Efficacy of empiric antibiotic treatment of late-onset neonatal sepsis caused by Enterobacteriaceae: A Systematic Review

Neonatal sepsis is a serious condition, where an adequate empiric antibiotic treatment is crucial. The objective of this systematic review is to assess whether the World Health Organisation's recommended treatment regime remains applicable for late-onset neonatal sepsis caused by Enterobacteriaceae, in the time of increased antimicrobial resistance. PubMed was searched for articles from 2009 to 2020. A total of 49 articles were eligible for inclusion. The review was carried out in accordance with PRISMA guidelines. For Klebsiella spp. 100%, 68%, and 63% of the studies found sensitivity to ampicillin, gentamicin, and third generation cephalosporin in <50% of the isolates. For Escherichia coli the corresponding values were 88%, 50%, and 42% respectively, whilst for Enterobacter spp. 100%, 70% and 94% of the studies found <50% sensitivity to these antibiotics. Overall, there is low sensitivity to all agents in the WHO's recommended empiric treatment regimes (WHO recommends ampicillin plus gentamicin as first line treatment and third generation cephalosporin as second line treatment). A revised guideline for empiric antibiotic treatment of neonatal sepsis is urgently needed due to increased threat of antimicrobial resistant Enterobacteriaceae causing neonatal sepsis.

Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis

BACKGROUND

Neonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms, which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries. We therefore completed a systematic review and meta-analysis of available data from all low- and lower-middle-income countries (LLMICs) since 2010, with a focus on regional differences in Gram-negative infections and AMR.

METHODS AND FINDINGS

All studies published from 1 January 2010 to 21 April 2021 about microbiologically confirmed bloodstream infections or meningitis in neonates and AMR in LLMICs were assessed for eligibility. Small case series, studies with a small number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. We included 88 studies (4 cohort studies, 3 randomised controlled studies, and 81 cross-sectional studies) comprising 10,458 Gram-negative isolates from 19 LLMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 55% to 65%). Klebsiella spp. was the most common, with a pooled proportion of 38% of Gram-negative sepsis (95% CI 33% to 43%). Regional differences were observed, with higher proportions of Acinetobacter spp. in Asia and Klebsiella spp. in Africa. Resistance to aminoglycosides and third-generation cephalosporins ranged from 42% to 69% and from 59% to 84%, respectively. Study limitations include significant heterogeneity among included studies, exclusion of upper-middle-income countries, and potential sampling bias, with the majority of studies from tertiary hospital settings, which may overestimate the burden caused by Gram-negative bacteria.

CONCLUSIONS

Gram-negative bacteria are an important cause of neonatal sepsis in LLMICs and are associated with significant rates of resistance to WHO-recommended first- and second-line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required.

Sepsis profile and outcome of preterm neonates admitted to neonatal intensive care unit of Cairo University Hospital

Background

This study demonstrates the experience of the neonatal intensive care unit (NICU) of a tertiary referral center in Egypt in management of prematures with neonatal sepsis. This retrospective study included preterm neonates admitted to NICU with clinical and/or laboratory diagnosis of sepsis. Blood culture was done followed by antimicrobial susceptibility testing for positive cases. Neonates with sepsis were classified into early onset sepsis (EOS) and late onset sepsis (LOS). Hematological scoring system (HSS) for detection of sepsis was calculated.

Results

The study included 153 cases of neonatal sepsis; 63 (41.2%) EOS and 90 (58.8%) LOS. The majority of the neonates had very low or moderately low birth weight (90.9%). All neonates received first-line antibiotics in the form of ampicillin-sulbactam, and gentamicin. Second-line antibiotics were administered to 133 neonates (86.9%) as vancomycin and imipenem-cilastatin. Mortalities were more common among EOS group (p < 0.017). Positive blood cultures were detected in 61 neonates (39.8%) with a total number of 66 cultures. The most commonly encountered organisms were Klebsiella MDR and CoNS (31.8% each). Klebsiella MDR was the most predominant organism in EOS (28.9%), while CoNS was the most predominant in LOS (39.2%) The detected organisms were divided into 3 families; Enterobacteriaceae, non-fermenters, and Gram-positive family. There 3 families were 100% resistant to ampicillin. The highest sensitivity in Enterobacteriaceae and Non-fermenters was for colistin and polymyxin-B. An HSS of 3–8 had a sensitivity and specificity of 62.3% and 57.6%, respectively for diagnosis of culture-proven sepsis.

