ORIGINAL

Niger J Paed 2014; 41 (1):33 –37

West BA

Tabansi PN

Prevalence of neonatal septicaemia

in the University of Port Harcourt

Teaching Hospital, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v41i1,6

Accepted: 30th April 2013

Abstra ct

Ba ckg ro u n d :

positive blood culture giving a

prevalence rate of neonatal

septicaemia as 33.1%. The

predominant predisposing factors

were out-born delivery (68.0%),

birth asphyxia (30.2%) and

prematurity (21.4%) while the

major clinical features of

septicaemia were respiratory

distress (30.2%), fever (26.6%)

and poor suck (22.5%). Klebsiella

Septicaemia is a major cause of

morbidity and mortality in the

neonatal period. Early detection

of neonatal septicaemia is often

hampered by its subtle and non-

specific symptoms and signs thus

a high index of suspicion is

needed.

Objectives: To determine the

p r e v a l e n c e o f n e o n a t a l

septicaemia, identify the

predisposing factors, clinical fea-

tures and causative organisms in

the University of Port Harcourt

Teaching Hospital.

(

)

West BA

Tabansi PN

Department of Paediatrics / Child health

University of Port Harcourt

Teaching Hospital,

Port Harcourt , Rivers State,

Nigeria.

p n e u m o n i a e

( 6 5 . 4 % ) ,

Staphylococcus aureus (15.4%) and

Escherichia coli (7.7%) were the

commonest organisms isolated in

neonates with septicaemia.

Methods: Four hundred and six

neonates with clinical suspicion of

sepsis were recruited into the

study over a six months period.

Blood culture was used as gold

standard for the diagnosis of neo-

natal septicaemia.

Conclusion: Prevalence of blood

culture-proven septicemia is high,

being 33.1%. Klebsiella pneumo-

niae is the predominant cause of

neonatal septicaemia in Port Har-

court.

Results: One hundred and sixty-

nine (41.6%) neonates had

Key Words: Neonatal septicae-

mia; Prevalence; Port Harcourt.

Introduction

fore carried out to determine the prevalence of neonatal

septicaemia, identify associated predisposing factors as

well as the bacteriological profile of neonatal septicemia

in the Special Care Baby Unit of the University of Port

Harcourt Teaching Hospital, Nigeria.

Neonatal septicaemia continues to be an important cause

of morbidity and mortality in spite of great advances in

antimicrobial therapy, neonatal l₁i_,f₂e_,₃support measures

and early detection of risk factors.

This is due to high

susceptibility of the newborn to infections, attributable

to impaired immune defence system especially in the

4

preterm. Neonatal septicaemia accounts for 13%-15%

Materials and methods

2

of all neonatal deaths globally. Its contribution is higher

in developing countries, wh_-₈ere figures of between 30%-

This study was prospectively carried out in the Special

Care Baby Unit of the University of Port Harcourt

Teaching Hospital, Nigeria over a six month period,

from 1 July to 31 December, 2007. The hospital which

is located in the South-South geopolitical zone of Nige-

ria, serves as a referral and regional intensive care

centre.

5

0% have been reported. Early detection and treat-

ment of neonatal septicaemia is thus an important prior-

ity but this is often hampered by its₉_-s₁u₂ btle, diverse and

st

non-specific symptoms and signs.

The organisms

responsible for neonat_,a₄l septicaemia vary across geo-

3

graphical boundaries. In addition, one organism or

group of organisms may over time replace another as the

leading cause of neonatal septicaemia in a particular

region. Early treatment with appropriate antibiotics

Five hundred and eleven babies, aged 0-28 days were

admitted into the Special Care Baby Unit during the

period of study, of which 406 who presented with one or

more symptoms/signs suggestive of sepsis or risk factors

of sepsis were recruited into the study. The clinical data

3

would therefore minimize the risk of severe morbidity

and mortality, besides reducing the emergence of mul-

3

tidrug resistant organisms. The present study was there-

3

4

of these babies such as age, birth weight, sex, gestational

age and place of birth (inborn or outborn) were re-

corded.

blood culture. There were 120 (42.1%) neonates with

early onset septicaemia (onset of illness within the first

72 hours of life) and 49 (40.5%) with late onset

septicaemia (onset of illness after 72 hours of life).

