Bacteriological profile and
antibiotic sensitivity pattern of neonatal sepsis in a tertiary care
hospital of northern India
Bhat M. 1, Saini G.S. 2
1Dr. Minakshi Bhat, Lecturer, Pediatrics, Terna Medical College, Nerul,
Navimumbai, 2Dr. G.S. Saini , Professor, Pediatrics, SMGS Hospital,
Government Medical College, Jammu, India
Address for
Correspondence: Dr. Minakshi Bhat, Lecturer department of
Pediatrics, Terna Medical College, Nerul, Navimumbai. Emal Id:
minakshi_libra@yahoo.in
Abstract
Introduction:
Neonatal sepsis is the single most important cause of neonatal deaths
in the community. Objectives:
To identify the common bacterial pathogens associated with neonatal
sepsis and to identify their antibiotic sensitivity pattern. Material and Methods:
During the study period, all the neonates admitted in neonatology ward
were screened for sepsis by physical examination and clinical features.
All infants satisfying the criteria for sepsis were subjected for blood
culture. Growths, if any were noted and standard antibiotic sensitivity
was performed by the Kirby-Bauer disc diffusion method as per the CLSI
recommendations. Results:
Out of 2520 neonates admitted in neonatal intensive care unit over a
period of one year, 89 neonates were diagnosed as having septicemia.
Incidence of sepsis in our hospital was 35.3/1000 neonatal admissions.
Out of 89 clinically suspected and positive screening test cases of
neonatal sepsis, 48.31% were culture proven cases of neonatal sepsis.
Klebsiella was found to be the predominant pathogen (34.88%) of the
culture positive cases followed by staphylococcus aureus in 32.5% and
E. coli in 9.30% cases. Majority of the organisms were resistant to
commonly used antibiotics like ampicillin, cloxacillin and ceftriaxone.
Aminoglycosides were relatively more effective treatment modalities
against gram negative organisms while vancomycin was the most sensitive
drug against Staphylococcus aureus. Conclusions:
In view of growing bacterial resistance to commonly used antibiotics,
knowledge of bacterial pathogens prevalent in NICU and their
antimicrobial susceptibility pattern will help the clinician to select
appropriate antibiotics for treatment of suspected neonatal sepsis
cases.
Keyword:
Incidence, Neonatal sepsis, Bacterial isolates, Antibiotic
susceptibility pattern, Gram-positive, Gram-negative
Manuscript received:
24th October 2016,
Reviewed: 5th November 2016
Author Corrected;
20th November 2016,
Accepted for Publication: 30th November 2016
Introduction
Neonatal sepsis is a significant cause of morbidity and mortality among
neonates Worldwide [1,2,3,4]. The overall incidence of culture proven
sepsis varies between 1-8 cases per 1000 live births with equal
distribution of early and late onset cases [5,6,7,8]. Neonatal sepsis
can be divided into two sub-types depending upon whether the onset of
symptoms is before 72 hours of life [early onset sepsis (EOS)] or later
[late onset sepsis (LOS)]. Early-onset infections are caused by
organisms prevalent in the maternal genital tract or in the delivery
area. Late- onset septicemia is caused by the organisms thriving in the
external environments of the home or the hospital [9]. The organisms
commonly associated with EOS are group B streptococcus and E coli in
the west ,while in India most cases are due to Gram- negative organisms
especially E. coli, klebsiella, and enterobacter sp.[10,11]. Organisms
that have been implicated in LOS are coagulase-negative Staphylococci
(CONS), Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli,
Enterobacter spp., Pseudomonas aeruginosa and anaerobes [11,12]. Prompt
diagnosis and effective treatment is necessary to prevent deaths and
complications due to septicemia. The blood culture remains the
“Gold Standard” for the diagnosis for neonatal
sepsis though its sensitivity is 50-80 percent [12]. But the results of
blood culture takes hours to days, thus necessitating initial empirical
treatment of suspected cases. Hence, the current study was designed to
determine the common bacterial agents associated with neonatal sepsis
and their antibiotic susceptibility pattern in a tertiary care hospital
in Northern India.
