Serious community-acquired neonatal infections in rural Southeast Asia (Bohol Island, Philippines)

Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital

Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.

Current status and challenges in the care of patients with bacterial meningitis in the Philippines: A scoping review

OBJECTIVE

Bacterial meningitis is associated with high morbidity and mortality if not treated early. Due to the high disease burden, there are barriers in the provision of healthcare services for these patients, especially in low- to middle-income countries, such as the Philippines. We aimed to give an overview of healthcare services delivery and identify gaps in the provision of care for patients with bacterial meningitis in the Philippines.

METHOD

We conducted a scoping review on the available literature on the epidemiology, research, health services delivery, diagnostics and management of Filipino patients with bacterial meningitis. A qualitative summary of the results was conducted to provide an overview of the findings.

RESULTS

There is a paucity of epidemiological data and research on bacterial meningitis. Healthcare expenditure remains out-of-pocket, with limited coverage from the national health insurance programme. There is an inadequate number of neurologists as well as inequities in the distribution of manpower and facilities due to the devolution of the healthcare system. Diagnosis remains a challenge due to the inaccessibility of tests for CSF analysis. Costs of antibiotics, adjunctive treatment, neurosurgical interventions and rehabilitation are also prohibitive. Outbreaks can be prevented by strengthening existing surveillance systems and improving vaccination coverage against the most common causative organisms.

CONCLUSION

Enormous challenges still exist with regards to health services delivery in patients with bacterial meningitis in the Philippines in terms of epidemiologic data and research, access to healthcare facilities and diagnostic tools, healthcare costs, surveillance systems and immunisation against causative pathogens.

Understanding Bacterial Isolates in Blood Culture and Approaches Used to Define Bacteria as Contaminants: A Literature Review

BACKGROUND

Interpretation of blood culture isolates is challenging due to a lack of standard methodologies for identifying contaminants. This problem becomes more complex when the specimens are from sick young infants, as a wide range of bacteria can cause illness among this group.

METHODS

We used 43 key words to find articles published between 1970 and 2011 on blood culture isolates and possible contaminants in the PubMed database. Experts were also consulted to obtain other relevant articles. Selection of articles followed systematic methods considering opinions from more than 1 reviewer.

RESULTS

After reviewing the titles of 3869 articles extracted from the database, we found 307 relevant to our objective. Based on the abstracts, 42 articles were selected for the literature review. In addition, we included 7 more articles based on cross-references and expert advice. The most common methods for differentiating blood culture isolates were multiple blood cultures from the same subject, antibiograms and molecular testing. Streptococcus pneumoniae, Hemophilus influenzae, Neisseria meningitidis and group A and B streptococcus were always considered as pathogens, whereas Bacillus sp., Diphtheroids, Propionibacterium and Micrococcus were commonly regarded as contaminants. Coagulase-negative staphylococci were the most frequent isolates and usually reported as contaminants unless the patient had a specific condition, such as long-term hospitalization or use of invasive devices (catheters).

CONCLUSIONS

Inaccurate interpretation of blood culture may falsely guide treatment and also has long-term policy implications. The combination of clinical and microbiological knowledge, patient's clinical history and laboratory findings are essential for appropriate interpretation of blood culture.

A three year descriptive study of early onset neonatal sepsis in a refugee population on the Thailand Myanmar border

BACKGROUND

Each year an estimated four million neonates die, the majority in the first week of life. One of the major causes of death is sepsis. Proving the incidence and aetiology of neonatal sepsis is difficult, particularly in resource poor settings where the majority of the deaths occur.

METHODS

We conducted a three year observational study of clinically diagnosed early onset (<7 days of age) neonatal sepsis (EONS) in infants born to mothers following antenatal care at the Shoklo Malaria Research Unit clinic in Maela camp for displaced persons on the Thailand-Myanmar border. Episodes of EONS were identified using a clinical case definition. Conventional and molecular microbiological techniques were employed in order to determine underlying aetiology.

RESULTS

From April 2009 until April 2012, 187 infants had clinical signs of EONS, giving an incidence rate of 44.8 per 1000 live births (95% CI 38.7-51.5). One blood culture was positive for Escherichia coli, E. coli was detected in the cerebrospinal fluid specimen in this infant, and in an additional two infants, by PCR. Therefore, the incidence of bacteriologically proven EONS was 0.7 per 1000 live births (95% CI 0.1-2.1). No infants enrolled in study died as a direct result of EONS.

CONCLUSION

A low incidence of bacteriologically proven EONS was seen in this study, despite a high incidence of clinically diagnosed EONS. The use of molecular diagnostics and nonspecific markers of infection need to be studied in resource poor settings to improve the diagnosis of EONS and rationalise antibiotic use.

