Septicaemia in high risk neonates at a teaching hospital in Ile-Ife, Nigeria

Antibiotic resistance pattern of Pseudomonas spp. from patients in a tertiary hospital in South-West Nigeria

Introduction

Pseudomonads constitute critical agents of opportunistic infections in hospital settings particularly in immunocompromised patients and Pseudomonas aeruginosa is a major flagship member of these infectious agents. This study assessed the distribution of Pseudomonas spp. associated with infections in patients and their antibiotic resistance patterns as part of an antibiotic stewardship intervention program and resistance surveillance.

Methods

One hundred and fifty Pseudomonas spp. from different clinical specimens were obtained from the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife. Culture was carried out on MacConkey and blood agar while phenotypic characterization was done by Gram staining, oxidase, and catalase test. Species identification was done using MICROBACT^TM 24E bacterial identification kit and confirmed by 16S rDNA polymerase chain reaction (PCR) assay. Antibiotic susceptibility testing to eight antibiotics in four classes was done.

Results

Pseudomonas aeruginosa was the most frequently occurring species (96.0%); P. putida (2.67%) and P. fluorescens (0.67%) were also identified as well as an isolate of Burkholderia pseudomallei (0.67%). The highest resistance rate among isolates was observed towards gentamicin (35.4%); piperacillin/tazobactam was the most active antibiotic. Multidrug-resistant (MDR) strains constituted 12.8% of the isolates and most MDR strains also displayed a high multiple antibiotic resistance index (MAR).

Conclusions

Pseudomonas aeruginosa is emerging as a highly MDR pathogen in our hospital setting. This calls for the establishment of a surveillance system and antimicrobial stewardship programme in place. Furthermore, we propose a review of the current antibiotics prescription policy, and infection control programmes (ICPs) if we must control the spread of MDR-P. aeruginosa in this environment.

Burden and factors associated with clinical neonatal sepsis in urban Uganda: a community cohort study

Background

Neonatal sepsis is one of the most important causes of mortality in developing countries and yet the most preventable. In developing countries clinical algorithms are used to diagnose clinical neonatal sepsis because of inadequate microbiological services. Most information on incidence and risk factors of neonatal sepsis are from hospital studies which may not be generalized to communities where a significant proportion of mothers do not deliver from health facilities. This study, conducted in urban Uganda, sought to determine the community based incidence of clinical neonatal sepsis and the factors associated.

Methods

This was a cohort of mother-neonate pairs in Kampala, Uganda from March to May 2012. The enrolled neonates were assessed for clinical sepsis and factors associated, and followed up till the end of the neonatal period. STATA version 10 was used to analyse the data.

Results

The community based incidence of neonatal sepsis was 11% (95% CI: 7.6–14.4). On bivariate analysis, lack of financial support from the father (OR 4.09, 95% CI 1.60–10.39) and prolonged rupture of membranes more than 18 h prior to delivery (OR 11.7, 95% CI 4.0–31.83) were significantly associated with neonatal sepsis. Maternal hand washing prior to handling the baby was found to be protective of neonatal sepsis (OR 0.41, 95% CI 0.18–0.94). Of the 317 infants who completed the follow up period, one died within the neonatal period giving a neonatal mortality of 0.003%.

Conclusion

The high incidence of clinical neonatal sepsis in this urban community with high rates of antenatal care attendance and health facility delivery places a demand on the need to improve the quality of antenatal, perinatal and postnatal care in health facilities with regards to infection prevention including promoting simple practices like hand washing. The astoundingly low mortality rate is most likely because this was a low risk cohort. However it may also suggest that the neonatal mortality in developing countries may be reduced with promotion of simple low cost interventions like community follow up of neonates using village health teams or domiciliary care.