Materials
and Methods
Study setting and
duration- This prospective observational cohort study was
conducted in the department of Paediatrics SMGS Hospital, in
collaboration with the department of microbiology, Government Medical
College Jammu over a period of one year from December 2014 through
November 2015. Prior approval was obtained from the Research and
Ethical committee of our institute and informed consent was obtained
from each patient’s next of kin. During the study period, A
total of 2520 neonates admitted in neonatal intensive care unit (NICU)
were screened for sepsis by the examining physician and sepsis was
clinically suspected if the neonate had symptoms and signs suggestive
of sepsis such as poor feeding, poor activity, respiratory distress,
apnea, seizure, lethargy, bulging anterior fontanel, fever,
hypothermia, jaundice, vomiting, loose stools, abdominal distension,
cyanosis, bleeding, mottling, tachycardia, weak pulse, grunting,
retractions, nasal flaring were noted. Septic screening tests like band
cell count, C- reactive protein, and micro erythrocyte sedimentation
rate were done in all cases. All neonates in whom sepsis was suspected
and had at least two positive screening tests were included in the
study. All blood cultures were collected from a peripheral vein under
all aseptic precautions before starting any antibiotic therapy. A
minimum 1.5ml of blood was collected from each patient using proper
aseptic precautions and inoculated immediately into 30 mL of Tryptic
soya broth (Hi -Media Laboratories, Mumbai). The bottles were incubated
aerobically at 37°C for 24 hours. Subcultures were made on
sheep blood agar, MacConkey agar and chocolate agar routinely after 48
hours and 7 days. All the inoculated culture plates were incubated at
37°C for overnight. After incubation, the growth was identified
by colony characteristics and standard biochemical tests. Antibiotic
sensitivity was tested by the Kirby-Bauer disc diffusion method as per
the CLSI recommendations (NCCLS Supplement 2000) for routinely used
antibiotics like ampicillin, cloxacillin, gentamycin, chloramphenicol,
amikacin, netlmycin, ceftriaxone, ciprofloxacin and vancomycin.
Statistical Analysis- Data
were coded and entered into MS-Excel sheet. Statistical analysis were
done using software SPSS 20 version. Descriptive and inferential
statistics were used. Data were presented in percentages and simple bar
diagram.
Results
During study period 2520 neonates were admitted in the NICU .Out of
them 89 neonates were diagnosed as having septicemia .Incidence of
neonatal sepsis in our hospital in the present study was 35.5/1000
neonatal admissions. Blood culture was positive in 43 (48.3%) neonates
with sepsis. Bacteriological profile of 43 septicemic neonates with
positive blood cultures is shown in table No.1.
Table-1: Bacteriological
profile of 43 septicemia neonates with positive blood cultures
|
Organism
|
Total
(n=43)
|
EOS
(n=25)
|
LOS
(n=18)
|
|
klebsiella
|
15 (34.88%)
|
8 (32%)
|
7 (38.9%)
|
|
Staphylococcus
aureus
|
14 (32.5%)
|
8 (32%)
|
6 (33.3%)
|
|
E.
coli
|
4 (9.30%)
|
3 (12%)
|
1 (5.6%)
|
|
Citrobacter
|
4(9.30%)
|
2 (8%)
|
2 (11.1%)
|
|
Enterobacter
|
2 (4.65%)
|
2 (8%)
|
-
|
|
Aerobic
spore bearer
|
2 (4.65%0
|
1 (4%)
|
1(5.6%)
|
|
Salmonella
species
|
1 (2.32%)
|
1 (4%)
|
-
|
|
Candida
|
1 (2.32%0
|
-
|
1 (5.6%)
|
(Figures in brackets indicate percentages)
Out of culture proven cases, 28 (65.11%) sepsis cases were attributable
to gram negative species while only14 (32.6%) cases were attributable
to gram positive. Klebsiella was the commonest organism isolated in
15(34.88%) neonates & Staphylococcus aureus in 14(32.5%).
Klebsiella was the commonest organism isolated in both early onset
(32%) and late onset sepsis (38.9%) followed by Staphylococcus aureus
(32% EOS and 33.3% LOS respectively).
Bacterial isolates and their sensitivity to various antibiotics is
shown in table no.2. Klebsiella isolates were sensitivity to netilmycin
(60%), amikacin(53.3%), ciprofloxacin (53.3%), Ceftriaxone (46.7%),
chloramphenicol (33.3%), gentamycin (26.7%) , and ampicillin (13.3%).
Staphylococcus was sensitive to vancomycin in 71.5% cases followed by
amikacin , netilmycin (50% each) and Gentamycin (28.8%). Thus the
aminoglycosides had good sensitivity for both gram positive and gram
negative organisms while most of the organisms showed resistance to
commonly used drugs like ampicillin, cloxacillin and ceftriaxone.