Conclusion

Neonatal sepsis was encountered in 21.5% of admitted preterm neonates; LOS was more common (58.8%). Mortality was 51.6%. Klebsiella MDR and CoNS were the most commonly encountered organisms in both EOS and LOS. The isolated families were 100% resistant to ampicillin. The hematological scoring system (HSS) showed limited sensitivity for detection of sepsis.

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.

Study of Antibiotic Susceptibility among Bacterial Isolates in Neonatal Intensive Care Unit of a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction:

Neonatal sepsis is a major cause of neonatal morbidity and mortality worldwide, especially in developing countries like Nepal. Antibiotic resistance among microorganisms poses new challenges in the treatment of neonatal sepsis. The present study is conducted with the objectives of determining clinico-bacteriological profile and antibiotic susceptibility among isolated bacteria in a neonatal intensive care unit.

Methods:

A descriptive cross-sectional study was conducted from January 1, 2017, to December 31, 2019, in the neonatal intensive care unit of a tertiary care hospital after obtaining ethical clearance from Institutional Review Committee (Ref: 2020-064). The sample size was calculated and 77 neonates with culture-proven sepsis were included in the study. The antibiotic susceptibility tests of the isolates were done by Kirby-Bauer disc diffusion method. Data entry was done in Statistical Packages for the Social Sciences version 20.

Results:

Of the 841 specimens (blood, cerebrospinal fluid, urine, tracheal aspirate and pus) processed for culture, bacteria were isolated in 84 (10.0%) specimens. Among the 84, gram-negative bacilli were the predominant isolates 76 (90.5%); of which Acinetobacter baumannii was the most common 27 (32.1%). Both the Gram-negative and the Gram-positive bacteria showed high resistance to Penicillin and Cephalosporins. Gram-negative bacteria showed maximum sensitivity to Colistin, Carbapenems, Tigecycline and Fluoroquinolones. Gram-positive bacteria showed maximum susceptibility to Amikacin, Vancomycin and Carbapenems.

Conclusions:

Judicious use of antibiotics based on the updated knowledge of prevalent organisms in the local hospital setting and their antibiotic sensitivity pattern is of utmost importance for the effective treatment of neonatal sepsis.

Spectrum and Antimicrobial Susceptibility Pattern of Micro-Organisms Associated With Neonatal Sepsis in a Hospital in Karachi, Pakistan

Background Neonatal sepsis is one of the most common causes of neonatal mortality and morbidity, particularly in developing countries. Its causative bacteria and their respective sensitivity patterns are different in each hospital and region. The objective of this study was to determine the causative bacteria and their antibiotics sensitivity patterns at the neonatal unit. Methods This prospective study was carried out at the Neonatology Unit of Kharadar General Hospital (KGH) from January 2017 to Jun 2019. A total of 162 neonates with suspected sepsis and positive blood cultures were included in the study. Blood culture was done by standard microbiological techniques (BACTEC Method). Continuous data were presented as mean and standard deviation, while categorical data were presented in frequency and percentages. Result Out of a total of 162 neonates with blood culture positive neonatal sepsis, males were 106 (65.4%). Gram-positive and Gram-negative bacteria were found with a frequency of 83 (51.5%) and 79 (48.5%), respectively. Staphylococcus aureus and Pseudomonas were the commonest isolates in 50.5% and 25.7% of cases, respectively. The Gram-positive organism was mostly sensitive to amikacin and vancomycin whereas the Gram-negative was mostly sensitive to amikacin, imipenem, meropenem, and ciprofloxacin. Conclusion Staphylococcus aureus was the most common bacteria isolated. For the sepsis, the causative bacteria and antibiotics sensitivity pattern changes over a period of time. Continued surveillance is required to help reduce morbidity and mortality through developing institution-based guidelines.

Survival Status and Predictors of Mortality among Newborns Admitted with Neonatal Sepsis at Public Hospitals in Ethiopia

Background

One-fourth of neonatal death is due to neonatal sepsis and nearly 98% of these deaths are occurring at low- and middle-income countries. In Ethiopia, forty percent of under-five mortality occurs during the neonatal period, of which neonatal sepsis accounts for 30-35% of neonatal deaths next to prematurity and its complications. On the other side, among the survived neonates with neonatal sepsis, there exist as vulnerable to short and long-term neurological and developmental morbidity impacting the overall productivity of the child as adult.