Aetiology of neonatal sepsis in Nigeria, and relevance of Group b streptococcus: A systematic review

BACKGROUND

Group B Streptococcus (GBS) causes invasive infections in neonates and has been implicated as a cause of prelabour rupture of membranes, preterm delivery and stillbirths. The success of phase II trials of polyvalent polysaccharide GBS vaccines indicates that these infections are potentially preventable. Nigeria is the most populous country in Africa with one of the highest birth rates, one of the highest neonatal sepsis incidence rates and one of the highest mortality rates in the world. Therefore, before the possible introduction of preventive strategies such as intrapartum antibiotic prophylaxis or GBS vaccine into Nigeria, it is vital that there is accurate data on the aetiology of neonatal sepsis and on the incidence of GBS neonatal sepsis in particular. The objective of this study was to determine the incidence and aetiology of neonatal sepsis in Nigeria with a focus on GBS sepsis and also to assess the potential impact of a GBS vaccine.

METHODS

A literature search was conducted on the databases of African journals online, PubMed and Google Scholar for works conducted between 1987 to 2017. Case reports, reviews, and studies not stating specific culture methods or specific bacteria isolated were excluded. Data extracted included; incidence of neonatal sepsis, method of blood culture, blood volume, sample size, bacterial agents isolated and history of antibiotic use. PRISMA guidelines were followed and modified Down's and Black criteria used to evaluate the quality of studies.

RESULTS

A total of 5,114 studies were reviewed for neonatal sepsis out of which 24 consisting of a total of 2,280 cases were selected for final review. Nine studies met criteria for assessment of hospital based incidence of neonatal sepsis representing 31,305 hospital births. The incidence of neonatal sepsis was 18.2/1000 livebirths with range from 7-55/1000 livebirths while the GBS incidence was 0.06/1000 livebirths with range from 0-2/1000 live births. We discovered various limitations such as identification techniques that could result in underestimation of the true incidence of GBS sepsis. Pathogens such as Klebsiella pneumoniae and Staphylococcus aureus were more commonly isolated than GBS.

IMPLICATIONS OF KEY FINDINGS

The hospital based incidence of neonatal sepsis was high at 18.2/1000 live births while that due to GBS was 0.06/1000 live births. The burden of neonatal sepsis, including that attributable to GBS is substantial and could be reduced by preventive strategies such as intrapartum antibiotic prophylaxis or GBS vaccine. There is however very sparse meaningful data currently. Well planned prospective studies with larger sample sizes, more advanced isolation and identification techniques and those following up invasive disease cases for possible short and long term sequelae are needed-not only prior to possible introduction of the vaccine to determine the baseline epidemiology, but also thereafter to monitor its impact on the population. Strategies need to be developed to also reduce the morbidity and mortality attributable to other bacteria that have an incidence even greater than that of GBS.

Risk factors and practices contributing to newborn sepsis in a rural district of Eastern Uganda, August 2013: a cross sectional study

Background

In Uganda, newborn deaths constituted over 38 % of all infant deaths in 2010. Despite different mitigation interventions over years, the newborn mortality rate is high at 27/1,000 and newborn sepsis contributes to 31 % of that mortality. Therefore, improved strategies that contribute to reduction of newborn sepsis need to be developed and implemented. Understanding the context relevant risk factors that determine and practices contributing to newborn sepsis will inform this process.

Methodology

A cross sectional study was conducted at Kidera Health Centre in Kidera Sub County, Buyende district between January and August 2013. A total of 174 mothers of sick newborns and 8 health workers were interviewed. Main outcome was newborn sepsis confirmed by blood culture. Independent variables included; mothers’ demographics characteristics, maternal care history and newborn care practices. The odds ratios were used to measure associations and Chi square or Fisher’s exact tests to test the associations. 95 % confidence intervals and P values for the odds ratios were determined. Logistic regression was conducted to identify predictor factors for newborn sepsis.

