4/25/2016 BacteriologicalprofileandantibioticsensitivitypatternofneonatalsepticaemiainaruraltertiarycarehospitalinNorthIndiaThakurS,ThakurK,Soo

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ThakurS
ThakurK
SoodA
ChaudharyS
BRIEFCOMMUNICATION
~SearchinGoogleScholar Year:2016|Volume:34|Issue:1|Page:6771
for
ThakurS Bacteriologicalprofileandantibioticsensitivitypatternofneonatalsepticaemiainaruraltertiarycarehospitalin
ThakurK NorthIndia
SoodA
ChaudharyS
SThakur1,KThakur1,ASood1,SChaudhary2
1DepartmentofMicrobiology,Dr.RPGMC,Kangra,Tanda,HimachalPradesh,India
~Relatedarticles
2DepartmentofPediatrics,Dr.RPGMC,Kangra,Tanda,HimachalPradesh,India
Bloodculture
drugresistance
extendedspectrumbeta DateofSubmission 10Sep2014
lactamases
DateofAcceptance 30Jul2015
methicillinresistant
Staphylococcusaureus DateofWebPublication 15Jan2016
neonates
CorrespondenceAddress:
SThakur
~ArticleinPDF(631KB) DepartmentofMicrobiology,Dr.RPGMC,Kangra,Tanda,HimachalPradesh
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DOI:10.4103/02550857.174108

~Abstract
~Introduction
~MaterialsandMe... ~Abstract
~Results
Background:ThereisnotmuchpublishedliteratureonneonatalsepticemiaavailablefortheSubHimalayan
~Discussion
regionofNorthIndia.Hence,weundertookthisstudytofindoutthebacteriologicalprofileandantibiotic
~Conclusion sensitivitypatternofneonatalsepticemiaintheneonatalIntensiveCareUnit.MaterialandMethods:Blood
~References cultureswereperformedforallclinicallysuspectedneonatalsepticemiacasesfor1year.Identificationofall
~ArticleFigures pathogenicisolateswasfollowedbyantibioticsensitivitytesting.Results:Wedidbloodculturesfor450neonates
~ArticleTables and42%wereculturepositive.Earlyonsetsepsiswere92(49%)and96(51%)werelateonsetsepsis.Gram
positiveisolateswere60%and40%wereGramnegative.Staphylococcusaureus(40%),coagulasenegative
ArticleAccessStatistics Staphylococcusspecies(16%),nonfermentergroupoforganisms(NFGOs)(15%),andKlebsiellapneumoniae
(10%)werethemainisolates.Nasalcannula101(54%),birthasphyxia91(48%),andprematurity73(38%)were
Viewed 683 theprominentriskfactorsassociatedwithsepticemia.Grampositiveorganismswerehighlyresistanttopenicillin
Printed 19 (87%)whereasGramnegativeisolatesshowedhighresistancetothirdgenerationcephalosporins(5389%)and
Emailed 0 aminoglycosides(5067%).TheS.aureusisolatesweremethicillinresistantin41%whereasextendedspectrum
PDFDownloaded 159 betalactamaseproductionwasseenin48%Gramnegativeisolates.Conclusion:Ourstudyhighlightstherecent
Comments [Add] emergenceofGrampositiveorganismsaspredominantcauseofneonatalsepticemiainthispartofSub
Himalayanregion,alongwiththereviewofliteraturewhichshowssimilarresultsfromNorthIndiaandrestofthe
worldtoo.ThoughGramnegativebacteriastillremainthemaincauseofmortalityinneonatalsepticemia,we
wanttodispelthecommonnotionamongpractitionersthattheyarethepredominantisolatesinneonatal
septicemia.

Keywords:Bloodculture,drugresistance,extendedspectrumbetalactamases,methicillinresistant
Staphylococcusaureus,neonates

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4/25/2016 BacteriologicalprofileandantibioticsensitivitypatternofneonatalsepticaemiainaruraltertiarycarehospitalinNorthIndiaThakurS,ThakurK,Soo
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NeonatalHospital
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[cited2016Apr24]34:6771.Availablefrom:http://www.ijmm.org/text.asp?2016/34/1/67/174108

~Introduction

Neonatalsepticemiaisresponsibleforapproximately25%oftheneonataldeathsintheworld[1]andmostlyin
developingcountries.[2]Increasedprevalenceofextendedspectrumbetalactamases(ESBLs)andmethicillin
resistantStaphylococcusaureus(MRSA)andmultipledrugresistant(MDR)strainsisacauseofconcernin
NeonatalIntensiveCareUnits(NICU)worldwide.Septicemiahasbeenclassifiedasearlyonsetsepticemia(EOS)
andlateonsetsepticemia(LOS).[3]ThemicroorganismsmostcommonassociatedwithEOSincludeGroupB
Clickonimagefordetails.
Streptococcus(GBS),EscherichiaMoreDetailscoli,coagulasenegativeStaphylococcusspecies(CONS),
HaemophilusinfluenzaeandListeriamonocytogene.[4]andLOSiscausedbyCONS,S.aureus,E.coli,Klebsiella
spp.,Pseudomonasspp.,Enterobacterspp.,Candidaspp.,GBS,Serratiaspp.,Acinetobacterspp.andanaerobes.
TherecenttrendsshowanincreaseininfectionsduetoCONS.[4]

