Challenges in Treatment Strategies for Management of Neonatal Sepsis

Abstract

Background: Neonatal sepsis is an important cause of morbidity and mortality in newborns. The symptoms and signs of neonatal sepsis are often non-specific and similar to other common neonatal diseases, investigation results are also non-specific and low sensitivity of blood culture also causes diagnostic dilemma and often empirical antibiotic treatment is given. This is why, there is challenges in making the diagnosis and treating neonatal sepsis. Objectives: To find the etiology, sensitivity and specificity of clinical features and investigations and optimal and effective treatment for neonatal sepsis. Materials and methods: The study was a prospective study done in the neonatal ward of a tertiary hospital in Bangladesh; total 100 neonates diagnosed as neonatal sepsis, were enrolled in this study. All study subjects were fully evaluated clinically, thoroughly investigated and properly treated as per protocol. Results: The sensitivity and specificity of clinical features and investigations were statistically significant (i.e. p <0.05) and etiologic agents were isolated by urine culture and sensitivity to antibiotics were shown and outcome measure e.g. mortality was 22% (OR 3.54; 95% CI 2.046.13; P <0.05). Conclusion: There are challenges in making diagnosis and treating neonatal sepsis, yet sincere approach to diagnosis and rational and appropriate use of antibiotics along with necessary adjuvant therapy can mitigate the challenges. DOI: https://doi.org/10.3329/jdmc.v29i1.51166 J Dhaka Med Coll. 2020; 29(1) : 23-28 1. Dr. Tahsinul Amin, Associate Professor, Dept. of Neonatology, Sher-e-Bangla Medical College, Barishal. 2. Dr. Ayesha Najma Nur, Consultant (Obstetrics and Gynecology), CWCH, Dhaka. 3. Dr. Imran Mahmud, Registrar, Department of Medicine, Dhaka Medical College, Dhaka Correspondence: Dr. Tahsinul Amin. Associate Professor, Dept. of Neonatology, Sher-e-Bangla Medical College, Barishal. E-mail :tahsinul_amin@yahoo.com. Mobile: 01715734232 Received: 05-12-2019 Revision: 15-01-2020 Accepted: 21-03-2020 Introduction Globally bacterial infection (sepsis, meningitis, pneumonia etc.) is a leading cause of 2.9 million neonatal deaths every year.1 Strategies to reduce preventable infection-related neonatal deaths by 2030 to meet the WHO Sustainable Development Goal (SDG) is a global health priority. Neonates are especially vulnerable to sepsis due to perinatal exposure to infective agents, compromised immune system and maternal and neonatal risk factors.1 In recent years neonatal mortality has decreased at much lower rates, and currently represents 40% of all childhood mortality.2 Three-fourths of these deaths occur in the first week of life.3 Neonatal sepsis is the third leading cause of neonatal mortality, only behind to prematurity and perinatal asphyxia.4 is responsible for 13% of all neonatal mortality, and 42% of deaths in the first week of life.5,6 In developing countries, clinically diagnosed sepsis is present in 49–170 per 1000 live births, culture-proven sepsis in 16 per 1000 live births and neonatal meningitis in 0.8–6.1 per 1000 live births.7 Infants with neonatal infections are more likely to have adverse neuro-developmental outcomes at follow up, including cerebral palsy, lower mental and psychomotor development index scores, visual impairment and impaired growth.8,9 Risk factors for early-onset neonatal sepsis (EOS) include prematurity, immunologic immaturity, maternal Group B streptococcal (GBS) colonization, prolonged rupture of membranes, and maternal intra-amniotic infection.10 Intra-partum antimicrobial prophylaxis administered to GBS-colonized women has reduced the burden of disease associated with early onset GBS invasive infections.11 Late-onset neonatal sepsis (LOS) attributable to Gram-positive organisms, including coagulase negative Staphylococci and Staphylococcus aureus, is associated with increased morbidity and mortality among premature infants.11 Invasive candidiasis is an emerging cause of late-onset sepsis, especially among infants who receive broad spectrum antimicrobial agents.12 Despite recent medical advances have improved neonatal care, yet many challenges remain in the diagnosis and management of neonatal infections.13 The diagnosis of neonatal sepsis is complicated by the non-specific signs and symptoms of sepsis, low sensitivity of the gold standard blood culture test (particularly following intra-partum antibiotic prophylaxis), delayed availability of culture results (approximately 48–72 hours after blood collection) and the frequent presence of noninfectious conditions that resemble sepsis, especially in preterm infants, and by the absence of optimal diagnostic tests.14 Since neonatal sepsis is a high-risk disease, especially in preterm infants, clinicians are compelled to empirically administer antibiotics to infants with risk factors and/or signs of suspected sepsis.15 Unfortunately, both broad-spectrum antibiotics and prolonged treatment with empirical antibiotics are associated with adverse outcomes and increased antimicrobial resistance.16 Given current challenges with diagnosis, and the high mortality and morbidity associated with neonatal sepsis, particularly in low-income countries, there is a need to develop novel approaches for identifying neonates at greatest risk.17 Although there are challenges in making the diagnosis and providing appropriate treatment for neonatal sepsis, we need to overcome those obstacles with rational approach to investigate and manage neonatal sepsis. The objective of this prospective study was to find out the etiology, sensitivity and specificity of the clinical features and investigations and optimal and effective treatment for neonatal sepsis.