Results

21.8 % (38/174) of newborns had laboratory confirmed sepsis. Staphylococcus aureus was the commonest aetiological agent. Mothers not screened and treated for infections during antenatal (OR = 3.37; 95 % CI 1.23–9.22) plus inability of sick newborns to breast feed (OR = 3.9; 95 % CI 1.54–9.75) were factors associated with increased likelihood of having laboratory confirmed sepsis. Women not receiving health education during antenatal about care seeking (OR 2.22; 95 % CI 1.07–4.61) and newborn danger signs (OR 2.26; 95 % CI 1.08–4.71) was associated with laboratory confirmed newborn sepsis. The supply of antibiotics and sundries was inadequate to sufficiently control sepsis within health facility.

Conclusion

Lack of antenatal care or access to it at health facilities was likely to later result in more sick newborns with sepsis. Poor breastfeeding by sick newborns was a marker for serious bacterial infection. Therefore district sensitization programs should encourage women to attend health facility antenatal care where they will receive health education about alternative feeding practices, screening and treatment for infections to prevent spread of infections to newborns. Supply of antibiotics and sundries should be improved to sufficiently control sepsis within the health facility.

Phenotypic and molecular characteristics of methicillin-resistant Staphylococcus aureus isolates from Ekiti State, Nigeria

Introduction

The characteristics and antimicrobial resistance profiles of Staphylococcus aureus differs according to geographical regions and in relation to antibiotic usage. The aim of this study was to determine the biochemical characteristics of the prevalent S. aureus from Ekiti State, Nigeria, and to evaluate three commonly used disk diffusion methods (cefoxitin, oxacillin, and methicillin) for the detection of methicillin resistance in comparison with mecA gene detection by polymerase chain reaction.

Materials and methods

A total of 208 isolates of S. aureus recovered from clinical specimens were included in this study. Standard microbiological procedures were employed in isolating the strains. Susceptibility of each isolate to methicillin (5 μg), oxacillin (1 μg), and cefoxitin (30 μg) was carried out using the modified Kirby–Bauer/Clinical and Laboratory Standard Institute disk diffusion technique. They were also tested against panels of antibiotics including vancomycin. The conventional polymerase chain reaction method was used to detect the presence of the mecA gene.

Results

Phenotypic resistance to methicillin, oxacillin, and cefoxitin were 32.7%, 40.3%, and 46.5%, respectively. The mecA gene was detected in 40 isolates, giving a methicillin-resistant S. aureus (MRSA) prevalence of 19.2%. The S. aureus isolates were resistant to penicillin (82.7%) and tetracycline (65.4%), but largely susceptible to erythromycin (78.8% sensitive), pefloxacin (82.7%), and gentamicin (88.5%). When compared to the mecA gene as the gold standard for MRSA detection, methicillin, oxacillin, and cefoxitin gave sensitivity rates of 70%, 80%, and 100%, and specificity rates of 76.2%, 69.1%, and 78.5% respectively.

Conclusion

When compared with previous studies employing mecA polymerase chain reaction for MRSA detection, the prevalence of 19.2% reported in Ekiti State, Nigeria in this study is an indication of gradual rise in the prevalence of MRSA in Nigeria. A cefoxitin (30 μg) disk diffusion test is recommended above methicillin and oxacillin for the phenotypic detection of MRSA in clinical laboratories.

Effect of case management on neonatal mortality due to sepsis and pneumonia

Background

Each year almost one million newborns die from infections, mostly in low-income countries. Timely case management would save many lives but the relative mortality effect of varying strategies is unknown. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST).

Methods

We conducted systematic searches of multiple databases to identify relevant studies with mortality data. Standardized abstraction tables were used and study quality assessed by adapted GRADE criteria. Meta-analyses were undertaken where appropriate. For interventions with biological plausibility but low quality evidence, a Delphi process was undertaken to estimate effectiveness.

