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Concerns regarding neonatal sepsis data from Peshawar
Author's response: Multidrug resistant neonatal sepsis in Peshawar Pakistan
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Syed A Ali, Research Assistant Department of Paediatrics, The Aga Khan University, Karachi, Pakistan., Tauseef A Khan, Anita K. M. Zaidi.
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syed.ali{at}aku.edu Syed A Ali, et al.
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Dear Editor We wish to raise a few concerns regarding the study reported by S Rahman and colleagues.[1] We found it surprising that only five species of micro-organisms were isolated in this series of over a 1000 blood cultures obtained from neonates with sepsis. Similar studies done in other major cities of Pakistan, with much smaller sample sizes have shown a wider spectrum of pathogens . Anwer SK (2000)[2] showed 11 species types in 109 blood cultures, Bhutta ZA (1997)[3] showed 13 species types in 38 cultures, and 11 species types in a series of 276 positive blood cultures (2001)[5]. Khan IA (1987)[4] showed more than 8 different species types from 89 cultures. In addition to the 5 species causing neonatal sepsis reported by Rahman et al (Esherichia coli 36.6 %, Staphylococcus aureus 29.5 %, Pseudomonas 22.4 %, Klebsiella 7.6 % and Proteus 3.8 %), all the other investigators have also reported Serratia spp and Enterococcus, and most reported Streptococcus pneumoniae, Salmonella spp and group B Streptococcus. Although the authors do not clearly state whether they excluded hospital-acquired infections in their series, the studies reported by Bhutta ZA5 did exclude nosocomial infections. The antimicrobial susceptibility data reported by Rahman et al. are not interpretable as the number of micro-organisms on which antimicrobial susceptibility testing was performed is not presented. In addition, the susceptibility results are not internally consistent; 60 % of the Staphylococcus aureus tested are reported to be ampicillin-sensitive but only 27 % were Amoxicillin + Clavulanate (Augmentin) sensitive. This represents a highly unusual susceptibility result with a high percentage of S. aureus not producing beta-lactamase enzymes to inactivate penicillin (ampicillin), but still showing resistance to a penicillin-beta-lactamase combination such as Augmentin. We wonder if the 60 % reported sensitivity of S. aureus to ampicillin is erroneous since the vast majority of S.aureus even in developing countries, are now penicillin (ampicillin)- resistant [5,6,7,8]. We also find the 73 % resistance rate of S. aureus to amoxicillin-clavulanate (which is equivalent to methicillin-resistance for S. aureus) surprisingly high, and question if this indicates the presence of hospital-acquired infections in this series. Syed A Ali
Department of Paediatrics References
(1) S Rahman, A Hameed, M T Roghani, Z Ullah. Multidrug resistant
neonatal sepsis in Peshawar, Pakistan. Arch Dis Child Fetal Neonatal Ed
2002;87:F52-F54.
(2) Anwer SK, Mustafa S, Pariyani S, Ashraf S, Taufiq KM. Neonatal sepsis:
An etiological study. J Pak Med Assoc 2000; 50(3): 91-93.
(3) Bhutta ZA, Yusuf K. Early onset neonatal sepsis in Pakistan: A case
control study of risk factors in a birth cohort. Am J Perinatol 1997;
14(9): 577-581.
(4) Khan IA, Akram DS. Neonatal sepsis – Etiological study. J Pak Med Assoc
1987;37: 327-30.
(5) Bhutta ZA. Spectrum of nonnosocomial neonatal sepsis. State of the
World's newborns: Pakistan. Saving Newborn Lives Oct 2001.
(6) Kuruvilla KA, Pillai S, Jesudason M, Jana AK. Bacterial profile of sepsis in a neonatal unit in South India. Indian Pediatr 1998;35: 851-8.
(7) Tallur SS, Kasturi AV, Nadgir SD, Krishna BVS. Clinico-bacteriological
study of neonatal septicemia in Hubli. Indian J Pediatr 2000;67(3):169-74.