Theknowledgeofbacteriologicalprofileanditsantibioticsensitivitypatternsisofimmensehelpinsavinglives
ofneonateswithsepticemia.[5]

AlthoughextensiveresearchonneonatalsepticemiaisavailableworldwideandinIndia.However,veryfew
studieshavebeenconductedonneonatalsepticemiainthestateofHimachalPradeshandnoneinthispartofthe
state.

Hence,weundertookacrosssectionalprospectivestudywastoinvestigatethecausativeorganismsofneonatal
septicemiaandtoassesstheirantibioticsusceptibilitypatternovertheperiodof1yearinNICUofatertiarycare
hospitalintheruralarea.

~MaterialsandMethods

ThestudywasconductedafterobtainingInstitutionalEthicsCommitteeandInstitutionalReviewBoardapproval.

ItwasacrosssectionalstudycarriedoutintheNICUofatertiarycaremedicalcollegeandhospitalfromApril
2012toMarch2013.Thevariousneonatalandmaternalriskfactorswerealsoanalysed.Theneonatalriskfactors
studiedwerelowbirthweight(LBW),birthasphyxia,meconiumstaining,congenitalanomalies,prematurity,
centralvenouscatheterisation>10days,nasalcanulausage,andcontinuouspositiveairwaypressureuse.

Thematernalriskfactorsincludedsocioeconomicstatus,difficultdelivery(caesarean,forceps,vacuum),
prematureruptureofmembranes,prolongedruptureofmembranes,maternalfever,recurrentabortions,prenatal
carereceived,urinarytractinfection,historyofstillbirth,amniocentesis,cervicalcerclageoperation,and
chorioamnionitis.

Atotalof450suspectedpatientsofneonatalsepticemiawereincludedinthestudy.Neonatalsepticaemiawas
suspectedifoneormoreofthefollowingsignsandsymptomswerepresent:Convulsions,respiratoryrate
>60/min,severechestindrawing,nasalflaring,grunting,bulgingfontanelle,pusdrainingfromtheear,redness
aroundumbilicusextendingtotheskin,temperature37.5C(99.5F)or36.4C(97.52F),lethargy,
unconsciousness,reducedmovements,notabletofeed,notattachingtothebreast,notsucklingatall,crepitations
inlungs,cyanosis,andreduceddigitalcapillaryrefilltime.

Twomillilitresofbloodwascollectedfromallneonatesasepticallypreferablybeforeadministrationofthe
antibioticsandinoculatedinto20mlofbrainheartinfusionbroth(HiMedia,India)onthebedside.

BloodculturebottlesweretransportedimmediatelytotheMicrobiologyLaboratoryandwereprocessedasper
standardmicrobiologicaltechniquesandtheisolateswereidentified.[6]

AntibioticsensitivitytestingwasperformedonMuellerHintonagarplatesbymodifiedKirbyBauerdisk
diffusionmethodasperClinicalLaboratoryStandardInstituteguidelines.[7]E.coliATCC25922,S.aureusATCC
25923,P.aeruginosaATCC27853wereusedasstandardstrains.ScreeningforMRSAwasdoneusingacefoxitin
(30g)disc.[7]Resistancetoceftazidime(30g)diskwasusedasascreeningmethodfordetectionofESBL
confirmedbydoubledisksynergytest.[7]

~Results

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Ofatotalof450neonatesinvestigatedwithbloodculture,188(42%)werefoundtobepositiveforneonatal
septicemia.Maleswere117(62%)and71(38%)females.Meanageatadmissionwas3.775.02days.Inborn
neonates111(59%)weremorecommonthanoutborn77(41%).Of188neonates,106(56%)and82(44%)were
normalbirthweightandLBWneonates,respectively,and73(39%)werepreterm.VeryLBWneonates,thatis,
weightbelow1.5kgwere19(11%).EOSandLOSwere92(49%)and96(49%)neonates,respectively.EOSwas
seenmorecommonininbornneonates(56%)comparedtotheoutborn(39%).

Thecommonclinicalpresentationswererespiratorydistresssecondarytobirthasphyxia(48%),fever(20%),
neonataljaundice(8.5%),pneumonia(8%),decreasedacceptanceoffeedsandlethargy(7%),andseizuresor
meningitis(5%).Theneonatalriskfactorssuchasbirthasphyxia,useofanasalcannula,andprematurityshowed
associationwithcultureprovenneonatalsepticemia(P<0.05).Noneofthematernalriskfactorswerefoundtobe
significantlyassociatedwithneonatalsepticemia.

