Neonatal sepsis at Mulago national referral hospital in Uganda: Etiology, antimicrobial resistance, associated factors and case fatality risk

Background Sepsis is the third most common cause of death among neonates, with about 225,000 newborns dying every year globally. Data concerning the microbial etiology of neonatal sepsis and antimicrobial resistance profiles of its causative agents are necessary to inform targeted and effective treatment and prevention strategies. Objective To determine the proportion of newborns with symptoms and signs of sepsis who had a positive blood culture, its bacterial etiology, the antimicrobial resistance patterns as well as the factors associated with culture-positivity and case fatality at Mulago national referral hospital in Uganda. Methods We conducted a cross-sectional study among 359 neonates with symptoms and signs of sepsis who presented to the pediatric emergency care unit of Mulago national referral hospital from mid-January to end of December 2018. We performed blood culture and antimicrobial susceptibility testing, and conducted polymerase chain reaction to identify methicillin-resistantStaphylococcus aureus(MRSA) isolates. We used multivariable logistic regression to estimate the association between potential risk factors and culture-positive neonatal sepsis. Findings Of the 359 neonates recruited, 46 (12.8%; 95% CI 9.5%, 16.7%) had a positive blood culture. The predominant isolated bacteria wereStaphylococcus aureusin 29 (63.0%),Escherichia coliin seven (15.2%), andKlebsiella pneumoniaein five (10.9%). Of the 46 pathogens, 73.9% were resistant to ampicillin, 23.9% to gentamicin and 8.7% to ceftriaxone. We isolated MRSA from the blood specimens of 19 (5.3%) of the 359 neonates, while 3 (0.8%) grew extended spectrum beta lactamase producers. The case fatality risk among neonates with neonatal sepsis was 9.5% (95% CI: 6.6%, 13.0%). Cesarean section delivery was strongly associated with culture-positive sepsis (adjusted odds ratio 3.45, 95% CI: 1.2, 10.1). Conclusion One in eight neonates with clinical signs of sepsis grew a likely causative bacterial pathogen.S.aureuswas the main pathogen isolated and a third of these isolates were MRSA. A significant proportion of the isolated bacterial pathogens were resistant to the first and second line antibiotics used for the treatment of neonatal sepsis. There is need to revisit the current treatment guidelines for neonatal sepsis.