early-onset than late-onset neonatal sepsis cases. There was substantial between-study heterogeneity in all analyses. Studies were at moderate to high risk of bias.

CONCLUSION

Neonatal sepsis is common and often fatal. Its incidence remains unknown in most countries and existing studies show marked heterogeneity, indicating the need to increase the number of epidemiological studies, harmonise neonatal sepsis definitions and improve the quality of research in this field. This can help to design and implement targeted interventions, which are urgently needed to reduce the high incidence of neonatal sepsis worldwide.

A Cross-sectional Study of Group B Streptococcus-Associated Sepsis, Coinfections, and Antibiotic Susceptibility Profile in Neonates in Pakistan

BACKGROUND

Neonatal sepsis is a leading cause of morbidity and early-life mortality worldwide, and previous data have reported the highest neonatal mortality rate in Pakistan.

PURPOSE

The present study aimed to decipher the prevalence of group B Streptococcus (GBS)-associated sepsis, coinfections, and antibiotic susceptibility of isolated microbes in neonates.

METHODS

Blood samples of 100 cases of neonatal sepsis were subcultured on blood agar, GBS agar, and MacConkey agar for isolation of GBS and suspected microbes.

RESULTS

Of 100 neonatal blood samples, 85 blood samples were culture-positive, including mixed culture growth (n = 18), 25 samples as early-onset neonatal sepsis (EONS) and 60 as late-onset neonatal sepsis (LONS). Staphylococcus aureus showed high percent positivity (31.4%), followed by Candida sp (16.5%), GBS (14.1%), Klebsiella (14.1%), Staphylococcus epidermidis (11.8%), Pseudomonas (9.4%), Acinetobacter (9.4%), Esherichia coli (8.2%), and Enterococcus (5.9%). GBS was isolated more frequently from EONS than from LONS with 50% coinfections. Mode of delivery, gender, and respiratory distress in neonates were significantly associated with culture-positive sepsis. GBS isolates were highly (91.7%) susceptible to vancomycin, cefotaxime, and chloramphenicol, followed by penicillin (83.3%), ampicillin, and tetracycline (75%). GBS isolates were resistant to erythromycin, clindamycin, ciprofloxacin, and linezolid.

IMPLICATIONS FOR PRACTICE

Our findings evidenced GBS-associated risk factors and antibiotic susceptibility pattern of neonatal sepsis, which will help clinicians in management, control, and treatment of neonatal sepsis.

IMPLICATIONS FOR RESEARCH

The epidemiological evidence of GBS-associated neonatal sepsis, demographic characteristics, risk factor data analysis, and drug resistance pattern has disease prevention implications in neonates in low-income countries including Pakistan.

Antimicrobial therapy utilization in neonates with hypoxic-ischemic encephalopathy (HIE): a report from the Children's Hospital Neonatal Database (CHND)

OBJECTIVE(S)

Quantify antimicrobial therapy (AMT) use in newborns with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia (HIE/TH).

STUDY DESIGN

Newborns with HIE/TH were identified from the Children's Hospital Neonatal Database (CHND). Early infection (onset ≤7 days of life) was defined as "confirmed" (culture proven) or "suspected infection" (culture negative but treated) and compared with a "no infection" group.

RESULTS

1501/1534 (97.8%) neonates received AMT. 36 (2.3%) had confirmed, 255 (16.6%) suspected, and 1243 (81.0%) had no infection. The median (IQR) AMT duration was 13 (8-21), 8 (7-10), and 3 (3-7) days for the three groups, respectively (p < 0.001). AMT duration of use varied significantly across centers, adjusted for covariates (OR 1.88, 95% CI: 1.43-2.46).

CONCLUSION(S)

Incidence of early confirmed infection in neonates with HIE/TH (23/1000) is significantly higher than reported rates of early onset sepsis in term and near term infants (0.5-1.0/1000 live births). Antimicrobial-stewardship opportunities exist in infants with negative cultures.

