DOI: 10.5958/2319-5886.2015.00124.

International Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 3
th
Received: 4 June 2015
Research article

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 14 June 2015
Accepted: 16th June 2015

BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA: A RETROSPECTIVE ANALYSIS

FROM A TERTIARY CARE HOSPITAL IN LONI
*Sneha Ann Oommen1, Santosh Saini2, Kunkulol Rahul R3
1

UG Student, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
Professor & HOD, Department of Microbiology, Rural Medical College, PIMS, Loni
3
Coordinator, Directorate of Research, PIMS-DU, Loni
2

*Corresponding author email: sneha_ann_oommen@yahoo.co.in

ABSTRACT
Background: Septicemia continues to be a major cause of neonatal mortality and morbidity worldwide.
Epidemiology and surveillance of neonatal sepsis helps in implementation of rational empirical antibiotic
strategy. Objectives: To study the bacteriological profile and antibiotic sensitivity pattern and types of neonatal
septicemia among the suspected blood & CSF samples coming to Microbiology Department of Pravara Rural
Hospital. Methodology: All the reports fulfilling the eligibility criteria were studied for Percentage of neonatal
sepsis in suspected blood and CSF samples, Percentage of bacteriological sepsis (Gram-positive and Gramnegative sepsis), Bacterialogical profile, Percentage of EOS (Early Onset Sepsis) and LOS (Late Onset Sepsis) in
confirmed cases, Antibiotic Sensitivity Tests. Result: The study showed a culture positivity of 259 blood culture
samples (23.31%) for bacterial growth out of 1111 and 36 (5.99%) positive out of 601 C.S.F culture samples.
Early onset sepsis (92.54%) was found to be predominant with Klebsiella the predominant EOS pathogens and
Coagulase Negative Staphylococci (CONS) as predominant LOS pathogen. Gram Negative sepsis (59.32%)
predominated in this study. In this study the predominant organisms were found to be Klebsiella (28.81%).The
antibiotic sensitivity testing showed that gram negative isolates were sensitive to Meropenem and gram positive
isolates to Linezolid, Netilmicin and Chloramphenicol . Conclusion- The most common bacteria causing neonatal
sepsis was found to be Klebsiella and the gram negative samples showed highest sensitivity for Meropenem and
Cefazolin was found to be most resistant. The gram positive samples showed highest sensitivity for Linezolid and
Penicillin and Ampicillin were found to be most resistant.
Keywords: Neonatal Sepsis, Rural, Antibiotic Sensitivity,Culture ,Bacteriological Profile
INTRODUCTION
Neonatal septicemia refers to a generalized bacterial
infection that has been documented by positive blood
culture or CSF culture during the first 28 days of life
and it is an important cause of morbidity and
mortality in neonates[1]. In common clinical usage,
neonatal sepsis specifically refers to the presence in a
neonate of a bacterial blood stream infection, such as
meningitis,
pneumonia,
pyelonephritis
or
gastroenteritis in the setting of fever.
Sneha et al.,

According to the World Health Organization (WHO)

estimates, there are about 5 million neonatal deaths a
year, 98% occurring in developing countries with
neonatal infection being one of the major causes,
causing about 1.6 million deaths annually [2]. Sepsis
and meningitis are responsible for most of these
deaths.
Neonatal septicemia is one of the four leading causes
of morbidity and mortality among neonates in India
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[3]

