We read with interest the article by Tiskumara R et al on the epidemiology of neonatal infections in Asia.1 This study highlights the relatively high incidence of neonatal sepsis and the antimicrobial resistance pattern in this part of the world. However, we have some reservations with regard to the reported findings of the study, in particular the incidence of group B streptococcal (GBS) infections. The authors report GBS to be the most common organism causing early onset sepsis (EOS) in the participating units. This, in our opinion, does not portray the true picture because:

a. The information from the National Neonatal Perinatal Database (NNPD) of India, one of the largest databases from Asia that prospectively collected information regarding all live-births from 16-18 major hospitals, found the proportion of neonatal sepsis caused by GBS to be <1.0%. The consistent pattern seen across all 3 phases of data collection - 1995, 2000 and 2002-2003, also argues against any ‘epidemiological shift’ over the years (Table).2, 3, 4 This information, available in the public domain, was probably missed by the esteemed authors.

b. In a recently published review on neonatal sepsis in developing countries, GBS was found to be responsible for only 0.2, 7.1 and 7.8 percent of sepsis in East Asia, Middle East/Central Asia, and South Asia respectively (the proportion increased to 13.1% in EOS from all developing countries but it could have been due to inclusion of centers from Africa with a relatively high incidence of GBS).5

c. Of the heterogeneity between study sites: GBS was isolated from only 4 out of 7 centers in the present study; units in Iran, India and Thailand did not have any episodes of GBS infection. Also, the number of episodes of EOS was very small (n=47).

Given these facts, the authors’ conclusion that ‘the pattern of organisms in Asia is similar to that of resource-rich countries’ does not seem to be appropriate. As the authors themselves point out, the selection bias (study units being better resourced than others in the region) could be responsible for these results.

References:

1. Tiskumara R, Fakharee SH, Liu CQ, Nuntnarumit P, Lui KM, Hammoud M, Lee JK, Chow CB, Shenoi A, Halliday R, Isaacs D; Asia-Pacific Neonatal Infections Study. Neonatal infections in Asia. Arch Dis Child Fetal Neonatal Ed 2009; 94:F144-8.

2. Neonatal morbidity and mortality: report of the National Neonatal- Perinatal Database. Indian Pediatr 1997;34:1039-42.

3. National Neonatal Perinatal Database. Report for the year 2002-03. India: National Neonatology Forum; 2004. Available at: http://www.newbornwhocc.org/nnpd.htm

4. Deorari AK. For the Investigators of National Neonatal perinatal Database. Changing pattern of bacteriologic profile in neonatal sepsis among intramural babies. J Neonatol 2006; 20: 8-15.

5. Zaidi AK, Thaver D, Ali SA, Khan TA. Pathogens associated with sepsis in newborns and young infants in developing countries. Pediatr Infect Dis J 2009; 28:S10-8.

(Table sent as a word document through e-mail)