作者：Muhammad Javed， Abdul Majid Memon
【摘要】 Objective:To study organisms in cases of early neonatal sepsis， and sensitivity patterns of these isolates. Methods: All pregnant mothers admitted from Jan 2006 Dec 2006 were registered. Neonates delivered at the hospital were examined upto 72 hours of birth， with special emphasis on the signs and symptoms of suspected sepsis. Neonates with no maternal or neonatal risk factor were included in the study， blood examination and appropriate cultures were taken. Antibiotics as cephatexime and amikacin were started on empirical bases until final cultures report was received. In cases of negative cultures， antibiotics were stopped. Other wise it continued according to culture and sensitivity for 10 to 14 days. Results: Among these 257 cases， 113 neonates full filled our criteria. Staph aureus being the commonest organism in our study (59.29%) followed by Klebsiella pneumoniae (19.47%) and Entrococci (19.47%). These findings are not consistent with other studies in the country.Conclusion: Neonatal sepsis is a major cause of mortality and morbidity. Choice of antibiotic should depend on the local studies from time to time.
【关键词】 Neonatal sepsis; Isolates; Sensitivity
INTRODUCTION
Globally 5 million children die every year， and 1.6 million neonates die due to sepsis in under developed countries. Pakistan is among one of the highest countries in Eastern Mediterranean region with high neonatal mortality[13]. 60% of neonatal deaths take place in the first week of life. Sepsis is one of the commonest causes of this high neonatal mortality rate[46]. There are number of risk factors for this high neonatal mortality due to sepsis.
Neonatal sepsis is defined as early neonatal sepsis from birth to 72 hours of life， and late neonatal sepsis after 72 hours of birth， Organisms in cases of early neonatal sepsis are usually transmitted by the mother (vertical transmission)， and in cases of late neonatal sepsis from the environment (nosocominal).
Maternal factors include chorioamnionitis， infections at the time of labour， prolong rupture of membranes over 18 hours， and repeated vaginal examinations at the time of labour. Neonatal factors are pre maturity， low birth weight， and meconium aspiration.
Sign and symptoms of the sepsis are often nonspecific. Babies response to stimuli， the colour of umbilicus， respiratory rates and abnormal heart rate， particularly bradycardia， are the important parameters.
We studied the organisms and sensitivity patterns in blood culture proven cases of early neonatal sepsis at Hamdard University Hospital.
MATERIALS AND METHODS
All mothers admitted from Jan 2007～Dec 2007 were registered on a pre designed Performa， by the House Officers/Resident Medical Officers of Hamdard College of Medicine && Dentistry/Hamdard University Hospital. Neonates of all mothers delivered at the hospital were examined， first immediately at birth and then daily until mother was discharged in two to three days.Special emphasis was given on the signs and symptoms of suspected as babies response to stimuli， the colour of umbilicus， respiratory rates and abnormal heart rate， particularly bradycardia. Neonates with suspected sepsis and with no maternal risk factors as maternal infection， fever， mother using antibiotics before delivery， prolong labour， premature rupture of membranes and signs of chorioamnionitis were excluded. Neonates with prematurity， congenital and chromosomal anomalies were also excluded from the study， blood examination and cultures were collected by the house officers. Special instructions were given to avoid skin contamination at the time of collection. Antibiotics as cephatexime and amikacin were started on empirical bases until final cultures report were received. In cases of negative cultures， antibiotics were stopped. Other wise it continued according to culture and sensitivity for 10 to 14 days.
RESULTS
Total numbers of deliveries at Hamdard university hospital from Jan 2006 to Dec 2006 were 950. And 257/950 (27.05%) had proven sepsis. There were 113 neonates meeting our criteria， Positive blood cultures in our study were 43.96%. These figures are different from study by Rehana Akhtar， Aslam haider[6 ]and Nadeem Haider and Sajjid Maqbool[7]. Staph aureus is the commonest organism in our study (67， 59.29%) followed by Klebsiella (22， 19.47%) and Entrococci (22， 19.47%)， which is not consistent with other studies of Karachi and Lahore[8，9] showing Staph. aureus as major organism[10].
Escherichia coli (E. coli)， which is the commonest organism in other international and national studies， is only present in 2 cases in our study(1.77%). And no case had Pseudomonas.
Where as Klebsiella and Entrococci were isolated in 39.8% of cases， Staph aureus was resistant to ampicillin， cloxicillin and third generation in 20% cases， and sensitive to vancomycin in 100% cases. Entococci was resistant to ampicillin and cotrioxazole in 90% cases and sensitive to quinilone and meronium in 100% cases. Klebsilla was sensitive to most of the common drugs as ampicillin， cloxicillin， first second and third generation antibiotics (Table 1).
The sensitivity patterns of organism are also different from other national studies.There was no case of Methicillin resistant Staph aureus cases in our study.
Table 1 Laboratory susceptibility to common antibiotics
DrugsStaph aureusKlebsiellaStreptococciAmpicilin80%10 %100 %Cloxicclin80%20 %100 %1st Generation Cephalosporins100 %60 % 100 %2nd Generation Cephalosporins 90 %60 %100%3rd Generation Cephalosporins80 %80 %100 %Aminoglycosides Not done80 %Not doneCo troxizole10 %10 %20 %Vancomycin 100 %Not done100 %Imiperamine (Panamum group)100 %80 %100 %Quinolones Not done100 % Not doneMeronium100 %100 %100%
Early neonatal spsis at tertiary care teaching hospital DISCUSSION
Neonatal sepsis is among the common causes of neonatal deaths. In spite of excluding maternal and neonatal contributing factors for sepsis， the incidence of neonatal sepsis is still high. In our study， the incidence of organisms is different from other national studies. In cases of neonatal sepsis the common organisms in other national studies are E.coli， Strep pneumonae， and Listeria. These organisms are usually vertically transmitted by the mother.Late onset sepsis after 72 hours of life is hospital acquired and the organisms are different from early onset neonatal sepsis.
In our study the commonest most organism was Stap aureus (59.29%)， followed by Strepfaecalis (19.47%) and Klebslella (19.47%). E. coli， which is reported to be the commonest organism in other national studies， is only present in 1.77% of cases in our study. Studies from India and Bangladesh also confirms high incidence of Klebsiella and Entococci in neonatal sepsis〔1125〕.
Staph aureus is resistant to ampicillin， cloxicillin， and third generation in 20 % cases， and sensitive to vancomycin in 100% cases. Entococci is resistant to ampicillin and cotrioxazole in 90% cases and sensitive to quinilone and meronium in 100% cases. Klebsilla was sensitive to most of the common drugs as ampicillin， cloxicillin， first second and third generation antibiotics.The sensitivity patterns are also similar to other studies〔1125〕.
Studies of the vaginal flora both normal and at the time of labour needs to be studied to explore the relation between the organism of vaginal flora and isolate responsible for neonatal sepsis. And the antibiotic policy needs to be modified according to the local isolates.
ACKNOWLEDGMENTS
We want to thank Dr Mahnaz Munir Ahmed， chief executive， Hamdard University Hospital; Dr Waseem Haider Naqvi， clinical pathologist; Mr Rehan Khan， chief computer pision， Hamdard University; House Officers in Department of Gynaecology && Obstetrics， Hamdard College of Medicine && Dentistry and House officers， Department of Paediatrics， Hamdard University Hospital.
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