Early onset neonatal bloodstream infections in South African hospitals

Area of Science:

• Neonatal Medicine
• Infectious Diseases
• Public Health in LMICs

Background:

• Neonatal sepsis, particularly early-onset bloodstream infections (EO-BSI), is a significant cause of mortality in low- and middle-income countries (LMICs).
• Rising antibiotic resistance has diminished the efficacy of standard empiric antibiotic regimens like ampicillin plus gentamicin for EO-BSI pathogens.
• This necessitates an updated understanding of causative agents and treatment effectiveness in these settings.

Purpose of the Study:

• To analyze pathogen profiles and empiric antibiotic coverage for early-onset bloodstream infections (EO-BSI) in neonatal units in the Western Cape Province, South Africa.
• To identify factors associated with mortality in neonates with EO-BSI, stratified by hospital type (central vs. peripheral).
• To evaluate the effectiveness of current empiric antibiotic strategies against prevalent EO-BSI pathogens.

Main Methods:

• Retrospective analysis of blood culture-confirmed EO-BSI episodes from nine neonatal units (3 central, 6 peripheral) in South Africa (2017-2018).
• Review of clinical and laboratory records to determine pathogen distribution, empiric antibiotic coverage rates, and mortality predictors.
• Stratification of mortality factors by hospital type to identify specific vulnerabilities.

Main Results:

• A total of 136 EO-BSI episodes were identified, with higher incidence rates in central hospitals (1.3/1000 live births) compared to peripheral ones (0.5/1000 live births).
• Preterm (68.3%) and low birth weight (61.8%) neonates were disproportionately affected. Predominant pathogens included Streptococcus agalactiae, Klebsiella pneumoniae, Listeria monocytogenes, Acinetobacter baumannii, and Escherichia coli.
• Empiric antibiotic coverage was lower in central (64%) versus peripheral hospitals (84%). Gram-negative EO-BSI and discordant empiric therapy significantly increased mortality risk (4-fold and 3-fold, respectively).

Conclusions:

• Preterm and low birth weight neonates are the most vulnerable populations for EO-BSI.
• Gram-negative pathogens and empiric antibiotic therapy discordant with pathogen susceptibility present significantly higher mortality risks.
• The findings underscore the need for improved diagnostic and therapeutic strategies for neonatal sepsis in LMICs, considering local resistance patterns and patient risk factors.