Methods

A longitudinal prospective cohort study was conducted among selected 289 neonates with neonatal sepsis who were admitted in the neonatal intensive care unit at public hospitals in Ethiopia from 1^st March 2018 to 31^st December 2019. Data were entered into Epi data version 3.02 and exported to SPSS V 25 for analysis. The Kaplan-Meier survival curve together with log-rank test was used to estimate the survival time of the neonates. Variables which had p value < 0.05 in multivariable analysis using the cox proportional hazard model were declared as statistically significant predictors of mortality.

Results

The study was conducted with a total of 289 neonates admitted with neonatal sepsis. The cumulative proportion of surviving at the end of the fourth day was 99.5%, and it was 98.2% at the end of the fifth day. In addition, it was 96.6%, 93.5%, and 91.1% at the end of the sixth, seventh, and eighth day, respectively. The incidence of mortality was 8.65 per 100 neonates admitted with neonatal sepsis. Having a history of intrapartum fever (AHR: 14.5; 95% CI: 4.25, 49.5), history of chorioamnionitis (AHR: 5.7; 95% CI: 2.29, 13.98), induced labor (AHR: 7; 95% CI: 2.32, 21.08), and not initiating exclusive breastfeeding within one hour (AHR: 3.4; 95% CI: 1.34, 12.63) were the independent predictors of mortality.

Conclusion

The survival status of neonates among neonates admitted with neonatal sepsis was high at the early admission days and high cumulative proportion of death as the admission period increased. The risk of mortality was high among the neonates with early onset of neonatal sepsis as compared with late onset of neonatal sepsis and history of intrapartum fever, history of diagnosed chorioamnionitis, onset of labor, and EBF initiation within one hour were the independent predictors of mortality among neonates admitted with neonatal sepsis.

Clinical and Bacteriological Profile of Neonatal Sepsis: A Prospective Hospital-Based Study

BACKGROUND

Neonatal sepsis remains one of the leading causes of mortality and morbidity in developing countries. With a dearth of data on neonatal sepsis in our country, this study was conducted to determine the incidence of clinical neonatal sepsis and evaluate the clinical, bacteriological, and antimicrobial susceptibility profile of organisms. Material and Methods. A prospective cross-sectional study was conducted in the Neonatal Unit of the National Hospital from 1st January to 31st December 2016. All neonates admitted with suspected clinical sepsis were included. Sepsis screens and cultures were sent under aseptic conditions. Data was analyzed using STATA™ version 12. Clinical features and neonatal and maternal risk factors were analyzed using chi-squared test. Bacteriological profile was analyzed with descriptive statistics.

RESULTS

During the study period, incidence of culture positive neonatal sepsis was 19 per 1000 admissions with a blood culture positivity rate of 14%. 54.5% had culture-positive early-onset sepsis (EOS). Prematurity (p = 0.012), APGAR < 6 (p = 0.018), low birth weight (p < 0.001), and maternal intrapartum antibiotics (p = 0.031) significantly increased risk for culture-positive EOS. Prematurity (p < 0.001), low birth weight (p = 0.001), and parental nutrition (p = 0.007) were significantly associated with increased risk of culture-positive late-onset sepsis. A positive screen had sensitivity of 81.8% and negative predictive value of 87.7%. Gram-negative organisms were most commonly isolated (64.6%). Coagulase-negative Staphylococci (31%) were the commonest isolate followed by Klebsiella pneumoniae (27%) and Acinetobacter (18.8%). Ninety percent of Acinetobacter were carbapenem resistant. Gram-negative sepsis had mortality of 88.9%.

CONCLUSION

Preterm, low birth weight, low APGAR scores, intrapartum antibiotics, and parental nutrition were significantly associated with neonatal sepsis. Coagulase-negative Staphylococci, Klebsiella pneumoniae, and Acinetobacter were the principal causative organisms. Gram-negative organisms had high resistance to commonly used antibiotics.

Pattern of bacterial profile and antibiotic susceptibility among neonatal sepsis cases at Cairo University Children Hospital

Objectives

Neonatal sepsis is the third leading contributor to mortality and morbidity. Emanating resistance to antibiotics in neonatal intensive care units (NICUs) is considered a major burden. In this study, we aimed to investigate the bacterial prevalence and antibiotic profile among patients admitted with sepsis in the NICU of Cairo University Children Hospital.