Of188(42%)positivebloodcultures,theGrampositivebacteria(GPB)andGramnegativebacteria(GNB)
accountedfor(60%)and(40%).Respectively,AmongGrampositiveorganisms,66%isolateswereS.aureusand
amongGramnegativeorganisms,NFGOwasthemostcommonorganismisolated(40%).AmongNFGO,only
Acinetobacterspp.(3%)couldbeidentified.Otherorganismsisolatedaresummarisedin[Table1].
Table1:GrampositiveandGramnegativepathogensisolatedfromneonates

Clickheretoview

CONSandNFGOwereconsideredaspathogensonlyifthetemperaturewas>38Cor<36C,historyof
initiationofantibiotictherapyorpresenceoftheintravenouscatheter.

Theresistancetopenicillin,amoxicillinandclavulanicacidandazithromycinwas87%,66%and48%
respectivelyamongGPBandGNB[Figure1].Methicillinresistancewasdetectedin29(41%)ofS.aureus.There
were30(40%)MDRisolatesamongthetotalof75isolatesofS.aureus.Alltheisolatesweresensitiveto
vancomycin.

Figure1:AntibioticresistancepatternamongGrampositiveisolates

Clickheretoview

Gramnegativeorganismsshowedhighresistancetothethirdgenerationcephalosporins.Theyalsoshowedhigh
resistancetoamoxicillinandclavulanicacidcombination(81%),netilmicin(67%)andgentamycin(63%).
Resistancetociprofloxacinandamikacinwasobservedin(52%)and(50%)respectively[Figure2].ESBL
productionwasdetectedin24(48%)ofGNBthatincludedKlebsiellapneumoniae12(50%),E.coli6(25%),
NFGO4(16%)andEnterobacterspp.2(8%).

Figure2:AntibioticresistancepatternamongGramnegativeisolates

Clickheretoview

HighresistanceagainstpenicillinandamoxicillinandclavulanicacidwasfoundforbothGPBandGNB.The
thirdgenerationcephalosporinshowedweakactivityagainstalltestedbacteria.Theconsiderablepreponderance
ofamikacinactivityovergentamicinandnetilmicinwasobservedinGNB.Imipenemresistancewasobserved
among04%GNB.Outofthe45Enterobacteriaceaeisolatesinourstudy33(73.3%)wereMDR.Allthe
Acinetobacterspp.werealsoMDR.

Therewere22(12%)mortalitywhichwas17%amongfemaleneonatescomparedto8.5%amongmaleneonates.
HighestmortalityofneonateswasseenwithKlebsiellapneumoniae(27.7%)followedbyNFGO(20%)and
Enterobacterspp.(20%).Theneonatalfactorssignificantlyassociatedwithmortalitywerefemalesex,LBW,birth
asphyxia,andnasalcannula(P<0.05).

~Discussion

Septicemiaremainsasignificantcauseofmorbidityandmortalityinthenewborn.Theclinicaldiagnosisof
neonatalsepticemiaisdifficultasitpresentswithnonspecificsignsandsymptoms.Anearlydiagnosisof
neonatalsepticemiaisimportanttoinitiateappropriateandprompttreatment.Thecorrectandtimelyidentification
ofinfectiousagentsandtheirantibioticsensitivitypatternsareessentialtoguidethecliniciansregardingboththe
empiricalanddefinitivetreatment.

Thebacteriologicalprofileofsepticemiakeepschangingwiththepassageoftimefromregiontoregionand
hospitaltohospital,inthesamecityorcountry.TheemergenceofresistantbacteriainNICUsettingsleadsto
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failureinthetreatmentofneonatalsepticemia.Tosupplementthemanagementofsepticemiainneonates,weneed
todolongitudinalsurveillanceoftheNICUsandformulateperiodicguidelinesforempiricaltreatment.Inrecent
years,therehasbeenalotofimprovementinmedicalfacilitiesandasaresult,thesurvivalrateofthepretermand
LBWbabieshasimproved.Butatthesametime,theseneonateswithimmatureimmunedefensesareexposedto
NICUfloraforalongerduration.MostoftheneonatalsepticemiacasesnowareeitherLBWorpreterm.[4]Inthe
presentstudy,44%wereLBWand39%werepretermneonateswhichhasledtomoreLOS(51%)ascomparedto
EOS(49%).Mhadaetal.reported23%ofpretermneonates,intheirstudy.[8]Amongthematernalriskfactors,the
difficultdelivery(32%)intheformofCaesarean,forcepsorvacuumwasfoundmuchhigherriskfactorinour
studyascomparedto(14.88%)byTalluretal.[9]