(8) Ako-Nai AK, Adejuyigbe EA, Ajayi FM, Onipede AO. The Bacteriology of
Neonatal Septicemia in Ile-Ife, Nigeria. J Trop Pediatr 1999;45:146-51.
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Sajjad ur Rahman, Consultant Neonatologist St. Mary's Hospital Praed Street London W2 1NY
Send letter to journal:
sajjadjan{at}hotmail.com Sajjad ur Rahman
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Dear Editor This is in response to the letter from SA Ali et al.[1] 1. The total number (1598)and the culture positive babies (1003)in our article [1] represent cases after the patients meeting the exclusion criteria were taken out. We did grow isolated cases of Strp sp. Salmonella and Enterococci which happened to fall in the excluded group. In the spectrum as a whole, these oganisms accounted for <0.5 % of the organisms. This is similar to the study done by Maryam W et al[2]in a public sector institution with population of exactly similar socioeconomic, cultural, religious and climatic background as ours. Their study was done in the same time period as ours but completely independent and blinded from ours. In their series of 284 cases, they grew E. Coli 130 cases (45.77 %), Klebsiella 49 cases (17.25 %), Pseudomonas 46 cases (16.2 %), Staph A 39 cases (13.73 %), Staph Epi 18 cases (6.34 %), Strep sp 1 case (0.35 %) and Salmonella 1 case (0.35 %). The numbers are slightly different among the studies from south of Pakistan. This is not surprising because neonatal sepsis is known for the temporal and regional variation of the spectrum of its organisms even in different hospitals within the same city. 2. The basic message from the majority of studies from Pakistan is the same "Gram Negative organisms are the main caues of neonatal sepsis in Pakistan followed by Staph A". This group of organisms is responsible for >99 % of the spectrum and unfortunately the grave situation of multidrug resistance is emerging among these organisms. That is where one needs to concentrate instead of the organisms responsible for <0.5 % of the spectrum (Salmonella, Strep sp etc) which do not carry any significane for overall neonatal mortality and morbidity. 3. Out of 296 cases of Staph A in our series, Ampicillin was tested on 285 cases with 171 (60 %)sensitive to it while 279 were tested for Augmentin with 75(26.88 %) sensitive to it. I agree with S Ali et al. that this pattern of sensitivity looks unusual as for as Staph A is concerned though this phenomenon is known to occurr with Beta lactamase producing E. Coli. It may be due to the varying strengths of Augmentin discs available or known biochemical instability of Clavulonic acid or difficulty of interpretation when a combination of two antibiotics is used in one disc using disc diffusion technique. However, I would love to listen some more expert opinion about this. Our series did not exclude hospital acquired infections. 4. The longitudinal analysis of our data shows an increasing sensitivity to Penicillin and decreasing sensitivity to Cephalosporins, particularly Cefotaxime, over the last half decade. This is consistent with the change in antibiotic use in Pakistan since early 1990s when Penicillin/Gentamicin was switched over to Cephalosporins/ Amikacin as the first line antibiotic regime. Most of the Gram negative organisms in Pakistan still maintain a very high degree of sensitivity to Amikacin [2,3]but not to Gentamicin. I feel Penicillin/Amikacin may be a very good choice as the first line antibiotic in the neonatal units in Pakistan. This is a high time to review our antibiotic policies and at the same time approach the government to rationalise the antibiotic marketing in the country. References (1) Rahman S, Hameed A, RoghaniM T , and Ullah Z. Multidrug resistant neonatal sepsis in Peshawar Pakistan. Arch Dis Child Fet Neo Ed 2002;87:F52-4 (2) Maryam W et al. Neonatal sepsis spectrum of antibiotic resistance. Proceedings of 10th Annual National Pediatric Conference PPA. 2001; 57. (3) Anwar SK et al. Neonatal Sepsis: an etiological study. JPMA. 2000 Mar; 50(3)91-4. |
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