.The neonatal period accounts for 38 % of all deaths

in children younger than 5 years. The National
Neonatal Perinatal Database (NNPD) reported an
incidence of 8.5 per 1000 live births for blood culture
proven sepsis [4] .The incidence of sepsis in the
neonate is greater than at any other period of life and
varies from hospital to hospital depending on the
rates of Prematurity, Prenatal care, conduct of labour
and environmental condition in nurseries.
Neonatal sepsis may be classified according to the
time of onset of disease as Early Onset Septicemia
(EOS) i.e. from birth to 7 days and Late Onset
Septicemia (LOS) i.e. from 7 days to 28 days. The
clinical relevance is that the EOS is mainly due to
bacteria acquired before or during delivery while
LOS is from nosocomial or community sources.
The EOS infections are caused by organisms
prevalent in the maternal genital tract or in the
delivery area. The predisposing factors include low
birth weight (LBW), prolonged rupture of
membranes; foul smelling liquor, multiple per
vaginum examinations, maternal fever, difficult or
prolonged labour and aspiration of meconium.
The LOS infections are caused by the organisms
thriving in the external environments of the home or
the hospital. The infection is often transmitted
through the hands of the care-providers. The
predisposing factors include LBW, lack of
breastfeeding, poor cord care, superficial infection
(pyoderma, umbilical sepsis), aspiration of feeds, and
disruption of skin integrity with needle pricks and use
of intravenous fluids.
In the literature, however there is little consensus as
to what age limits apply, with EOS ranging from 48
hours to 7 days after delivery. This makes it difficult
to compare studies where cases are grouped into EOS
and LOS without further details.
Neonatal meningitis occurs in 2-4 cases per 10000
live births and contributes significantly to mortality
from neonatal sepsis; it is responsible for 4% of all
neonatal deaths .Since studies have shown the
presence of neonatal meningitis in the absence of
bacteremia it becomes significant to also examine the
CSF culture to exclude the presence neonatal
meningitis [5] .
A wide variety of bacteria may cause neonatal sepsis,
to compound the problem, regional and temporal
differences in etiological agents exist. The
uncertainty surrounding the clinical approach to the

treatment of neonatal septicemia can be minimized by

periodic epidemiological surveys of etiological agents
and their antibiotic sensitivity patterns leading to
recognition of the most frequently encountered
pathogens in a particular setting.
The epidemiological data from other developing
countries shows important differences in the
incidence, risk factors, pattern and antimicrobial
sensitivities of the pathogens and mortality from that
of developed countries. Group B streptococci disease
is the most important cause of neonatal sepsis in
Europe and North America, but there is a
preponderance of gram negative organisms in tropical
and developing countries like ours [6].
As neonatal septicemia is a life-threating emergency
and delays in diagnosis and treatment with
appropriate antibiotics may have devastating
consequences, surveillance is needed to identify the
common signs and the pathogens of neonatal
septicemia in a particular area.
The purpose of this research is to give an overview
of the burden of bacterial sepsis and meningitis in the
newborn population in a rural setup. The focus will
be on the pathogens mostly implicated and their
antibiotic susceptibility pattern, as knowledge of the
bacteriological profile of the etiologic agents would
help to reduce the associated mortality in neonatal
septicemia.
This is retrospective study at a rural tertiary hospital
to determine the bacteriological profile of neonatal
septicemia and the antibiotic sensitivity patterns of
the isolated bacteria from the suspected blood and
CSF samples. A retrospective analysis of 1111 blood
samples and 601 CSF samples showing clinical
picture suggestive of neonatal sepsis was done for a
period of 2 years.
Aims & Objectives:
1. To find out the percentage of neonatal septicemia
among the suspected blood & CSF samples coming to
Microbiology Department in a rural tertiary hospital.
2. To determine the percentage of early onset sepsis
& late onset sepsis in confirmed cases.
3. To determine the bacteriological profile of neonatal
septicemia in a rural tertiary hospital.
4. To determine the antibiotic sensitivity of the
isolated bacteria.
METHODOLOGY
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Study design: This is a retrospective observational

