ORIGINAL ARTICLE

Bacteriological Profile and Antibiogram of NeonatalSepticemia

Narayan Gyawali & Raj Kumari Sanjana

Received: 1 January 2012 /Accepted: 9 October 2012 /Published online: 20 November 2012# Dr. K C Chaudhuri Foundation 2012

AbstractObjectives To determine the incidence of neonatal septice-mia, identify the bacterial isolates and study their antimicro-bial susceptibility pattern in neonates visiting out-patientdoor (OPD) and admitted to the pediatric ward and neonatalintensive care unit (NICU) of the College of MedicalSciences, Teaching Hospital, Chitwan, Nepal.Methods Blood culture of all neonates who were suspectedfor septicemia was performed. Isolate identification andantimicrobial susceptibility testing was done by standardmicrobiological method.Results Out of the total 7,868 blood culture samples sub-mitted to the microbiology laboratory, 1,572 (19.97 %)samples were from suspected cases of neonatal septicemia.The blood culture was positive for neonatal sepsis in 238(15.13 %) samples. The incidence of gram positive andgram negative organisms were 44.1 % and 55.9 % respec-tively. Staphylococcus aureus remained the predominantisolate followed by Klebsiella spp. Most of the gram posi-tive isolates exhibited higher resistance to penicillin andcephalosporin. Susceptibility to commonly used aminogly-cosides and quinolones was found. Similarly, more thantwo third isolates of gram negative Enterobacteriaceaeshowed resistance to ampicillin. Third generation cepha-losporin and aminoglycosides were found to be moresatisfactory among gram negative organisms as compared togram positive.

Conclusions The high incidence of neonatal septicemia inthe present setting reflects high magnitude of problem incentral part of Nepal. Organisms isolated in the studyexhibited higher resistance towards commonly used antimi-crobials. High resistances to recommended drugs awareshealth care workers to seek for alternative antimicrobialagents. The periodic survey of etiological agents and theirantibiotic susceptibility patterns is indeed necessary for thetimely alarm of such type of problems.

Keywords Neonatal septicemia . Bacteriological profile .

Antimicrobial resistance

Introduction

Neonatal septicemia refers to generalized bacterial infectiondocumented by a positive blood culture in the first 4 wk oflife. It remains the major cause of mortality and morbidityaccounting for 30–50 % neonatal deaths in developingcountries [1]. In Nepal a lot of neonatal mortality is account-able by septicemia and its treatment failure due to emergenceof drug resistance. The fact is that the isolated organisms havedeveloped increased drug resistance over the last few years[2, 3]. For this life threatening emergency, rapid treatmentwith antimicrobials is essential for a favorable outcome. Thus,increased frequency of resistance to antimicrobials is a matterof serious concern. Since etiological agents and their antimi-crobial susceptibility pattern may vary from one region toanother, knowledge of the prevalence of the local isolatesand their antimicrobial sensitivity pattern is of utmost impor-tance for prompt institution of antimicrobial therapy. Owing tothis fact, the aim of this study was to identify the commonetiological agents of neonatal septicemia and to determinetheir antimicrobial susceptibility pattern in College ofMedicalSciences (CoMS), Bharatpur, Nepal.