Results

Searches of 2876 titles identified 7 studies. Among these, 4 evaluated oral antibiotics for neonatal pneumonia in non-randomised, concurrently controlled designs. Meta-analysis suggested reductions in all-cause neonatal mortality (RR 0.75 95% CI 0.64- 0.89; 4 studies) and neonatal pneumonia-specific mortality (RR 0.58 95% CI 0.41- 0.82; 3 studies). Two studies (1 RCT, 1 observational study), evaluated community-based neonatal care packages including injectable antibiotics and reported mortality reductions of 44% (RR= 0.56, 95% CI 0.41-0.77) and 34% (RR =0.66, 95% CI 0.47-0.93), but the interpretation of these results is complicated by co-interventions. A third, clinic-based, study reported a case-fatality ratio of 3.3% among neonates treated with injectable antibiotics as outpatients. No studies were identified evaluating injectable antibiotics alone for neonatal pneumonia. Delphi consensus (median from 20 respondents) effects on sepsis-specific mortality were 30% reduction for oral antibiotics, 65% for injectable antibiotics and 75% for injectable antibiotics on pneumonia-specific mortality. No trials were identified assessing effect of hospital management for neonatal infections and Delphi consensus suggested 80%, and 90% reductions for sepsis and pneumonia-specific mortality respectively.

Conclusion

Oral antibiotics administered in the community are effective for neonatal pneumonia mortality reduction based on a meta-analysis, but expert opinion suggests much higher impact from injectable antibiotics in the community or primary care level and even higher for facility-based care. Despite feasibility and low cost, these interventions are not widely available in many low income countries.

Funding

This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.

Changing trends in newborn sepsis in Sagamu, Nigeria: bacterial aetiology, risk factors and antibiotic susceptibility

AIM

Sepsis is a major contributor to newborn deaths in the developing world. The objective is to determine the prevalence of newborn sepsis, the bacterial pathogens and antibiotic sensitivity pattern of the isolates.

METHOD

A study of consecutive babies hospitalised in Sagamu, Nigeria, with risk factors for or clinical features of sepsis was retrospectively done between January 2006 and December 2007, and prospectively between January and December 2008. Positive blood culture defined neonatal sepsis, and the antibiotic sensitivity pattern of the organisms was also determined.

RESULTS

There were 1050 admissions, and 174 (16.5%) babies had positive blood culture. Of the 527 babies with risk factors and clinical features of sepsis, 174 (33.3%) had confirmed sepsis: 119 (22.5%) had early-onset sepsis, while 55 (10.4%) had late-onset sepsis. The incidence of neonatal sepsis in the hospital was 51.3/1000 live births. Weight less than 1.5 kg, prolonged labour, prolonged rupture of membranes and lower socio-economic status were risk factors for sepsis. Staphylococcus aureus (31.0%), Klebsiella (23.0%), and coagulase-negative Staphylococcus (12.6%) and Escherichia coli (11.0%) were the leading aetiologies. The isolates were most sensitive to levofloxacin (95.7%), ofloxacin (95.1%), cefotaxime (86.7%) and ceftazidime (81.3%). Their sensitivity was 56.4% to cefuroxime and gentamicin, which are commonly used.

CONCLUSION

The prevalence of sepsis was high in this cohort of high-risk infants. The low in vitro sensitivity of the leading microbes to commonly used drugs is challenging. Guidelines on the reduction of emergence of drug resistance must be provided and instituted in newborn units.

Predictors of mortality in neonatal septicemia in an underresourced setting

OBJECTIVE

To determine the predictors of mortality in neonatal septicemia.

METHOD

The records of babies with culture-proven septicemia managed in a Nigerian newborn unit between 2006 and 2008 were studied using bivariate and multivariate analysis.

RESULTS

Out of 174 babies with septicemia, 56 (32.2%) died. Outborn babies, babies with estimated gestational age (EGA) less than 32 weeks, weight less than 1.5 kg, temperature less than 38 degrees C, respiratory distress, abdominal distension, poor skin color, hypoglycemia, and infection with gram-negative pathogens were significantly associated with death by bivariate analysis. Multivariate analysis of these risk factors confirmed that EGA less than 32 weeks (odds ratio [OR], 5.5), respiratory distress (OR, 3.4), abdominal distension (OR, 2.7), poor skin color (OR, 3.3), and hypoglycemia (OR, 5.2) had significant independent contributions to the occurrence of death among babies with culture-proven septicemia.