ThebacteriologicalprofilehaschangedworldwidefrompredominantGramnegativetoapredominantGram
positivebacteriaisolation.[10],[11],[12],[13],[14],[15]Manyrecentstudieshavereportedtheemergenceofsomenew
emergingorganismssuchasCONS,NFGO,andCandidaspp.asacauseofneonatalsepticemia.[16],[17],[18],[19],
[20]

OurstudyshowedapreponderanceofGrampositiveisolates,60%versus40%,Gramnegativeisolates.Ballotet
al.,KaufmanandFairchildandHoogenetal.reportedtheisolationofGPBin54.9%,68.2%,and75%,
respectively,whichisinconcordancewiththepresentstudy.[3],[21],[22]

ThecolonisationoftheskinandnasopharynxbyCONSandS.aureusinhealthcareworkers,overcrowdingin
nurseriesandNICU,andimproperhandwashingtechniquesmayleadtotransmissionofGrampositiveorganisms
inneonateshorizontally.ThereisapredominanceofGPBisolationinourstudyunlikeotherstudiesintheNorth
India.[23],[24]Thereasoncouldbeduetoovercrowdinginnurseries/NICUandlackofknowledgeaboutinfection
controlmeasuresamonghealthcareproviders.

OurstudyshowedS.aureus(66%)andCONS(31%)asthemostcommonGrampositiveorganismswhichis
quitehighascomparedtostudiesconductedbyAgnihotrietal.andSundarametal.[16],[17][Table2].NFGOand
KlebsiellapneumoniaewerethecommonGramnegativeisolates,whichwascomparabletotheotherstudiesin
theregion.[16],[17]NFGOtendtocolonizeandproliferateinnurseriesandaretransmittedbycrossinfection.

Table2:BacteriologicalprofileofneonatalsepticemiainstudiesfromNorth
India

Clickheretoview

BothGrampositiveandGramnegativeisolatesshowedahighresistancetocephalosporins,penicillin,and
amoxyclavinthecurrentstudy,itwasobservedthatantibioticresistanceamongtheGrampositiveisolateswas
highesttopenicillin(87%)followedbyamoxyclav(66%).SimilarreportsofhighresistancetoAmpicillin(71%)
werereportedbyBhatetal.[18]AlltheGrampositiveisolatesweresensitivetovancomycinsimilartoastudyby
Hoogenetal.[22]Inthepresentstudy,41%S.aureusisolateswerefoundtobemethicillinresistant,comparedto
11.1%reportedbyKaisthaetal.[25]Gramnegativeisolatesshowedahighresistancetoallcephalosporinswhich
issimilartotheresistancepatternreportedbyAgnihotrietal.andBhatetal.[16],[18]Klebsiellapneumoniae.
showedresistancetoallantibioticstestedexceptimipenem.Inourstudy,the48%wereESBLproducersas
comparedto72%asreportedbyBhatetal.[18]Thishighresistancepatterncouldbeattributedtotheinjudicious
useofantibioticsinourregion.

Inthepresentstudy,overallmortalitywasobservedin11.7%,whereasChaudharyreportedamortalityof45.5%
intheirstudy,whichisquitehighascomparedtoourstudy.[23]Thiscouldbeattributedtoadvancementin
medicaltechnologyandbetterneonatalcareinNICU.

~Conclusion

WewanttohighlightthefactthatGrampositiveorganismsparticularlyS.aureusandCONSarenow
predominantorganismscausingneonatalsepticemiainourinstitution,aswellaswholeofNorthIndiaas
suggestedbystudiesinpastdecade[Table2].TherehasbeenashiftfromthepredominanceofGramnegative
organismstoGrampositiveorganismsS.aureusinthepastdecadethroughouttheworld,thereasonforwhichis
notclear.[10],[11],[12],[13],[14],[15]AmongGramnegativebacteria(GNB),NFGOareoneofthenewlyemerging
groupsoforganismswithhighmortalitynextonlytoKlebsiellaspp.Highresistancetocephalosporinsisacause
ofconcern,astheyareoneofthemostcommonprescribedantibioticgroupsintheregion.Urgentneedfor
preventivemeasuresincludingproperhandwashing,barriernursing,andjudiciousselectionofantibioticsis
recommendedalongwithcontinuoussurveillanceoftheneonatalsepticemia.

Financialsupportandsponsorship

Nil.

Conflictsofinterest

Therearenoconflictsofinterest.

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4/25/2016 BacteriologicalprofileandantibioticsensitivitypatternofneonatalsepticaemiainaruraltertiarycarehospitalinNorthIndiaThakurS,ThakurK,Soo

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[PUBMED]

Figures

[Figure1],[Figure2]


Tables

[Table1],[Table2]

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