Aetiology of community-acquired neonatal sepsis in low and middle income countries

BACKGROUND

99% of the approximate 1 million annual neonatal deaths from life-threatening invasive bacterial infections occur in developing countries, at least 50% of which are from home births or community settings. Data concerning aetiology of sepsis in these settings are necessary to inform targeted therapy and devise management guidelines. This review describes and analyses the bacterial aetiology of community-acquired neonatal sepsis in developing countries.

METHODS

A search of Medline, Embase, Global Health and Web of Knowledge, limited to post-1980, found 27 relevant studies. Data on aetiology were extracted, tabulated and analysed along with data on incidence, risk factors, case fatality rates and antimicrobial sensitivity.

RESULTS

The most prevalent pathogens overall were Staphylococcus aureus (14.9%), Escherichia coli (12.2%), and Klebsiella species (11.6%). However, variations were observed both between global regions and age-of-onset categories. Staphylococcus aureus and Streptococcus pneumoniae were most prevalent in Africa, while Klebsiella was highly prevalent in South-East Asia. A notably higher prevalence of Group B Streptococcus was present in neonates aged 7 days or less. The highest case fatality rates were recorded in South-East Asia. Klebsiella species showed highest antimicrobial resistance.

CONCLUSION

Data on community-acquired neonatal sepsis in developing countries are limited. Future research should focus on areas of high disease burden with relative paucity of data. Research into maternal and neonatal vaccination strategies and improved diagnostics is also needed. All of this could contribute to the formulation of community-based care packages, the implementation of which has significant potential to lower overall neonatal mortality and hence advance progress towards the attainment of Millennium Development Goal 4.

Neonatal community-acquired pneumonia: pathogens and treatment

AIM

To analyse the bacterial pathogens and drug sensitivities for neonatal community-acquired pneumonia.

METHODS

Seven hundred sixty sputum samples from newborns with community-acquired pneumonia were cultured to determine microbial organisms present and their drug sensitivities.

RESULTS

Of the 760 specimens, 425 grew pathogens for a 55.9% positive rate. Among the 425 positive cultures, 278 grew gram-negative organisms (65.4%), 142 grew gram-positive organisms (33.3%), while 5 grew fungus (1.3%). The most common gram-negative organisms were Escherichia coli, Klebsiella pneumoniae and Hemophilus influenzae, while the most common gram-positive organisms were Staphylococcus aureus, Staphylococcus epidermidis and Staphylococcus haemolyticus. To the gram-negative organisms, the most sensitive drugs were meropenem, imipenem and amikacin, while to the gram-positive ones were vancomycin, teicoplanin and quinupristin/dalfopristin.

CONCLUSIONS

The most common causative bacteria were gram-negative organisms, which were highly sensitive to Meropenem, Imipenem and Amikacin, yet often treatable with more focused antibiotic coverage, which depended on the bacterium identified.

Pneumonia among young infants in rural Southeast Asia (Bohol Island, Philippines)

OBJECTIVE

To develop a clinical algorithm that can be used to identify pneumonia deaths in young infants in developing countries and estimate the disease burden in this population.

PATIENTS AND METHODS

Infants younger than 60 days hospitalized with signs of severe pneumonia who underwent clinical, microbiologic and radiological evaluation were the subjects. Stepwise logistic regression and subtractive iterative process were used to derive the algorithm.

RESULTS

Three-hundred and one infants had either clinical or radiographic pneumonia. The case fatality rate for 185 infants with radiographic pneumonia was 21%vs. 5% for clinical pneumonia. Age below 7 days was associated with an increased risk of dying. Among 7- to 59-day-old infants, poor feeding, cyanosis and absence of crackles were predictors of death from pneumonia. Using logistic regression, an algorithm consisting of any one of three clinical signs (cyanosis, poor feeding and abnormally sleepy) was developed in infants aged 7-59 days; 80% of deaths and 50% of those with radiographic pneumonia have at least one of these signs. It performed better than both the WHO case management algorithm and the IMCI algorithm.

CONCLUSION

Radiographic pneumonia is a common and serious infection among infants below 2 months old in the Philippines. Cyanosis, poor feeding and abnormal sleepiness are simple signs that can be used by health workers to identify seriously ill infants who are most likely to die from pneumonia.

Population-based incidence and etiology of community-acquired neonatal bacteremia in Mirzapur, Bangladesh: an observational study

BACKGROUND

To devise treatment strategies for neonatal infections, the population-level incidence and antibiotic susceptibility of pathogens must be defined.

