1
Bacteriology and Epidemiological study of
Neonatal septicemia
By
Muna Fadhil Abbas1 , Nihad Khalawe Tektook2 and Ashwaq J.kezar3
1,2,3
Middle Technical Universit y, Foundat ion of Technical Education, Co llage
of Medical and
Health Technology, Department of
Optical.
m12_moon@yahoo.com
Abstract
Objective: To determine the most common risk factors which are
Associated with neonatal septicemia and the type of the
Causative bacteria.
Study design: Across sectional study of 150 neonates below one month of
Age attending AL-Mansur pediatric hospital diagnosed as a
Case of septicemia.
Results: It was found that (64.7%) were males, (61.3%) were less than 7 days of
age, (60.7%) were less than 2500 gm body weight, and (55.3%) of neonates were
delivered before 37 weeks gestation. (64%) of the mothers were getting rupture of
membrane for more than 18 hours, and (61.3%) were having perinatal fever. the
higher percentage of infections was with gram negative bacteria (68.6%) compare to
gram positive (31.4%) Although Staphylococcus epidermidis is the Most of the
bacterial isolates causing septicemia
(20.7%) followed by Escherichia coli.
Conclusion: it was concluded that age, birth weight, gestational age with premature
rupture of membrane were the most important risk factors to get neonatal
septicemia, and gram negative bacteria more causing Neonatal septicemia compare
to gram positive .
Key wards: infant age, birth weight, gram negative & gram positive bacteria .
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Introduction
Septicemia is a common condition in children with a resultant high morbidity
and mortality [1,2]. Neonates are particularly vulnerable to infections because of
their weak immune barrier. Neonatal sepsis can be classified into two relatively
distinct illnesses,early onset sepsis occurs in the first 7 daysof life, late onset
sepsis occurs ≥7 days to 3months of life [3].Numerous risk factors have been
identified both in the neonates and children that make them susceptible to
infections,[2, 4].
The triad interactions of neonatal-maternal-bacterial determinants play a crucial
role in the increased incidence of bacterial sepsis during the neonatal period,[5].
The world Health Organization (WHO) estimated that there are approximately 5
million neonatal deaths per year of which 98% occur in developing countries. These
neonatal deaths are attributed principally to infection, birth asphyxia and
consequences of premature birth and low birth weight[6].The highest rates occur in
low birth weight infants, and those with maternal perinatal risk factors.
A neonate may be predisposed to sepsis by obstetric complications e.g. premature
rupture of membranes occurring ≥18 hours before birth, or maternal infection
(particularly of the urinary tract or endometrium, most commonly manifested as
maternal fever shortly before or during parturition),[7]. There has been a substantial
increase in the incidence of septicemia during the last decade, particularly in
developing countries,[8]. The source of the infection varies, being more likely to be
community- acquired in developing countries,[8,9], while hospital-acquired
infections are more common in America and Europe,[10].
Septicemia is more common in tropical countries than in Europe, [11,12]. One
of the factors reported to be responsible for this is climate which encourages the
growth of certain organisms [13].The division line between early and late onset
neonatal septicemia has usually been at 5 or 7 days of age [14], although some
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authors have preferred to group cases according to onset before or after the first 48
hours of life [15].
Material and methods
1- Across sectional study was done in Al- Mansour pediatric hospital collecting
150 neonates aged up to 1month admitted to hospital due to septicemia. Data
collection started from 1/10/2014 up to 1/4/2015.
A questionnaire was constructed for each neonate including certain demographic
data including age and gender, mother age, and certain neonatal and maternal risk
factors such as gestational age, birth weight of the neonate, time of rupture of
membrane, type and place of delivery, presence of perinatal fever and other
variables regarding the outcome of the case and certain laboratory data.
2-Culture and Identification
Blood collected were taken from patients who suffering from septicemia
When blood is drawn from patients by using a syringe (10 ml), 2 ml
each was injected into blood culture bottles for indicated found
bacterial pathogenic by used Bact systemm then identification of
Isolated Bacteria by Colonial morphology of grown bacteria on
culture media, Colony size , color , elevation , edges , hemolysis on
blood agar , IMVIC Test,, API 20 E Micro Tubes System(Fischbach,
2001) and used Vitek 2 system, which is an automated microbiology
system utilizing growth-based technology. The system is available in
three formats (VITEK 2 compact, VITEK 2, and VITEK 2 XL) that
differ in increasing levels of capacity and automation. All three
systems accommodate the same colorimetric reagent cards that are
incubated and interpreted automatically.
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3- Analysis of the data was done by using SPSS Package program. Frequencies and
percent of the studied parameters were done, and categorical data were compared
using Chi-squared test. Differences were considered to be statistically significant at
P<0.05.