Methods

Neonates with suspected sepsis were evaluated for bacterial sepsis in their blood cultures. The neonates with positive bacterial blood culture were included in this study, whereas neonates with negative culture were excluded. Positive samples were sub-cultured on blood, MacConkey, and chocolate agar plates. Organisms were identified by Gram staining and biochemical reactions. Antibiotic susceptibility was assessed by the Kirby–Bauer disc diffusion method.

Results

Seventy blood cultures (31.7%) were bacteria-positive: 45.3% for Klebsiella, 22.7% for coagulase-negative staphylococci (CoNS), and for Acinetobacter (10.7%), methicillin-resistant Staphylococcus aureus (MRSA) (9.3%), Pseudomonas (5.3%), Enterobacter (4%), and streptococci (2.7%). High resistance to all cephalosporins, B-lactamase combinations, penicillin, carbapenems, and aminoglycosides was observed. All Gram-negative Enterobacteria showed the highest sensitivity to levofloxacin, whereas Pseudomonas and Acinetobacter were highly sensitive to polymyxin B. Gram-positive samples were sensitive to vancomycin and linezolid. Streptococci were slightly sensitive to vancomycin and highly sensitive to macrolides and cefotaxime.

Conclusions

In our study, Klebsiella and CoNS were the most common isolates in neonatal sepsis. The levels of multidrug-resistant strains were alarmingly high. This finding negatively affected the outcomes, prompting the need for a strict guideline for antibiotics use.

Epidemiology of Neonatal Sepsis and Associated Factors Implicated: Observational Study at Neonatal Intensive Care Unit of Arsi University Teaching and Referral Hospital, South East Ethiopia

Background

Globally, sepsis remains one of the major causes of morbidity and mortality in neonates, in spite of recent advances in health care units. The major burden of the problem occurs in the developing world while most evidence is derived from developed countries. The objective of this study was to evaluate the epidemiology of neonatal sepsis and associated factors among neonates admitted to Neonatal Intensive Care Unit (NICU).

Methods

Hospital based prospective cross-sectional study was conducted from April 2016 to May 2017. Neonates with clinical sepsis were included into the study. Data were analyzed using SPSS version 20. Frequencies, proportion and summary statistics were used to describe the study population in relation to relevant variables. Multivariate logistic regressions were used to assess factors associated with neonatal sepsis. p-values of < 0.05 were considered statistically significant.

Results

A total of 901neonates were admitted to NICU of which 303 neonates were admitted with diagnosis of clinical sepsis making the prevalence of neonatal sepsis to be 34%. Bacteremia were confirmed in 88/303(29.3%) of clinical sepsis, and gram-positive bacteria constituted 47/88(53.4%). Of all positive blood cultures, 52/88(59.1%) were reported from late onset sepsis. Coagulase negative staphylococcus (CoNS) accounted for 22/88(25%) followed by E. coli and S. aureus, each contributing 18/88(20.3%) and 16/88(18.2%) respectively. Prolonged PROM, low fifth Apgar score, prematurity and low birth weight were strongly associated with increased risk of neonatal sepsis. Neonates born to mothers who received antibiotics during labor and delivery were at significantly lower risk of acquiring neonatal sepsis.

Conclusion

The prevalence of neonatal sepsis was high, and most causes of neonatal sepsis were gram positive bacteria and most bacteria isolates were from late onset sepsis. Obstetric factors were strongly associated with development of neonatal sepsis. Intrapartal antibiotic administration significantly reduces neonatal sepsis.

Clinical outcome and isolated pathogens among neonates with sepsis in Democratic Republic of the Congo: a cross-sectional study

Objective

Neonatal sepsis still remains a significant cause of morbidity and mortality in developing countries. The prediction of the neonatal sepsis outcome depends on the anticipation from the clinical history, suspicion from clinical findings and confirmation by laboratory tests. This study aimed to determine the clinical outcome and isolated pathogens among neonates with sepsis in Butembo, Democratic Republic of the Congo.

Results

The most frequent bacteria related to a poor outcome were Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and Klebsiella spp. Most of isolated bacteria were found to be hospital-acquired infections. Therefore, adherence to infection prevention and control measures would reduce reduced rate of neonatal sepsis in our setting. The empiric antibiotic treatment should cover the spectrum of bacteria responsible of neonatal sepsis in Butembo, DRC.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4346-5) contains supplementary material, which is available to authorized users.

Study of Antibiotic Sensitivity and Resistance Pattern of Bacterial Isolates in Intensive Care Unit Setup of a Tertiary Care Hospital

Objective

To evaluate the antibiotic sensitivity and resistance pattern in an intensive care unit (ICU) setting of a tertiary care hospital.