N. Gyawali (*)Department of Microbiology, Nepal Medical College, Attarkhel,Kathmandu, Nepale-mail: gyawali123@gmail.com

R. K. SanjanaDepartment of Microbiology, College of Medical Sciences,Teaching Hospital,Chitwan, Nepal

Indian J Pediatr (May 2013) 80(5):371–374DOI 10.1007/s12098-012-0911-9

Material and Methods

CoMS is one of the tertiary care center and teaching hospitalof central Nepal. Every day a lot of neonates are admittedhere owing to infection; sepsis. Among the total of 7,868blood samples received, 1,572 samples were suspected forneonatal sepsis and were submitted to microbiology labora-tory for culture and sensitivity during the period of January2009 to December 2010 and were included in this study.Samples were collected from the neonates with clinicalmanifestations of septicemia who visited either to out-patient door or admitted in the neonatal intensive care unit(NICU) and pediatric ward of CoMS during the period ofJanuary 2009 to December 2010. Selection was based on thesigns and symptoms of fever, refusal to feeding, respiratorydistress, cyanosis, cold clampy skin, tachycardia, seizures,hyperreflexia, jaundice, instability etc. Volume of 1–2 mlblood was drawn aseptically before starting antimicrobialtreatment and inoculated directly into Brain Heart Infusionbroth (BHI) in a ratio of blood: BHI of 1:10. The processingof collected blood samples for culture and isolation wasdone by standard microbiological method [4]. The antimi-crobial susceptibility testing was done by Kirby-Bauer diskdiffusion technique that is recommended by Clinical Labo-ratory Standards Institute (CLSI) recommendations [5]. Theconcentration of various antimicrobials that were used forsusceptibility testing are as follows (in μg): amikacin (30),ampicillin (30), cefotaxime (30), ceftriaxone (30), chloram-phenicol (30), ciprofloxacin (5), gentamicin (10), cotimox-azole, amoxyxillin (30), ofloxacin (5), penicillin (10),carbenicillin (100), piperacillin (100) and tobramycin (10)manufactured by Hi-media.

Results

Out of the total 7,868 blood samples received in the micro-biology laboratory for culture and sensitivity, 1,572 (1,278from inpatients and 294 from outpatients) were suspectedfor neonatal septicemia. Majority of the samples were frommales; 61 %. Bacterial growth was observed in 238 (15.1 %)of the samples. The incidence of gram positive and gramnegative organisms were 44.1 % and 55.9 % respectively.Staphylococcus aureus (39.6 %) remained the predominantisolate followed by Klebsiella spp (13.5 %). Frequencies ofisolates are shown in Table 1.

Majority of the gram positive isolates exhibited higherresistance to penicillin and cephalosporin group antimicro-bials. Susceptibility to commonly used aminoglycosides andquinolones was found. Similarly, more than two third iso-lates of gram negative Enterobacteriaceae showed resis-tance to ampicillin. Third generation cephalosporins andgentamicin/amikacin were found to be more satisfactory

among gram negative bacteria as compared to other antimi-crobial agents tested for these organisms. Antimicrobialresistance percentage of gram positive bacteria and gramnegative bacteria are shown in Table 2.

Discussion

Neonatal septicemia remains a major clinical problem inneonatology with high morbidity and mortality rate. Espe-cially, the amplitude of problem is higher in developingcountries like Nepal. In the present study, blood samplesreceived from the neonates comprised approximately one-fifth of the total blood samples for culture and sensitivityand the rate of positivity was 15.1 %, which reflects highmagnitude of problem in central part of Nepal. This findingis very close to that of Agnihotri et al. (19.2 %), Arora et al.(20.02 %) and Shrestha et al. (20 %) from Nepal and India[6–8]. However, variable results have been reported by otherstudies [9–11]. Administration of prior antibiotics from pri-mary centre, infection with anaerobes or effective control inspread of nosocomial infection, might be the reasons for thevariable results in different studies.

In the present study gram negative bacilli (55.9 %) pre-dominated over gram positive organisms (44.1 %). HoweverStaphylococcus aureus (39.6 %) was the most frequentorganism isolated followed by Klebsiella spp (13.5 %),which is in agreement with the studies done by Arora etal., Shrestha et al. and Karthikeyan [7, 8, 11]. Staphylococ-cus aureus is common hospital acquired organism whichaccounts for most of the infections [12, 13]. Similarly, itsgreater prevalence in neonatal septicemia could beexplained by the fact, that there is a high chance of trans-mission of this organism to neonates from health care work-ers and relatives [14]. Klebsiella spp and Enterobacter spphave been reported as the leading gram negative organismsby various studies [6–8]. Similarly, the present study also

Table 1 Frequency of isolates

Isolates Organisms FrequencyN (%)

Gram positive bacteria Staphylococcus aureus 94 (39.6)

Coagulase negativeStaphylococcus aureus

11 (4.6)

Enterobacteriaceae Klebsiella spp 32 (13.5)

Enterobacter spp 27 (11.3)

Escherichia coli 16 (6.7)

Citrobacter spp 7 (2.9)

Others Acinetobacter spp 30 (12.6)

Pseudomonas spp 21 (8.8)

Total 238 (100)

372 Indian J Pediatr (May 2013) 80(5):371–374

revealed Klebsiella spp as the most common isolatefollowed by Acinetobacter spp.