Table-2: Bacterial
isolates and their sensitivity pattern to various antibiotics
|
Organism
|
Amp.
|
Clox.
|
Chlor.
|
Genta.
|
Amik.
|
Netil.
|
Ceft.
|
Cipro.
|
Vanco.
|
|
Klebsiella
|
2
(13.3)
|
-
|
5
(33.3)
|
4
(26.7)
|
8
(53.3)
|
9
(60)
|
7
(46.7)
|
8
(53.3)
|
-
|
|
Staphylococcus
aureus
|
3
(21.4)
|
3
(21.4)
|
1
(7.1)
|
4
(28.6)
|
7
(50)
|
7
(50)
|
3
(21.4)
|
2
(14.2)
|
10
(71.4)
|
|
E.
coli
|
1
(25)
|
-
|
3
(75)
|
3
(75)
|
2
(50)
|
3
(75)
|
1
(25)
|
1
(25)
|
-
|
|
Citrobacter
|
1
(25)
|
-
|
2
(50)
|
2
(50)
|
2
(50)
|
2
(50)
|
2
(50)
|
2
(50)
|
-
|
|
Enterobacter
|
-
|
-
|
2
(100)
|
1
(50)
|
1
(50)
|
1
(50)
|
2
(100)
|
-
|
-
|
|
Salmonella
species
|
-
|
-
|
-
|
1
(100)
|
1
(100)
|
1
(100)
|
-
|
1
(100)
|
-
|
(Figures in brackets indicate percentages)
Amp.=Ampicillin,Clox.=Cloxacillin,Chlor.=Chloramphenicol,Genta.=Gentamycin,Amik.=Amikacin,Netil.=Netilmycin,Ceft.=Ceftriaxone,Cipro.=Ciprofloxacin,Vanco.=Vancomycin
Discussion
Neonatal sepsis refers to systemic and generalized bacterial infection
of the newborn documented by a positive blood culture in the first four
weeks of life and is one of the four leading causes of neonatal
mortality in India [13]. The gold standard for diagnosis of septicemia
is the isolation of bacterial agent from blood culture. The prevalence
of bacterial profile of blood culture and their susceptibility patterns
in an area, provide guidance to start empirical treatment which is the
cornerstone in the management of sepsis [13]. In this study, the
incidence of neonatal sepsis was 35.3/1000 neonatal admissions which is
consistent with studies done by Chacko et a [5], National Neonatal,
Perinatal Database [14] and Sharma et al [15]. In our study the blood
culture positivity rate in neonatal sepsis cases was 48.3%, similar
results were observed by Chacko et al [5]. However some studies have
reported higher blood culture positivity rates [15,16]. Also, the gram
negative organisms constituted the major group of isolates (65.11%)
from neonatal septicemia cases, which correlates with the findings
(67.85%) of Desai et al.[17] and another study [13]. Klebsiella was the
predominant pathogen of neonatal sepsis in our study (34.9%) followed
by Staphylococcus aureus (32.5%) and E coli (9%) which correlates with
the observations made by Deorari, and National Neonatal Perinatal
Database [1,18,19]. These observations were different from that
reported by Karthikeyan et al [20] wherein Staphylococcus aureus was
the predominant pathogen (61.5%) followed by Klebsiella (21.9%) and E.
col(13.5%) The results of antibiotic sensitivity revealed that majority
of the organisms were resistant to commonly used antibiotic like
ampicillin, cloxacillin and ceftriaxone. It has been also shown that
aminoglycosides like netilmycin, amikacin and gentamycin were most
effective antibiotics against gram negative organisms and also were
effective against Staphylococcus aureus. But vancomycin still remains
the most sensitive drug for Staphylococcus aureus. Similar results were
also reported in studies conducted by Mathur et al, Khatua et al, and
Tallur et al [2,16,21].
Conclusion
Incidence of neonatal sepsis in our study was 35.3/1000 neonatal
admissions. Klebsiella, Staphylococcus aureus and E coli are the most
common organisms causing neonatal sepsis. Both gram-positive and
gram-negative bacteria have developed resistance against commonly used
antibiotics like ampicillin, cloxacillin and ceftriaxone.
Aminoglycosides are relatively more effective treatment modalities.
Acknowledgements:
we sincerely thank Mrs. Janish Raina, laboratory technician for her
help and coordination.
Contribution:
Dr. Minakshi Bhat: Designing and drafting of the manuscript. Dr.
G.S.Saini : Final approval of the manuscript
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Bhat M, Saini G.S. Bacteriological profile and antibiotic sensitivity
pattern of neonatal sepsis in a tertiary care hospital of northern
India.Int.J Pediatr Res.2016;3(11):831-834.doi:10.17511/ijpr.2016.11.12.