review of the reports of blood cultures & CSF
cultures of all suspected cases of neonatal septicemia
in a tertiary rural hospital for a period of two years.
Ethical consideration: Approval from Institutional
Ethical Committee was dully taken and study was
done after ethical clearance. Data collected from
Medical records
The reports were obtained from the records of
Microbiology department and were subjected to the
following eligibility criteria:
Inclusion criteria: All the blood and C.S.F. samples
of suspected cases of neonatal septicemia were
considered. Sepsis was suspected if the mother
showed evidence of chorioamniotis, prolonged
rupture of membranes, diarrhea, fever or urinary tract
infection and the neonate manifested systemic signs
such as lethargy, chest retraction, grunting,
abdominal distension, tachycardia, hypothermia etc.
Exclusion criteria: Cases of incomplete reporting
were excluded from consideration. Aerobic spore
bearers, wherever grown, were regarded as
contaminants and excluded.
All the reports fulfilling the above eligibility criteria
were studied for
1. Percentage of neonatal sepsis in suspected blood
and CSF samples
2. Percentage of bacteriological sepsis (Grampositive
and
Gram-negative
sepsis),
Bacterialogical profile
3. Percentage of EOS (Early Onset Sepsis) and LOS
(Late Onset Sepsis) in confirmed cases
4. Antibiotic Sensitivity Tests
Statistical analysis: Data was tabulated by using the
Microsoft excel and data was presented as
percentage.
RESULTS
(i) Percentage of neonatal sepsis in suspected
blood and CSF samples : During the study period of
2 years, 1712 neonates were clinically diagnosed as
having sepsis of which 259 (23.31%) out of 1111
were confirmed by blood culture and 36 (5.99%) out
of 601 were confirmed by CSF culture.
(ii) Percentage of Gram-positive and Gramnegative sepsis: Of the 295 organisms isolated 175
(59.32%) were gram negative and 120 (40.67%) were
gram positive. The predominant gram negative
organism isolated were Klebsiella (48.57%) and

Pseudomonas (26.85%) followed by Acinetobacter

and E.coli (both 10.28%) as shown in Fig.1 The
predominant organisms isolated among the gram
positive were CONS (44.16%) and Staph.aureus
(37.50%) as shown in Fig 2.
(iii) Percentage of EOS (Early Onset Sepsis) and
LOS (Late Onset Sepsis) in confirmed cases :
Among the positive cases 273 (92.54%) were EOS
and 22 (7.45%) were LOS as shown in Fig.3.The
predominant organisms in EOS were Klebsiella
(29.30 %) followed by CONS (17.21%),
Pseudomonas (16.84%) and Staph.aureus (15.38%) as
shown in Fig.4.The predominant organisms in LOS
were CONS (27.27%),Klebsiella (22.72%) and
Staph.aureus (13.63%) as shown in Fig.5.
(iv)Bacteriological profile of neonatal sepsis : In
this study the predominant organisms were found to
be Klebsiella (28.81%) followed by CONS (17.96%),
Pseudomonas (15.93%) and Staph.aureus (15.25%) as
shown in Fig. 6.
(v) Antibiotic Sensitivity testing : The antibiotic
sensitivity testing showed that most of the gram
negative isolates were sensitive to meropenem
followed by chloramphenicol, ciprofloxacin ,
gentamicin and amikacin. They were not sensitive to
the commonly used antibiotics like penicillin,
ampicillin etc as shown in Fig.7.
The antibiotic sensitivity testing of the gram positive
isolates showed that they were maximally sensitive to
Linezolid, Netilmicin and Chloramphenicol as shown
in Fig.8.

Gram-Negative isolates (175)

85
47
18

18

Fig 1: Gram Negative Organisms isolated

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Int J Med Res Health Sci. 2015;4(3):652-658

53

Gram-Positive isolates (120)

1%
1%
1%
1%

45

Klebsiella

6%
6%
18

29%

CONS

6%
2

Pseudomonas

2
15%

Staph.aureus
18%
E.coli

16%

Fig 2: Gram Positive Organisms isolated

Fig 6: Bacteriological profile of Neonatal Sepsis

Antibiotic sensitivity of Gram negative

% of EOS and LOS in confirmed cases

7%

EOS

LOS

sensitivity

100
80
60
40
20
0

resistance

93%

Fig 3: Percentage of EOS (Early Onset Sepsis) and

LOS (Late Onset Sepsis) in confirmed cases

Early Onset Sepsis (273)

