INTRODUCTION: study. The details of the baby were

INTRODUCTION:
Neonatal sepsis is one of the major
causes of morbidity and mortality among the newborns in the developing
countries like India. It is responsible for approximately 25% of the neonatal
deaths in the world1. High rate of antibiotic resistance and abuse
of antibiotics in several hospitals without standard protocol against commonest
bacterial pathogen has further worsened the situation. Neonatal sepsis can be
defined as “a clinical syndrome characterized by systemic signs and symptoms
and bacteraemia during the first month of life”. Bacterial pathogens vary
geographically. Children infected within 72 hours of life are termed as early
onset sepsis (EOS) where as more than 72 hours termed as late onset sepsis
(LOS)2. Objective of
this study was to identify the organisms in culture positive sepsis patients
and find their sensitivity patterns followed by making comparisons with
previous studies. Ethical approval was obtained from the ethical committee of
Kalinga institute of medical science.   

 

 

 

 

 

 

 

 

 

MATERIAL
& METHODS: Our study was a prospective
observational study undertaken in NICU of large tertiary care hospital of
eastern India. The time period was from august 2015 to august 2016. All the
cases diagnosed as culture positive sepsis through Bactec method were
enlisted and taken into consideration. Our hospital posses high level well
equipped NICU with experienced neonatologists. The neonates who presented with signs and symptoms of
septicaemia, along with culture positive organism in blood were included in the
study. The details of the baby were noted along with the antibiotic sensitivity
pattern. The pattern of antibiotic resistance was compared to previous studies
undertaken in this area in different time period. SPSS version 24 was used for
statistical calculations.

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RESULTS:

                      Culture positive sepsis patients
were 54 in number. Among them 68% were male infants whereas 32% were female
infants. 42(77.7%) were having late onset sepsis and others were early. The
study group consisted of 76% out born patients and 24% inborn patients. Out of 12
inborn cases 8 mothers had 1 risk factor for sepsis, 2 mothers had 2 risk
factors of sepsis and 2 mothers had 3 risk factors.  36 patients were preterm and 18 patients were
term patients. 40 (74%) patients were small for gestational age.

                      Out of 54 patients
clinical or radiological pneumonia was observed in 10 (18%) patients.
Meningitis was diagnosed in 9 (16.6%) cases from CSF analysis. Septic arthritis
and osteomyelitis was diagnosed in 2 (3.7%) cases. Septicaemia was the
diagnosis in 36 (66.6%) cases. Lethargy and poor feeding were the most common
symptoms. 89% of patients were having lethargy. High sensitive C Reactive
Protein was raised qualitatively in all the cases. Other sepsis markers as well
as radiological pictures and CSF analysis follow it.

                  Out of 54 culture positive organisms
24 were gram positive and 30 were gram negative. From gram positive coagulase
negative staphyloccus are 11(45.8%). From gram negative cohort klebsiella was
more common (40%) than others. The antibiotic sensitivity pattern is pictured.
(Table1,2 & graph1,2). Several index studies, presenting different time and
geographic area were compared with our study in percentage resistance (GRAPH
3,4).

 

 

 

 

 

DISCUSSION:

                  
Sepsis is one of the important causes of neonatal morbidity and
mortality in hospitalized newborns.3 The
causative organisms in neonatal sepsis vary from place to place.4,5 In Western countries, Group B Streptococci (GBS)
is mainly responsible for neonatal sepsis where as in developing countries like
india gram negative bacterias like klebsiella and escherechia are commonest.6,7 In this study, 55.5% organisms causing neonatal
sepsis were gram negative and 44.4% gram positive. This is in agreement with
the studies done by Shrestha et al. 8 The most common pathogens
isolated from the patients of neonatal sepsis were Klebsiella pneumonia(22.2%).
In present study CONS are more common than other gram positive bacterias
(20.3%). These epidemiologic data are coincident to previous studies.9,10

                     As antibiotic use is
prevalent now a day the incident of neonatal sepsis has decreased. A
preponderance of male infants is apparent in almost all studies of sepsis in
newborns.5 In our study also, culture positivity was more in male infants. In
present study, late onset septicemia was observed in more cases, while it was
51.4% in Shaw Ck et al,3 (2007) study. Low birth weight 17 and prematurity were the common risk factors
associated with neonatal sepsis. Our study also goes hand in hand with this.

                     Present study showed high
increase in antibiotic resistance as compared to other 3 studies{3,10,13}.
In gm+ cases penicillin G resistance has decreased markedly. But resistance to
all other common antibiotics like erythromycin, ciprofloxacin, amoxicillin has
increased markedly with respect to other comparison groups by shah etal (2011)
shaw etal 2007 and mehmood etal 2002. In their study not a single case of
vancomycin resistance is met. But in our study 27% gm+ bacterias are resistance
to vancomycin. This discordance can be explained by the emergence of vancomycin
resistant staphylococcus aureus (VRSA). Negligence antibiotic use and
environmental acquired resistance may be common cause of this.14 Resistance
to macrolides, fluroquinolones increasing whereas the less used antibiotics
like tigycycline, tetracycline, daptomycine, lincomycin show good sensitivity.
Resistance is also increasing In gram negative organisms. The resistance in
gram negative cases are higher than the positive cases.  Ampicillin resistance in 95% isolates.
Increased resistance was also noticed against amikacin and gentamycin, which
are commonly used for empirical therapy. According to our antibiogram of our
hospital, higher generation ciprofloxacin, ?-lactamase inhibitor combinations,
carbapenems, tigycyclines, nalidixic acid, ticarcillin were effective against
Gram-negative bugs. But resistance in previous studies are much less to
conventional antibiotics.3,10,13 The drug treatment given
according to the protocol showed marked improvement in the outcome of patient. All
cases in our study were positive for high senstive quantitative CRP(>1gm/dl).
This shows hs C-reactive protein is a very good septic screen marker, other
screening markers also should be looked for.

CONCLUSION:

Blood
culture is the gold standard in diagnosis and treatment of neonatal septicemia.
Multiple antibiotic resistances among neonatal sepsis is a great headache for
the clinicians now a days. Slow progress in development of newer drugs and
rapidity in resistance development are major areas of concern. Abundant use of
precious antibiotics by doctors as well as common men who use medication
without consulting physician rather consulting medicine storekeepers is the
primary cause of rampant misuse. Paucity of abundant knowledge and specific
guidelines for treatment of several infections make situation even worse. It is
observed that some people demand antibiotics or stealthily use them for minor
viral problems.  Wise use of antibiotics
should be done or there will be no drugs available in the future for treatment.
There is a need of wide pan india studies on emerging resistance of antibiotics
as well as very strict antibiotics policy. Each and every hospital must have
its own local antibiogram mentioning empirical therapy options.

Our
study advises higher generation cephalosporins with ?-lactamase inhibitor
combination for empirical treatment. Vancomycin should be added to cover
Gram-positive ones. Reserve drugs should be kept for delay in improvement.
Strict hand washing and isolation of sepsis patients will help decrease the
emergence of nosocomial strains. Other possible strategies to reduce the load
of neonatal sepsis like barrier nursing, promotion of clean deliveries,
exclusive breast feeding, rationalization of admissions to and discharge from
neonatal units should be adapted for fighting antibiotics resistances. Decrease
in the CONS isolates can be done by proper skin treatment before collection of
blood, reducing the duration of central and peripheral blood lines. 

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