Nanoparticles from Actinobacteria: A Potential Target to Antimicrobial Therapy

Nanoparticles have gained significant importance in the past two decades, due to their multifaceted applications in the field of nanomedicine. As our ecosystems and habitats are changing due to global warming, many new diseases are emerging continuously. Treating these costs a lot of money and mostly ends up in failure. In addition, frequent use of antibiotics to control the emerging diseases has led the pathogens to develop resistance to antibiotics. Hence, the nanoparticles are targeted to treat such diseases instead of the costly antibiotics. In particular, the biosynthesized nanoparticles have received considerable attention due to their simple, eco-friendly and promising activity. To highlight, microbial mediated nanoparticles have been found to possess higher activity and thus have a promising role in antimicrobial therapy to fight against the emerging drug-resistant pathogens. In this context, this review article is aimed at highlight the role of nanoparticles in the field of nanomedicine and importance of actinobacteria in the nanoparticle synthesis and their need in antimicrobial therapy. This is a comprehensive review, focusing on the potential of actinobacteria-mediated nanoparticles in the field of nanomedicine.

Unfinished agenda of the neonates in developing countries: magnitude of neonatal sepsis: systematic review and meta-analysis

Purpose

Neonatal sepsis is the major cause of mortality and morbidity globally, particularly in developing countries. Despite studies revealed the extent of neonatal sepsis in developing countries, the findings were inconclusive. Therefore, the main aim of this study was to determine the pooled prevalence of neonatal sepsis in developing countries.

Methods

We used a systematic review and Meta-analysis study method. The reviewed studies were accessed through an electronic web-based search strategy from the electronic database (PUBMED), advanced google scholar, different journal sites. The data extraction was done by two researchers using a data extraction table and the disparity between data extractors was resolved by the third researcher. The analysis was done using STATA version 11. The I2 test was used to assess heterogeneity across studies. The Funnel plot, Begg's test, and Egger's test were used to check for publication bias. The random-effect model was used to determine the pooled effect size. All studies related to neonatal sepsis which fulfill the inclusion criteria were considered into this study. The quality of each study was checked using the Newcastle-Ottawa Scale and studies graded low score were excluded from the study.

Results

At the end, 36 articles fit with our study objectives. Studies conducted in Ethiopia were significant the source of heterogeneity of the study with a coefficient = 90, P-value = 0.025. The overall pooled prevalence of the study was 29.92%. The limitations of this study would be the authors were only used articles reported in the English language, and publication bias.

Conclusion

The pooled prevalence of neonatal sepsis was found to be high which accounted for a third of the neonates. Despite countries have established possible prevention and treatment mechanisms, neonatal sepsis is the major public health problem in lower and middle-income countries till now.

Risk factors of neonatal sepsis in India: A systematic review and meta-analysis

BACKGROUND

The incidence of neonatal sepsis in India is the highest in the world. Evidence regarding its risk factors can guide clinical practice and prevention strategies.

OBJECTIVE

To review, assess and synthesize the available literature from India on the risk factors of sepsis among neonates.

METHODOLOGY

A systematic review was conducted. We searched PubMed, CINAHL, Scopus, Web of Science, Popline, IndMed, Indian Science Abstracts and Google Scholar from inception up to March 23, 2018 to identify observational analytical studies reporting on risk factors of laboratory-confirmed neonatal sepsis in India. Two authors independently screened studies (title, abstract and full-text stages), extracted data, and assessed quality. A random-effects meta-analysis was performed as substantial heterogeneity was anticipated. Subgroup and sensitivity analyses were additionally performed. Effect size in our review included odds ratio and standardized mean difference.

RESULTS

Fifteen studies were included from 11,009 records, of which nine were prospective in design. Birthweight and gestational age at delivery were the most frequently reported factors. On meta-analyses, it was found that male sex (OR: 1.3, 95% CI: 1.02, 1.68), out born neonates (OR: 5.5, 95% CI: 2.39, 12.49), need for artificial ventilation (OR: 5.61; 95% CI: 8.21, 41.18), gestational age <37 weeks (OR: 2.05; 95% CI:1.40, 2.99) and premature rupture of membranes (OR:11.14, 95% CI: 5.54, 22.38) emerged as risk factors for neonatal sepsis. Included studies scored lowest on exposure assessment and confounding adjustment, which limited comparability. Inadequacy and variation in definitions and methodology affected the quality of included studies and increased heterogeneity.

CONCLUSIONS

Male neonates, outborn admissions, need for artificial ventilation, gestational age <37 weeks and premature rupture of membranes are risk factors for sepsis among neonates in India. Robustly designed and reported research is urgently needed to confirm the role of other risk factors of neonatal sepsis in India.