1
3
2
2
17

20

40

60

80

100

Fig 4: Organisms isolated in Early Onset Sepsis

Late Onset Sepsis (22)

Citrobacter

1
1

Proteus

Acinetobacter

Staph.aureus

2
2
3

Klebsiella

5
0

6
6

Fig 5: Organisms isolated in Late Onset Sepsis

Linezolid

Netilmicin

80

Ampicillin

Klebsiella

Ciprofloxacin

47
46

Erythromyc

CONS

Amikacin

42

16
17

Gentamicin

Acinetobacter

50

Penicillin

Enterococcus

Sensitivity
Resistance

Cotrimoxaz

Micrococci

100

Chloramph

Enterobacter

Fig 7: Antibiotic Sensitivity of Gram negative

organisms
Antibiotic sensitivity of Gram positive

Fig 8: Antibiotic Sensitivity of Gram positive

organisms
DISCUSSION
Clinical recognition of neonatal sepsis is not always
straight-forward .Appropriate intervention requires an
early etiological diagnosis. For effective management
of neonatal sepsis cases , study of the bacteriological
profile with their antibiotic sensitivity pattern plays
an important role .Several studies on neonatal sepsis
have documented the diversity of bacteria and their
temporal variability. The present study reiterates the
earlier findings and emphasizes the importance of
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periodic surveys of microbial flora encountered in

particular neonatal settings to recognize the trend.
The culture positivity of the blood samples were
23.3% and the CSF samples were 5.99% .Similar
blood culture positivity of around 24.88% was
reported by Mathur et al in their study[7]. But a
significantly higher blood culture positivity rate of
42% was reported by Ghanshyam et al in their study
in a tertiary care hospital in India [8] and a lower
blood culture positivity rate of 13.7% was reported by
Kaistha et al in their study [9].The CSF culture
positivity rates in the study by Katiyar et al was
2.06% which is lower than the findings in our study
[10]
.
The low culture isolation rate in this study might be
due to several reasons like administration of
antibiotics before blood or CSF collection either to
the mother or to the infant .Also the possibility of
infection with anaerobes cannot be ruled out
.Negative culture does not exclude sepsis as cases
with negative blood culture have been reported with
fatal illness and post-mortem evidence of infection
.Chow et al reported that 26% of all neonatal
septicemia was caused by anaerobes [11].
Early onset sepsis was found in majority of the
confirmed cases rather than late onset sepsis .The
percentage of EOS in this study was found to be
92.54% with Klebsiella, CONS, Pseudomonas and
Staph. aureus being the predominant pathogens
causing EO. The LOS was reported in 7.45%
cases,with CONS, Klebsiella and Staph.aureus
causing the LOS. Higher culture positivity rates in
LOS were reported by P. Jyothi et al (25.2%) and
Kaistha et al (14.18%) which differs from this study
[12]
.All the other studies reported higher culture
positive rates in EOS except in a study by Ahmed et
al in Bangladesh which reported the positivity rates of
EOS as low as 26%. They reported that the higher
mortality rates in early onset cases to be the reason
for this discrepancy [13] .
In this study, Gram negative organisms were isolated
in about 59.32% of the cases with Klebsiella
(48.57%) and Pseudomonas (26.85%) being the
predominant ones among the gram negative
organisms. Similar findings was reported by
Ghanshyam et al with 60% gram negative isolates
with Klebsiella as the predominant gram negative
isolate [8].Comparatively a higher incidence of gram