Results and Discussion
Septicemia still remained a very important cause of morbidity among neonates, this
may be due to immaturity of the immune system and abnormal phagocytic
function,[16].
In table (1), One hundred fifty cases of neonatal septicemia were collected, of which
(64.7%)
were males and (35.3%) were females,( male to female ratio 1.8:1),this
result resemble that seen in AO Mokuolu et al and O.O.Ayoola et al studies in
Nigeria in which they found that
male to female ratio was 1.2:1 and 1:1.1
respectively which is of non-significant effect [17],[18]. Also It was found that
(61.3%) of the sample were less than 7 days of age, which is higher than AO
Mokuolu study in which it was found that (49.2%) were less than 7 days,[17].
Regarding birth weight it was found that (60.7%) were less than 2500 gm, and the
gestational age (55.3%) of neonates were delivered preterm, less than 37 weeks
gestation and (44.7%) were delivered full term, This results is in consistent with I
Roy et al study in which they found that birth weight and gestational age were an
important risk factors for development of neonatal septicemia,[19].
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Table (1): Frequencies & Percent of the neonatal Parameters
neonatal Parameters
Frequency
Percent
97
53
92
64.7
35.3
61.3
More than7 days
58
38.7
Birth Weight of the Baby
<2500 gm
91
60.7
Gestational Age
≥2500 gm
Preterm<37 weeks
59
83
39.3
55.3
Full term≥37weeks
67
44.7
Gender
Age of the Baby
Groups
male
female
less than 7days
3
Table 2 reveals the maternal parameters. It was found that (72%) were more
than 20 years of age, (74%) were delivered with normal vaginal delivery, (64%)
were getting rupture of membrane for morethan 18 hours, this agree with M
Douraghi et al study in which it was found that premature rupture of membrane
affected the sepsis risk to more than threefold [5], but was more than those seen in
I Roy et al study in which they found that(28.9%) had a premature rupture of
membrane[19]. (61.3%) were attending antenatal clinic during pregnancy and 89
(59.3%) were receiving tetanus toxoid at least 2 doses and (51.3%) were breast fed
exclusively, this indicate a good educational standard of the mothers. Also it was
found that (61.3%) were having perinatal fever which is much higher than that seen
in I Roy et al study in which it was found that 5.2% of the mothers showed perinatal
fever, [19].
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Table (2): Frequencies & Percent of the maternal Parameters
Studied Parameters
Groups
Mother Age
< 20 years
≥ 20 years
N.V.D*
C.S**
> 18 hours
≤18 hours
Hospital
Home
yes
Type of Delivery
Time of Rupture of
Membrane
Place of Delivery
Presence of Perinatal
Fever
Antenatal care
Attendance> 4 Visits
Vaccination with Tetanus
Toxoid 2 Doses
Type of feeding
NO
Yes
NO
yes
NO
Breast
Mixed
Artificial
Frequency Percent
42
108
111
39
96
54
79
71
92
58
92
58
89
61
77
37
36
28
72
74
26
64
36
52.7
47.3
61.3
38.7
61.3
38.7
59.3
40.7
51.3
24.7
24
* N.V.D. = Normal vaginal delivery
** C.S. = Caesarean section
Certain investigation was done for each neonate such as hemoglobin level,
C.Reactive protein and culture of the blood to show the type of the microorganism
the infant infected with, and the outcome of each case,
(see table 3). It was
found that(70%) of the sample were of normal hemoglobin level, (28%)were of low
Hb, (41%) were with positive C Reactive protein, while in M Douraghi et al study
they found that more than half of the neonates with septicemia had positive C
Reactive protein [5].
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Table3: Investigations done to each infant and the outcome results
Studied Parameters
Hemoglobin Level
C Reactive Protein test
Type of Microorganism
Outcome of The Case
Groups
Low
Normal
high
+ve
-ve
Gram -ve
Frequency
42
105
3
62
88
103
Percent
28
70
2
41.3
58.7
68.6
Gram +ve
47
31.4
well
died
D.P.R.*
88
24
38
58.7
16.0
25.3
*D.P.R. = Discharge on parents responsibility
The outcome was shown that (58.7%)were discharged in good condition while
(16%) were died, and the rest were discharged on their parents' responsibility
(25.3%).This result is higher than that seen in a study done by Lepage et al [9] in
which they found that mortality rate was 9.3%, and in Rwanda and Akpede et al it
was 14.3% mortality [8], while in O.O.Ayoola et al study they found that 69.2%
were recovered, 25.7% were died and 5.1% were discharged on their parents'
responsibility[18], and in Alausa et al [20]they reported 38.4% mortality figures
which are higher than that what was seen in this study, this may be due to different
causative organisms with varying degree of severity of infection and complications
which is also affected with the
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8
climate that encourage growth of certain microorganisms [13]. In the same table it
was found that the higher percentage of infections was with gram negative bacteria
(68.6%) and (31.4%) was gram positive. This result agree with a research done by
S.I. Nwadioha, E.O.P.Nwokedi, et al in which they found that g-ve bacteria were
69.3% of the total isolates and g+ve were 30.7%[21].Also in O.O.Ayoola et al[18],
and in USA the gram negative organisms were isolated in (60%) of patients[22],
and 66% of isolates documented in east Africa was also gram negative [23].