Gut Microbiome in Critical Illness (Review)

Radical changes in the composition, diversity and metabolic activity of gut microbiome in critically ill patients most probably affect adversely the outcome of treatment. Microbiota dysfunction may be a predictor and presumably the main cause of infectious complications and sepsis. Clinicists use objective scales for evaluation of patient condition severity including specific parameters of disorders of organs and systems; however, microbiota function is not considered specific and, hence, not evaluated. Technical capabilities of the recent decade have allowed characterizing the intestinal microbiota and that helped understanding the ongoing processes. The authors have analyzed data about the role of intestinal microbiota as a metabolic 'reactor' during critical states, possible complications related to misbalance of 'harmful' and 'beneficial' bacteria, and examined potential of a targeted therapy aimed directly at correction of intestinal microbiota. Search for papers was carried out using Scopus and Web of Science databases 2001 to 2018 years: (Gut Microbiota) AND (Critically ill OR Intensive care unit), key words taken for the search were: intestinal microbiota, metabolism, sepsis, antibiotics, critically ill patients, multiple organ failure. A number of questions in understanding of the interaction between gut microbiome and host remain open. It is necessary to take into account interference of microbial metabolism while assessing metabolome of patients with sepsis. Among low-molecular compounds found in blood of sepsis patients, special attention should be paid to molecules that can be classified as ‘common metabolites’ of humans and bacteria, for example, degradation products of aromatic compounds, which many-fold rise in blood of septic patients. It is necessary to take into consideration and experimentally model changes in the human internal environment, which occur during radical transformation of microbiome in critically ill patients. Such approach brings in new prospects for objective monitoring of diseases by evaluating metabolic profile at a particular moment of time based on integral indices reflecting the status of microbiome/metabolome system, which will supply new targets for therapeutic intervention in future.

Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study

BACKGROUND

More than 500 000 neonatal deaths per year result from possible serious bacterial infections (pSBIs), but the causes are largely unknown. We investigated the incidence of community-acquired infections caused by specific organisms among neonates in south Asia.

METHODS

From 2011 to 2014, we identified babies through population-based pregnancy surveillance at five sites in Bangladesh, India, and Pakistan. Babies were visited at home by community health workers up to ten times from age 0 to 59 days. Illness meeting the WHO definition of pSBI and randomly selected healthy babies were referred to study physicians. The primary objective was to estimate proportions of specific infectious causes by blood culture and Custom TaqMan Array Cards molecular assay (Thermo Fisher, Bartlesville, OK, USA) of blood and respiratory samples.

FINDINGS

6022 pSBI episodes were identified among 63 114 babies (95·4 per 1000 livebirths). Causes were attributed in 28% of episodes (16% bacterial and 12% viral). Mean incidence of bacterial infections was 13·2 (95% credible interval [CrI] 11·2-15·6) per 1000 livebirths and of viral infections was 10·1 (9·4-11·6) per 1000 livebirths. The leading pathogen was respiratory syncytial virus (5·4, 95% CrI 4·8-6·3 episodes per 1000 livebirths), followed by Ureaplasma spp (2·4, 1·6-3·2 episodes per 1000 livebirths). Among babies who died, causes were attributed to 46% of pSBI episodes, among which 92% were bacterial. 85 (83%) of 102 blood culture isolates were susceptible to penicillin, ampicillin, gentamicin, or a combination of these drugs.

INTERPRETATION

Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed. Given the burden of disease, prevention of respiratory syncytial virus would have a notable effect on the overall health system and achievement of Sustainable Development Goal.

FUNDING

Bill & Melinda Gates Foundation.

A randomized synbiotic trial to prevent sepsis among infants in rural India

Sepsis in early infancy results in one million annual deaths worldwide, most of them in developing countries. No efficient means of prevention is currently available. Here we report on a randomized, double-blind, placebo-controlled trial of an oral synbiotic preparation (Lactobacillus plantarum plus fructooligosaccharide) in rural Indian newborns. We enrolled 4,556 infants that were at least 2,000 g at birth, at least 35 weeks of gestation, and with no signs of sepsis or other morbidity, and monitored them for 60 days. We show a significant reduction in the primary outcome (combination of sepsis and death) in the treatment arm (risk ratio 0.60, 95% confidence interval 0.48-0.74), with few deaths (4 placebo, 6 synbiotic). Significant reductions were also observed for culture-positive and culture-negative sepsis and lower respiratory tract infections. These findings suggest that a large proportion of neonatal sepsis in developing countries could be effectively prevented using a synbiotic containing L. plantarum ATCC-202195.