negative isolates was found in the study of Mathur et

al (87.1%) [7].
In this study Gram Positive were isolated in 40.67%
cases with CONS and Staph.aureus being the
predominant pathogen. In the study by P.Jyothi et al,
they also found CONS to the predominant Gram
positive organism [12] but majority of the other studies
reported Staph. aureus to be the predominant Gram
positive organism over CONS [8, 9, 14] .Various studies
have shown that in the last two decades, the isolation
of Gram positive organisms has increased
significantly [9].But nevertheless the predominance of
gram negative corroborates with the findings of other
studies done in the Indian context. Many studies have
shown the preponderance of gram negative organisms
in tropical and developing countries also [13, 15].
Klebsiella was found to be the predominant pathogen
causing neonatal sepsis which is in accord with many
studies like that of Ghanshyam et al (33.8%) ,
Zakariya et al (66%) , Mathur et al (38.5%) ,Kaistha
et al (28.3%) and P.Jyothi et al (31%) which were
done in India .Other studies from developing
countries also found Klebsiella as the common
organism. But studies done by Ahmed et al, Agnihotri
et al and Bhat et al showed the predominant pathogen
to be E.coli (30%),Staph.aureus (35.3%) and
Pseudomonas (33.2%) respectively .
Group B Streptococcus (GBS) was not isolated in this
study , unlike western , developed countries where it
is the major agent of neonatal septicemia This may be
attributed to low prevalence of GBS colonization of
pregnant women in this area or possibly , to the
presence of strains with low virulence [13].Since a
sizeable number of culture specimens were negative
by aerobic culture , the possibility of infection by
anaerobes must be entertained and anaerobic culture
can be performed routinely in cases of neonatal sepsis
[8]
. However, the feasibility, logistics and costeffectiveness of routine anaerobic culture for neonatal
sepsis need to be explored further.
The antibiotic sensitivity testing showed that most of
the gram negative isolates were sensitive to
meropenem
followed
by
chloramphenicol
,ciprofloxacin ,gentamicin and amikacin .They were
not sensitive to the commonly used antibiotics like
penicillin , ampicillin etc .The antibiotic sensitivity
testing of the gram positive isolates showed that they
were maximally sensitive to linezolid ,netilmicin and
cholramphenicol .This is comparable to the study
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done by P. Jyothi et al in which maximum sensitivity

was observed in imipenem and linezolid [12]
.Netilmicin and amikacin was found to be highly
sensitive in the study done by Agnihotri et al for
Staph.aureus and gram negative isolatesrespectively
[1]
.While the study by Mathur et al showed
Gentamicin to be sensitive in gram negative cases
[7]
.Many studies also reported cefotaxime to have
shown maximum sensitivity [7] but it could not be
compared as some of the samples from this study had
not undergone the sensitivity testing for cefotaxime .
Besides the antimicrobial sensitivity patterns differs
in different studies as well as at different times in the
same hospital.This is because of emergence of
resistant strains as a result of indiscriminate use of
antibiotics.Thus ,Meropenem and Linezolid were
found to the most sensitive drugs for gram negative
and gram positive respectively , but these two drugs
should not be used indiscriminately and kept as
reserve drugs , otherwise resistance to these drugs
may develop , thereby threatening the treatment .
Therefore, to conclude, an effective infection control
programme which will among others ensure good and
effective
hand
washing,
regular
antibiotic
susceptibility surveillance and evaluation, and the
enforcement and periodic review of the antibiotic
policy of the hospital as well as the encouragement of
rational antibiotic use will reduce the rates of
acquiring neonatal infections and development of
bacterial resistance.
CONCLUSION
Klebsiella was found to be the most common agent
causing the neonatal sepsis followed by CONS,
Pseudomonas, Staph.aureus and E.coli .Gram
Negative sepsis predominated in this study. Early
onset sepsis was found to be the major burden of
neonatal sepsis in the rural setting.
Meropenem was found to the most sensitive drug for
gram negative and Linezolid for gram positive. In the
gram negative samples Cefazolin was found to be
most resistant drug and Penicillin and Ampicillin in
the gram positive.
Acknowledgement: We acknowledge all the faculty
members of the Department of Microbiology for their
help and cooperation for this study.
Conflict of interest: None declared

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