Materials and methods

A cross-sectional, retrospective study was conducted for a period of 1 month in October 2017 on a total of 195 patients who were admitted to ICU of tertiary care hospital. The culture and sensitivity pattern of clinical isolates from blood, urine, sputum, endotracheal tube (ET) aspirate, catheter sites, and wound swabs were analyzed. Positive cultures were segregated and their antibiotic sensitivity testing was performed under the guidelines of clinical and laboratory standard institute (CLSI).

Results

Of the total 195 ICU admissions, cultures were sent for 167 cases. Of which 127 patients were culture positive and 40 cases were culture negative. Isolated bacteria were mostly gram-negative bacilli, of which Escherichia coli was (18.6%), Acinetobacter (14.5%), Klebsiella (11.6%), Pseudomonas (9.8%), and Proteus (1.74%). Among the gram-positive organisms, coagulase negative staphylococcus (CoNS) (15.6%) was most commonly isolated followed by Streptococcus (2.32%). Fungal growth was also seen in 26 (15.11%) samples. Samples that grew organisms were blood (n = 48), sputum (n = 17), urine (n = 39), ET aspirate (n = 40), pus (n = 11), catheter (n = 4), ear swab (n = 2), and stool (n = 1).

Conclusion

Gram-negative bacterial infections are increasing in ICUs, leading to inappropriate selection of antibiotics. Hence, antibiotic sensitivity and resistance pattern in a hospital setup has to be studied so as to guide the treating consultant to initiate empirical antibiotics in critical cases.

How to cite this article

Savanur SS, Gururaj H. Study of Antibiotic Sensitivity and Resistance Pattern of Bacterial Isolates in Intensive Care Unit Setup of a Tertiary Care Hospital. Indian J Crit Care Med 2019;23(12):547–555.

Bacteriological profile and antibiotic susceptibility of neonatal sepsis in neonatal intensive care unit of a tertiary hospital in Nepal

BACKGROUND

Neonatal sepsis, one of the leading causes of mortality in neonatal intensive care units (NICU) of developing countries like Nepal, is often not extensively studied. In order to decrease the morbidity and mortality associated with neonatal sepsis, neonatologists should have a keen knowledge of the existing bacteriological flora and their antibiotic susceptibility pattern. In this study, we aim to determine the bacteriological profile and antibiotic susceptibility pattern of culture positive neonatal sepsis in the NICU of a tertiary teaching hospital in Nepal.

METHODS

This was a retrospective cross-sectional study of all blood culture positive sepsis cases among neonates admitted to the neonatal intensive care unit of Patan Hospital, Nepal between April 15, 2014 and April 15, 2017. All neonates with a clinical suspicion of sepsis with a positive blood culture were identified. Patient demographics, clinical details, maternal risk factors, and laboratory data including bacteriological profiles and antimicrobial susceptibilities were recorded and analyzed.

RESULTS

Of the 336 neonates admitted in the NICU, 69 (20.5%) had culture-positive sepsis. The majority were early-onset sepsis (n = 54, 78.3%) and were among the preterm babies (n = 47, 68.1%). Most bacterial isolates were gram-negative, predominantly the Klebsiella species (n = 23, 33.3%). Klebsiella showed high resistance to commonly used antibiotics such as; Cefotaxime (90.5%), Gentamicin (75%), Ciprofloxacin (76.2%), Ofloxacin (72.2%) and Chloramphenicol (65%). However, they showed good susceptibility to Carbapenems (100%), Colistin (88.8%) and Tigecycline (81.8%). Among cultures with gram-positive species, Coagulase-negative Staphylococci (CONS) (n = 14, 20.3%) predominated. CONS showed high resistance to Oxacillin (80%), Cefotaxime (66.7%) and Meropenem (80%) but good susceptibility (100%) to Vancomycin and Linezolid. Prevalence of multidrug-resistant strain was 73.9%.

CONCLUSIONS

Klebsiella species and CONS were the most common causes of neonatal sepsis in our study. A significant proportion of the isolates were multidrug resistant strains, which pose a great threat to neonatal survival, and thereby, warrant modification of existing empirical therapy. Implementation of effective preventive strategies to combat the emergence of antibiotic resistance is urgently needed. We recommend a combination of Piperacillin-Tazobactam and Ofloxacin as the first line therapy and combination of Vancomycin and Meropenem as the second line empirical therapy in our NICU.