CONCLUSION

Most of the identified predictors of mortality are modifiable and can be used to draw up a screening tool to determine the clinical severity among septic babies.

Neonatal infections in the developing world

An estimated one million newborns die from infections in developing countries. Despite the huge burden, high-quality data from community-based epidemiologic studies on etiology, risk factors, and appropriate management are lacking from areas in which newborns experience the greatest mortality. Several planned and ongoing studies in South Asia and Africa promise to address the knowledge gaps. However, simple and low-cost interventions, such as community-based neonatal care packages supporting clean birth practices, early detection of illness through use of clinical algorithms, and home-based antibiotic therapy in areas in which hospitalization is not feasible are already available and have the potential to bring about a drastic reduction in global neonatal mortality due to infections if they are scaled up to national level. Concerted collaborative action by national governments, health professionals, civil society organizations, and international health agencies is required to reduce neonatal mortality due to infections.

International perspective on early-onset neonatal sepsis

Infections are a major cause of neonatal death in developing countries. High-quality information on the burden of early-onset neonatal sepsis and sepsis-related deaths is limited in most of these settings. Simple preventive and treatment strategies have the potential to save many newborns from sepsis-related death. Implementation of public health programs targeting newborn health will assist attainment of Millennium Development Goals of reduction in child mortality.

Blood culture contamination in Tanzania, Malawi, and the United States: a microbiological tale of three cities

We conducted retrospective, comparative analyses of contamination rates for cultures of blood obtained in the emergency rooms of Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania; Lilongwe Central Hospital (LCH) in central Malawi; and the Duke University Medical Center (DUMC) in the United States. None of the emergency room patients had indwelling intravascular devices at the time that the blood samples for cultures were obtained. In addition, we reviewed the contamination rates for a cohort of patients already hospitalized in the DUMC inpatient medical service, most of whom had indwelling intravascular devices. The bloodstream infection rates among the patients at MNH (n=513) and LCH (n=486) were similar (approximately 28%); the contamination rates at the two hospitals were 1.3% (7/513) and 0.8% (4/486), respectively. Of 54 microorganisms isolated from cultures of blood collected in the DUMC emergency room, 26 (48%) were identified as skin contaminants. Cultures of blood collected in the DUMC emergency room were significantly more likely to yield growth of contaminants than the cultures of blood collected in the emergency rooms at MNH and LCH combined (26/332 versus 11/1,003; P<0.0001) or collected in the DUMC inpatient medical service (26/332 versus 7/283; P<0.01). For the MNH and LCH blood cultures, lower contamination rates were observed when skin was disinfected with isopropyl alcohol plus tincture of iodine rather than isopropyl alcohol plus povidone-iodine. In conclusion, blood culture contamination was minimized in sub-Saharan African hospitals with substantially limited resources through scrupulous attention to aseptic skin cleansing and improved venipuncture techniques. Application of these principles when blood samples for culture are obtained in U.S. hospital emergency rooms should help mitigate blood culture contamination rates and the unnecessary microbiology workup of skin contaminants.

Neonatal septicemia in high risk babies in South-Eastern Nigeria

BACKGROUND

Septicemia is one of the major causes of morbidity and mortality in the neonatal period and it often has a rapid and fulminant course.

AIMS

To determine the incidence, predisposing factors, clinical features, bacteriologic pattern and antibiotic sensitivity of neonatal septicemia.

DESIGN

A prospective study was undertaken over a 1(1/2)-year period in the neonatal unit of Ebonyi State University Teaching Hospital, Abakaliki, Southeastern Nigeria.

METHODS

All newborns (age 0-28 days) admitted with clinical features and/or risk factors suggestive of neonatal septicemia were selected and screened for septicemia.