Two milliliter of venous blood was collected from a

peripheral vein of all such babies after adequate skin

preparation and before the commencement of antibiotics

for blood culture. The blood was aseptically introduced

into aerobic and anaerobic culture media. The blood

culture specimens were processed according₃ to standard

Table 1: Characteristics of Neonates with Positive

Blood Culture

Characteristics Study

Positive Blood % of study ᵪ2

Pvalue

Population Culture

Population

n = 406

n = 169

1

Sex

methods in the microbiology laboratory. Inoculated

Male

Female

264

142

120

49

45.5

34.5

4.55+ 0.03

0.01+ 0.92

5.18+ 0.02

17.03+ 0.00

blood culture media were considered negative if there

was no growth after continuous incubation for up to 7

days, subcultures being made each day. Antibiotic sensi-

tivity w₁₃as done using Kirby-Bauer disc diffusion

method.

Birth weight (kg)

<2.5 135

2.5

56

111

41.5

41.0

≥

271

Place of birth

Inborn

Outborn

GA at birth (weeks)

Preterm

Term

153

253

52

115

34.0

45.5

Neonates whose samples for investigations had been

sent to the laboratories were commenced empirically on

intravenous cloxacillin and gentamicin, based on previ-

ous antibiotic sensitivity pattern. Clinical response was

171

216

19

85

71

13

49.7

32.9

68.4

Post term

Age at onset of Illness (hours)

nd

monitored and therapy changed to another antibiotic (2

≤72

72

Weight for gestation:

*n = 240) (**n = 105)

AGA

SGA

LGA

285

121

120

49

42.1

40.5

0.09+ 0.76

2.26++ 0.32

>

line agent) if response was poor or patient was de_nt_derio-

rating. In the case of a positive blood culture, the 2 line

antibiotic chosen was determined by the susceptibility

pattern of the organism isolated.

The clinical details and results of laboratory investiga-

tions were recorded in a proforma. The results were ana-

lysed using the statistical package, SPSS version 14.0

and Epi-info version 6.04.

(

164

45

31

67

24

14

40.9

53.3

45.2

GA = Gestational age

SVD = Spontaneous vertex delivery

AGA = Appropriate for gestational age

SGA = Small for gestational age

LGA = Large for gestational age

Clinical Features: Respiratory distress (30.2%), fever

(26.6%), poor suck (22.5%) and jaundice (14.2%) were

Results

the commonest clinical features observed in neonates

with positive blood culture while the least was abdomi-

nal distension (3.0%) (Table 2).

There were 511 admissions into the Special Care Baby

Unit during the period of study. Of these, 406 neonates

were investigated for septicaemia.

Table 2: Clinical Features of Septicaemia in Neonates with

Characteristics of Neonates with Positive Blood Culture:

The characteristics of neonates with positive blood cul-

ture are shown in Table 1. One hundred and sixty nine

Positive Blood Culture

2

Clinical Features

Positive Blood Negative Blood

χ

p value

Culture

n = 169

No (%)

Culture

n = 237

N (%)

(

41.6%) neonates had positive blood culture, giving a

prevalence rate of blood culture proven septicaemia

among neonates admitted into the Special Care Baby

Unit as 33.1%. There were 120 (45.5%) males and 49

+

Respiratory distress 51 (30.2)

84 (35.4)

64 (27.0)

36 (15.2)

54 (22.8)

12 (5.1)

10 (4.2)

6 (2.5)

4 (1.7)

7 (3.0)

1.23

0.27

0.93

0.06_*

0.03

0.19

0.63

0.23

0.38

0.77

+

Fever

Poor suck

Jaundice

Hypothermia

Convulsion

Vomiting

Irritability

Lethargy

45 (26.6)

38 (22.5)

24 (14.2)

14 (8.3)

9 (5.3)

8 (4.7)

6 (3.6)

0.01

3.52

4.68

1.71

+

(

34.5%) females, with a M:F ratio of 2.4:1. Fifty six

41.5%) neonates had birth weights less than 2.5 kg and

+

1

11 (41.0%) were greater than 2.5 kg. Outborn neonates

+

0.27

with septicaemia accounted for 115 (45.5%) while the

inborn neonates, 52 (34.0%). Of 115 outborn neonates

with septicaemia, 43 (37.4%) were delivered by tradi-

tional birth attendants (TBA), 30 (26.1%) in other hospi-

tals, 18 (24.3%) in maternity homes and 14 (12.2%) in

churches. There were 1,368 live births during the period

of study, giving an incidence rate of septicaemia among

inborn babies as 38.0 per 1000 live births. One hundred

and ninety five inborn babies (48.0%) were admitted

during the period of study, giving the prevalence rate of

septicaemia in inborn babies in the Special Care Baby

Unit as 26.7%. Thirteen (68.4%) post term, 85 (49.7%)

preterm and 71 (32.9%) term neonates had positive

+

1.44

0.75

0.09

Abdominal distension 5 (3.0)