As neonatal septicemia is considered as a life threateningemergency condition, prompt treatment with antibiotics isnecessary. World Health Organization has recommended theuse of penicillin or ampicillin plus an aminoglycoside forneonates [15]. With the advent of third generation cephalo-sporin, the empirical use of antimicrobial approach for theneonatal septicemia has changed in many centers. The ap-propriate combination of these drugs is being followed inauthor’s hospital. In the present study, more than 95 % grampositive isolates exhibited resistant to penicillin. Similarly,90 % of gram negative isolates showed resistance to ampi-cillin. Probably, prolonged antepartum exposure to beta-lactamase (ampicillin and penicillin) may be related withthis resistance. Quinolones (ciprofloxacin and ofloxacin)and aminoglycosides (amikacina and gentamicin) are foundto be more effective in gram positive isolates. Likewise,activities of cephalosporins against gram positive werefound to be more satisfactory than that within gram negativeisolates as an average of 40 % of gram positive organismshad exhibited resistance to cephlalosporins. Whereas,among gram negative isolates, more than 75 % and 60 %of Enterobacteriaceae and Pseudomonas spp, Acineto-bacter spp respectively exhibited resistance to cephalospor-ins. The study of Rahman et al. from Pakistan has alsoshown similar result of resistance trend among Pseudomo-nas spp and other gram negative bacilli [16]. Similarly,reports from India have shown predominance of gram neg-ative bacteria exhibiting a range of resistance to cephalo-sporins; 25–75 %, and aminoglycosides; 23–69 % [3].

The low resistance exhibited by most isolates in the studyagainst the antimicrobials like aminoglycolides (amikacin,

gentamicin) and quinolones (ofloxacin, ciprofloxacin) maybe attributed to the less use of these antibiotics in clinicalsetting for neonates. In this study, Pseudomonas spp showedhigher resistance to cephalosporins as compared to amino-glycosides and quinolones. Similar type of antimicrobial re-sistance pattern of pseudomonas in sepsis has been reported inthe study of Movahedian et al. [17]. In the same study Psu-domonas was reported as major organism responsible forhighest mortality rate [17]. So, its resistance trend is the matterof discussion. However, the authors did not look for mortalityrate in the present study. More than 50% of Acinetobacter sppexhibited resistance to cephalosporins and aminohlycosides,which are common combination for its therapy.

Antibiotic resistance among the organisms in the presentstudy was quite high. High resistances to recommendeddrugs like cephalosporins, ampicillin and aminoglycosidesawares health care workers to seek for alternative antimi-crobial agents. As the present study showed vancomycin tobe less resistant drug as compared to other antimicrobials inStaphylococcus aureus and quinolones in gram negativeorganisms, in this scenario use of vancomycin along withaminoglycosides can be recommended as alternative inStaphylococcus aureus. However, use and effectiveness ofquinolones in neonates should be further explored. Thus,this situation is serious as alternative drugs are either moreexpensive like vancomycin or doubtful use. To prevent thelogarithmic growth of this problem, we should stress moreupon preventive measures, so that minimum of our neonatesdevelop sepsis. Similarly, the periodic survey of etiologicalagents and their antibiotic susceptibility patterns should bedone as the patterns of bacterial organisms are constantlychanging with time and place and then the uncertaintyregarding the choice of antibiotics can be minimized.

Table 2 Antimicrobialresistance percentage ofisolates

Antimicrobials Gram positive Enterobacteriaceae (%) Pseudomonasspp (%)

Acinetobacterspp (%)

Amikacin (30 μg) 31.7 24.2 22.7 52.6

Ampicillin – 93.5 – –

Ceftriaxone (30 μg) 44.3 82.8 47.1 52.5

Cefotaxime (30 μg) 51.2 78.6 70.9 65.3

Ceftazidime – 86.6 66.7 73.4

Chloramphenicol ( 30 μg) 17.3 43.6 41.7 44.6

Ciprofloxacin (5 μg) 33.7 58.6 30 44.9

Cotrimoxazole 61.3 62.6 55.3 47.2

Gentamicin (10 μg) 22.4 69.8 37.2 56.2

Ofloxacin (5 μg) 21.3 31.0 14.6 31.2

Penicillin (10 μg) 95.7 – – –

Vancomycin (30 μg) 1.6 – – –

Carbenicillin (100 μg) – – 69.2 –

Piperacillin (100 μg) – – 68.9 66

Tobramycin (10 μg) – – 29.3 –

Indian J Pediatr (May 2013) 80(5):371–374 373

Conflict of Interest None.

Role of Funding Source None.

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