According to the frequency of affection (table 4) showed that Staphylococcus
epidermidis comprise the higher percentage of infection (20.7%), Escherichia coli
(18.7%), Enterobacter spp (16%) then Klebsiella spp
(15.3%), Pseudomonas
aeruginosa (12.7%), Staphylococcus aureus (10.7%)and the least was Proteus
mirabilis (6%)
Table 4: Types of bacteria isolated from blood culture of septicemic neonates
Types of Microorganism
No
%
Staphylococcus epidermidis
31
20.7
Escherichia coli
28
Enterobacter spp
24
18.7
16
Klebsiella spp
23
Pseudomonas aeruginosa
19
Staphylococcus aureus
Proteus mirabilis
6
15.3
12.7
16
10.7
9
6
9
Table 5 reveals the correlation ship of the outcomes of the case with the neonatal
parameters. It was found that age, birth weight, and gestational age of the neonate
showed highly significant effect on the outcome of the cases,
P value less than 0.005; this result was expected as the immune system of young
age,low birth and prematurely delivered neonates is still immature, which let them
more susceptible to infection, while gender showed no effect.
Table 5: Correlation ship of the neonatal parameters with the outcome of the
case by (Contingency- coefficients)
outcome of the case
No
%
No
%
Male
55
56.7
16
16.5
26
26.8
97
Contingency
- coefficients
P-value
%
CC= 0.055
P= 0.796
100
NS
Female
33
62.3
8
15.1
12
22.6
53
100
Age of the Baby/
day
<7
47
51.1
13
14.1
32
34.8
92
100
≥7
41
70.7
11
19.0
6
10.3
58
100
Birth Weight of
the Baby/ gm
<2500
65
71.4
17
18.7
9
9.9
91
100
≥2500
23
39.0
7
11.9
29
49.2
59
100
Gestational Age/
week
<37
59
71.1
13
15.7
11
13.3
83
100
≥37
29
43.3
11
16.4
27
40.3
67
100
Neonatal
Parameter
Gender
Well
Died
Disch. On
parents
responsibility.
No
%
Total
No
CC=0.264
P=0.004
HS
CC=0.404
P=0.000
HS
CC=0.307
P=0.000
HS
In table 6 the correlation ship between maternal parameters and the outcome, in
which it was found that the time of rupture of membrane showed highly significant
association with the outcome of the case, P less than0.005 and there is a significant
correlation with the type and place of delivery, P=0.027 and 0.032 respectively,
while the presence of perinatal fever showed no correlation, P = 0.229. this result is
consistent with M Douraghi et al research in which they found that premature
rupture of membrane affected the sepsis risk to more than threefold.
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10
Table 6: Correlation ship of the maternal parameters with the outcome of the case by
(Contingency- coefficients)
No
%
No
%
Disch. On
parent
respons.
No
%
64
66.7
9
9.4
23
24.0
96
100
> 18 hours
24
44.4
15
27.8
15
27.8
54
100
N.V.D
72
64.9
14
12.6 25
22.5
111
100
16
41.0
10
25.6
13
33.3
39
100
Hospital
41
51.9
11
13.9
27
34.2
79
100
Home
47
66.2
13
18.3
11
15.5
71
100
Yes
59
64.1
13
14.1
20
21.7
92
100
No
29
10.0
11
19.0
18
31.0
58
100
outcome of the
case
Maternal parameter
<18 hours
Time of rupture
membrane
Type of delivery
Place of delivery
Presence of
perinatal fever
C.S
Well
Died
Total
No
%
Contingencycoefficients
P-value
CC= 0.255
P= 0.005
HS
CC=0.214
P=0.027
S
CC=0.210
P=0.032
S
CC=0.139
P=0.229
NS
Conclusion
It was concluded that as smaller the infant for age (<7 days) and
weight(<2500gm) is more prone to have septicemia, also the more the baby
delivered with gestational age less than 37 weeks he is more vulnerable to get
infection due to low immune system. Also it was concluded that premature rupture
of membrane lead to more infection to the fetus.
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