*= Statistically significant

+

= df = 1

3

5

Predisposing Factors: The predominant predisposing

factors to septicaemia in neonates was outborn delivery

Fig 2:

(

68.0%) followed by birth asphyxia (30.2%), prematur-

ity (21.4%) and prolonged rupture of foetal membranes

greater than 24 hours (17.8%) while peripartum pyrexia

(

7.1%) and foul smelling amniotic fluid (7.1%) were the

least (Table 3).

Table 3: Predisposing Factors to Septicaemia in Neonates with

Positive Blood Culture

2

Predisposing Factors Positive Blood Negative Blood

χ

p value

Culture

n = 169

No (%)

Culture

n = 237

No (%)

+

*

Outborn delivery

Birth asphyxia

Prematurity

115 (68.0)

51 (30.2)

37 (21.4)

30 (17.8)

12 (7.1)

138 (58.2)

72 (30.4)

47 (19.8)

68 (28.7)

21 (8.9)

4.05

0.04

+

0.00

0.26

6.45

0.41

6.19

0.97

0.61_*

0.01

0.52_*

+

PROM

Outcome

+

Peripartum pyrexia

Foul smelling

Amniotic fluid

12 (7.1)

36 (15.2)

0.01

Of 169 neonates with blood culture proven septicaemia,

38 (81.7%) were discharged home, 6 (3.6%) were

discharged against medical advice while 25 died giving

a mortality rate of 14.7%.

1

*

=

Statistically significant

PROM = Prolonged rupture of membranes

+

=

df = 1

Causative Organisms

The commonest organism isolated from blood culture

was Klebsiella pneumoniae (58.2%), followed by

Staphylococcal aureus (20.0%), Escherichia coli (8.1%)

and Proteus spp (5.5%) while the least common organ-

ism isolated was Streptococcus spp (0.9%).

Klebsiella pneumoniae (50.0%) and Staphylococcus

aureus (21.2%) were the commonest organisms isolated

in both preterm and term/post-term neonates (Fig 1).

Discussion

The 33.1% prevalence of culture proven neonatal septi-

caemia in our SCBU is comparable to figu₁₄res of 31.7%

8

and 34.4% reported in Calabar and Jos, Nigeria re-

spective₅ly. It is higher than the 27.8₁%₆ observed in Bang-

1

ladesh and 10.7% in Ogun State, Nigeria and much

highe₇r than 5.0₁%₁ , 6.5% an₁d₈ 8.9% reported in Saudi Ara-

1

bia, London and Iraq respectively. These differ-

Fig 1: Distribution of Organisms in Preterm and Term/

Post-Term Neonates

ences could be a reflection of the different population

characteristics and varying predisposing factors.

7

6

5

4

3

2

1

0

6

5.5

In the present study, septicaemia was often observed in

males than females. This is in line with the gene₁₉r_,a₂₀l con-

5

0

cept of greater male susceptibility to infection.

This

is also consistent with earlier observa₅_,t₁i₈o_,₂n₁_,s₂₂in studies

conducted within and outside Nigeria. This pat-

8,16

tern is however not universally reported indicating

%

Total

that other poorly understood factors may be operational.

2

1.2

1

9

.6

Out born delivery observed in the present study as an

important risk factor to se₆p_,₈t_,₂i₂caemia has also been ob-

7.7

5

^.²³^.⁴1.7

0

³^.⁸³^.⁸¹.9

1.9

3.4

1.7

0

served by several authors.

This is not surprising as

Preterm

Term/Post-term

Organisms isolated by gestational age at birthl

most deliveries outside the hospital are usually super-

vised by traditional birth attendants whose unhygienic

methods contribute to infections as observed in our

study.