RESULTS

The study identified 33 septicemic neonates of the 138 neonates (23.9%) screened, 19/92 (20.7%) for inborns and 14/46 (30.4%) for outborns, representing an incidence of 7.98/1000 live births. Prolonged/obstructed labor, severe birth asphyxia, maternal pre-partum/peripartum pyrexia and home/traditional birth attendant deliveries were the main predisposing perinatal factors. Respiratory distress, fever and jaundice were the predominant presenting clinical findings. Gram-positive organisms were cultured from 18 neonates with Staphylococcus aureus accounting for 45.5% of the cases, while Escherichia coli was the predominant Gram-negative organism accounting for 18.2% of the cases. Group B streptococcus accounted for only one case and there was no case of Listeria monocytogenes. Early onset septicemia was commoner in in born while late onset septicemia was commoner with out born (chi2 = 10.45, P < 0.05). The bacterial isolates showed a high degree of in vitro antimicrobial resistance to conventional antibiotics and the antibiotic sensitivity pattern of the organisms indicated the use of ceftriaxone and gentamicin as initial therapy while awaiting culture results. The overall mortality rate was 26.7%. Early onset septicemia and concomitant meningitis were associated with high mortality.

CONCLUSION

Neonatal septicemia is a major cause of morbidity and mortality in the study site. Most of the predisposing factors were due to poor obstetric care and unsterile delivery practices which could be avoided and prevented, and the causative organisms were different from those in the developed countries. There was appreciable resistance to commonly used antibiotics. Simple and sustainable interventions such as promotion of clean and timely deliveries, modern newborn care and specialized diagnostic facilities, hand washing and barrier nursing, and restriction of antibiotics may help reduce the burden of neonatal infection in the study community.

Bacterial isolates from blood cultures of children with suspected septicaemia in Calabar, Nigeria

Background

Septicaemia is a common cause of morbidity and mortality among children in the developing world. This pattern has changed little in the past decade. Physical signs and symptoms, though useful in identifying possible cases have limited specificity. Definitive diagnosis is by bacteriologic culture of blood samples to identify organisms and establish antibiotic susceptibility. These results are usually not available promptly. Therefore a knowledge of epidemiologic and antimicribial susceptibility pattern of common pathogens is useful for prompt treatment of patients. This report highlights the pattern of bacterial isolates in our environment from a retrospective study of our patients' records.

Methods

One thousand, two hundred and one blood samples were analysed from children aged 0–15 years, admitted into the children's wards of the University of Calabar Teaching Hospital, Calabar, Nigeria with features suggesting septicaemia. Samples were collected under aseptic conditions and cultured for aerobic and anaerobic organisms. Isolates were identified using bacteriologic and biochemical methods and antibiotic sensitivity determined by agar diffusion method using standard antibiotic discs.

Results

Bacteria was isolated in 552 (48.9%) of samples with highest rates among newborns (271 : 50.8). The most frequent isolates were Staphylococcal aureus (48.7%) and Coliforms (23.4%). Results showed high susceptibilities to the Cephalosporins (Ceftriazone- 100%:83.2%, Cefuroxime-100%:76.5%) and Macrolides (Azithromycin-100%:92.9%) for S. aureus and coliforms respectively. This study underscores the importance of septicaemia as a common cause of febrile illness in children and provides information on common prevalent aetiologic agents and drug susceptibilities of the commonest pathogens.

Conclusion

Staphylococcus aureus and coliforms were the leading causes of septicaemia in children in this locality, and the third generation cephalosporins and azithromycin were shown to be effective against these pathogens.

Neonatal sepsis: an international perspective

Neonatal infections currently cause about 1.6 million deaths annually in developing countries. Sepsis and meningitis are responsible for most of these deaths. Resistance to commonly used antibiotics is emerging and constitutes an important problem world wide. To reduce global neonatal mortality, strategies of proven efficacy, such as hand washing, barrier nursing, restriction of antibiotic use, and rationalisation of admission to neonatal units, need to be implemented. Different approaches require further research.

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.