METHODS

Surveillance for suspected neonatal sepsis was conducted in Mirzapur, Bangladesh, from February 2004 through November 2006. Community health workers assessed neonates on postnatal days 0, 2, 5, and 8 and referred sick neonates to a hospital, where blood was collected for culture from neonates with suspected sepsis. We estimated the incidence and pattern of community-acquired neonatal bacteremia and determined the antibiotic susceptibility profile of pathogens.

RESULTS

The incidence rate of community-acquired neonatal bacteremia was 3.0 per 1000 person-neonatal periods. Among the 30 pathogens identified, the most common was Staphylococcus aureus (n = 10); half of all isolates were gram positive. Nine were resistant to ampicillin and gentamicin or to ceftiaxone, and 13 were resistant to cotrimoxazole.

CONCLUSION

S. aureus was the most common pathogen to cause community-acquired neonatal bacteremia. Nearly 40% of infections were identified on days 0-3, emphasizing the need to address maternal and environmental sources of infection. The combination of parenteral procaine benzyl penicillin and an aminoglycoside is recommended for the first-line treatment of serious community-acquired neonatal infections in rural Bangladesh, which has a moderate level of neonatal mortality. Additional population-based data are needed to further guide national and global strategies.

Antimicrobial resistance among neonatal pathogens in developing countries

INTRODUCTION

Knowledge of antimicrobial resistance and trends in resistance patterns among major pathogens causing infections in young infants (up to 90 days of life) is an important component of developing community-based management strategies. Hospital-based data suggest alarming rates of resistance to ampicillin and gentamicin, the first-line antimicrobial agents recommended by WHO for treatment of serious infections in young infants.

METHODS

We searched the literature published since 1990 for studies from developing countries reporting resistance among serious community-acquired infections (including sepsis, pneumonia, and meningitis) in young infants.

RESULTS

Only 10 relevant reports were retrieved. Among the 3 major pathogens studied (Escherichia coli, Staphyloccoccus aureus, and Klebsiella species), a high proportion of E. coli were ampicillin (72%) and cotrimoxazole (78%) resistant; 19% were resistant to third generation cephalosporins. Among Klebsiella species, almost all were resistant to ampicillin, 45% to cotrimoxazole, and 66% to third generation cephalosporins. Resistance to gentamicin was low among E. coli (13%), but much higher among Klebsiella species (60%). Methicillin resistance S. aureus (MRSA) was rare (1 of 33 isolates) but 46% were resistant to cotrimoxazole.

CONCLUSIONS

Antimicrobial resistance data for infections in young infants from community-based studies were extremely limited. Significant resistance, in particular to cotrimoxazole among all pathogens, and to gentamicin and third generation cephalosporins among Klebsiella and emerging resistance in E. coli is cause for concern. Limited data pose a challenge in devising simple community-based management strategies. Further studies from different developing country regions are needed to determine prevalence of resistant strains, as well as assess regional and time trends.

Pathogens associated with sepsis in newborns and young infants in developing countries

INTRODUCTION

Knowledge of pathogens causing infections in young infants (up to 90 days of life) is essential for devising community-based management strategies. Most etiological data from developing countries are hospital-based and may have little relevance to communities in which most babies are born at home.

METHODS

We searched the literature for studies from developing countries reporting etiology of community-acquired infections (sepsis, pneumonia, meningitis) published since 1980. Hospital-based studies reporting early onset sepsis, sepsis among babies admitted from, or born at home were included.

RESULTS

Of 63 studies, 13 focused on community-acquired infections, but limited data were available from home-born neonates. In the first week of life (3209 isolates), Klebsiella species (25%), Escherichia coli (15%), and Staphylococcus aureus (18%) were major pathogens. Group B streptococci (GBS) were relatively uncommon (7%), although regional differences existed. After the first week of life (835 isolates), S. aureus (14%), GBS (12%), Streptococcus pneumoniae (12%), and nontyphoidal Salmonella species (13%) were most frequent. S. pneumoniae (27%) was most common in the postneonatal period (among 141 isolates). Gram-negatives predominated (77%) among home-delivered babies (among 170 isolates).

CONCLUSIONS

Limited information is available on etiology of serious bacterial infections in community settings. Hospital-based studies suggest that most infections in the first week of life are due to Gram-negative pathogens, and many may be environmentally rather than maternally-acquired, owing to unhygienic delivery practices. Such practices may also explain the predominance of Gram-negative infections among home-born infants, although data from home settings are limited. These findings have implications for developing prevention and management strategies in communities and hospitals.