Klebsiella pneumoniae

Escherichia coli

Staphylococcus aureus

Coliform spp

Proteus spp

Staphylococcus epidermidis

Enterococcus faecalis

Streptococcus spp

Pseudomonas aerugenosa

Antibiotic Sensitivity Pattern

The clinical features of neonatal septicaemia are usually

vague and non-specific and thus a high index of suspi-

cion on the part of the doctor is of essence. In the pre-

sent study, the commonest clinical features of septicae-

mia were respiratory distress, fever, poor suck and jaun-

di₂c₃e. This finding agrees with the report by M₁u₆stafa et

al in Pakistan and Njokanma and colleagues in Ogun

The antimicrobial susceptibility testing of Klebsiella

pneumonia and Staphylococcus aureus, the commonest

gram negative and positive organisms respectively

showed least sensitivity to the penicillins (3.8% -

2

2.2%), moderate sensitivity to the cephalosporins

(

14.3% - 66.7%) and high sensitivity to the quinolones

77.1% - 90.9%)

2

4

State, Nigeria. In contrast, Missallati and colleagues in

the Middle East, found lethargy and poor suck as the

3

6

5

commonest clinical features while Omene in Benin,

septicaemia in our hospital. This therefore calls for

Nigeria found jaundice and fever as the commonest

clinical features. These differences in the clinical fea-

tures of sepsis confirm the diverse and non-specific

nature of presentation. The result of the present study

which showed a predominance of Klebsiella pneumonia

followed by Staphylococcus aureus and Esche₅richia coli

regular review of empiric antibiotics in suspected cases

of neonatal septicaemia in the SCBU. It is pertinent to

note that the predominant organisms showed very high

sensitivity₂₂t_,₂o₆_,₂t₉he quinolones as observed by other re-

searchers.

This is however not surprising as the

quinolones are usually not used commonly in the paedi-

atric age group because of their inadequate safety

margin.

2

agrees with previous study in Port Harcourt and other

6

,16,22,26

This is cont₁r₄a_,₂r₇y_,₂₈h_,₂o₉ wever to

parts of Nigeria.

other studies also carried out in Nigeria

These differences could be due to the fact that organisms

vary from plac₃ e to place as well as over time within the

same locality.

In view of the result of our study, we therefore recom-

mend a combination of the cephalosporins and gen-

tamicin as first line therapy in the management of neo-

nates with suspected septicaemia while awaiting culture

and sensitivity result.

Critical review of the antimicrobial sensitivity of Kleb-

siella pneumoniae and Staphylococcus aureus, the two

commonest gram negative and positive organisms re-

spectively, showed least sensitivity to the commonly

used penicillins followed by gentamicin. There was

however moderate sensitivity to the cephalosporins and

very high sensitivity to the quinolones. The observed

very poor sensitivity to the penicillins w₆as also observed

Conclusion

The high prevalence of septicaemia in the newborn, the

diverse and non-specificity of its clinical features, the

changing pattern of organisms causing infection, the

emerging bacterial resistance and the potential for poor

outcome therefore calls for periodic surveys of neonatal

units.

2

28

29

in a previous study in Port Harcourt, Illorin Ile-Ife

1

8

in Nigeria and Iraq . The sensitivity to gentamicin in

the present study was also poor, be₁l₆o_,₁w₈_,₂₂5_,₂0₆_,%₂₇_,.₂₉This was

also observed by other researchers.

A mod-

erate sensitivity of 5₈8.3%-66.7% was however observed

2

in Illorin, Nigeria. The present study recorded moder-

ate sensitivity to the ceph₂a₆l_,₂o₈s_,₂p₉orins as observed in La-

Author’s Contributions

22

gos while other studies

recorded much higher

West BA: Conceived the research Contributed to

methodology, recruitment of subject, planning

and collection of samples and other data

Contributed to data analysis and discussion

Tabansi PN: Contributed to methodology, planning of

research and data analysis

Supervision and cross-checking of correctness

of data collection, Contributed to writing and

proof reading of the manuscript

sensitivities. This study thus shows that antibiotic sensi-

tivities differ from region to region as well as at differ-

ent times in the same hospital. This could be attributed

to the development of resistant strains as a result of in-

discriminate use of antibiotics. The observed high resis-

tance rates to the penicillins and gentamicin is not sur-

prising as these drugs have been the first line antibiotics

for several years followed by the cephalosporins for

both prophylaxis and treatment of neonates with

Conflict of interest: None

Funding: None

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