The reported incidence of neonatal sepsis is 38 per 1000 live births in Asia. The incidence is lower in western countries.⁵ In developing countries neonatal mortality from all causes are about 34 per 1000 live births, most of the deaths occurring in the first week, most on the first day. In contrast in developed world it is five. In Asia, neonatal mortality is 34 and in Africa it is 42, although there are wide variations within the country and within the countries themselves.⁵ Early onset sepsis usually presents within first 72 hours of life. In severe cases, the neonate may be symptomatic in utero (fetal tachycardia, poor beat to beat variability) or within a few hours after birth¹. It is associated with acquisition of microorganism from the mother, transplacental infection or an ascending infection from the cervix caused by organisms that colonize in the mother’s genitourinary tract. The infant may acquire the microbe by passage through the colonized birth canal during delivery.^1,2,6,7 Late onset sepsis usually presents after 72 hours of age.¹ It is acquired from the environment. The infant’s skin, respiratory tract, conjunctiva, gastrointestinal tract and umbilicus may become colonized from environment, leading to possibility of late onset sepsis from invasive microorganisms. Vectors for colonization include vascular or urinary catheter, indwelling lines or contact from care givers with bacterial colonization.^1,2,6,7

Risk Factors for Neonatal Septicaemia

Prematurity is the single most prognostic factor in neonatal septicaemia. Premature infants have 3-10-fold higher risk compared to term babies.⁸ Babies with birth weight less than 2500 grams are more likely to develop septicaemia due to inappropriate immunological response. Birth weight less than 1000 grams increases the neonatal infection rate by 26 folds when compared to term infants.⁹ Birth asphyxia is one of the perinatal risk factors for sepsis as asphyxia depress the immune functions. Additional intervention frequent suctioning, intubation, prolonged ventilator care to manage asphyxia may impact extra risk of contracting infections in neonates and birth injuries may further complicate the issue.^10,11 Male infants are 2 to 6 time more at risk of neonatal septicemia than females.¹² Septicaemia is found to be more common among those infants whose mother had prolonged rupture of membrane with increased risk of contamination of amniotic fluid by organism from birth canal before delivery.¹³ Maternal fever in association with polymorphonuclear leucocytosis and presence of bacteriological evidence of infection has been investigated as predisposing condition for sepsis. The reported range of neonatal sepsis when chorioamnionitis is present is 3% to 20%.¹⁴

The presence of foul-smelling liquor or Meconium stained liquor has been found significant risk factor for neonatal sepsis.¹¹ Multiple vaginal examinations (>3 vaginal examination after onset of labour) are associated with 20% of early onset sepsis. It is an independent risk factor in causing neonatal septicemia.¹¹ Labour lasting for more than 24 hours with prolonged duration of second stage of labour with ruptured membranes, increases the chances of invasion of microorganisms in to the foetus.¹¹ Abnormal presentation, difficult labour and instrumental vaginal delivery are associated with increased risk of infection. Unclean delivery practice in home deliveries and prolonged hospital stay of babies delivered by operative means predispose them to infections acquired from the environment.¹⁵

The microorganisms most commonly reported from developed world to be associated with early onset infection include GBS (40.7%) and E. coli (17.2%) are predominant organism others being Streptococcus viridians, Enterococci and Staphylococcus aureus.^13,15

In developing countries gram negative bacilli are the predominant causative microorganisms for early onset of sepsis mainly represented by Klebsiella, E. coli and Pseudomonas. Of the gram-positive Staphylococcus aureus, CONS, Streptococcus pneumonia and Streptococcus pyogenes are common isolate. Group B Streptococcus is generally rare or not seen at al.^13,16,17

Clinical Signs and Symptoms

1. General- Alteration in behaviour and change in established feeding pattern is an early sign. Lethargy, refusal to feed, feed intolerance, failure to gain weight, temperature instability (Hypothermia/ Fever).
2. Circulatory System- Pallor, cyanosis, cold clammy skin, bradycardia/ tachycardia, poor capillary filling and hypotension.
3. Respiratory System- Apnoea, dyspnoea, tachypnoea with chest retraction, cyanosis, grunting and flaring.
4. Central Nervous System- Lethargy. Irritability, high pitched cry. Blank look, hypotonia, abnormal reflexes, seizures, tremors and bulging anterior fontanel.
5. Gastrointestinal Tract- Vomiting, diarrhoea, abdominal distension hepatomegaly and splenomegaly.
6. Renal System- Oliguria.
7. Haematological System- jaundice, pallor, splenomegaly, petechiae, purpura and mucosal bleeding.
8. Skin changes- Multiple pustules, abscesses, sclerema, mottling, umbilical redness and discharge.

Aim of the Study

This study aimed to determine the clinical profile and bacteriological spectrum of neonatal sepsis.

MATERIALS AND METHODS

The descriptive study conducted in the neonatology unit of G.B Pant Pediatric Hospital and Research centre Srinagar Kashmir. The study was done from June 15 to May 2013. The study population consisted of all symptomatic neonates (0 to 28 days) with a maternal history suggestive of infection admitted in this unit within the study period.

Inclusion Criteria

Neonates Born to Mothers with at Least One of the following Risk Factors are Included-

1. Premature rupture of membranes (PROM) > 12 hours.
2. More than 3 vaginal examinations after rupture of membranes.
3. Intrapartum fever (>38⁰C).
4. Foul-smelling liquor.
5. Meconium stained liquor.
6. Maternal UTI within 2 weeks prior to delivery.
7. Prolonged and difficult delivery with instrumentation.

Exclusion Criteria

1. New born babies with gestational age < 28 weeks.
2. Neonates with birth weight less than <1000 gm.
3. Neonates with lethal congenital anomalies.
4. Still born and fetal deaths.
5. Post-dated neonates.

Patient selection

Patient selection was done in two phases-

• Phase 1: all the neonates, in-born or out-born with at least one of the following anamnestic or clinical criteria as developed by the French National Agency for Accreditation and Health.¹⁸

1. Anamnestic Criteria: Unexplained prematurity with gestational age ≤35 weeks, prolonged rupture of membranes (≥12 hours), stained or purulent amniotic fluid, untreated recurrent urogenital infections in the last trimester of pregnancy, maternal fever of ≥38^oC during labour, delivery at home, apparently healthy twin with other symptomatic.
2. Clinical Criteria: Fever (temperature >38°C) or hypothermia (temperature <35°C), respiratory signs (apnoea, respiratory distress), neurologic signs (Hypotonia, weak reflexes, perturbation of consciousness, convulsions, coma, irritability), digestive signs (refusal to suck, vomiting, diarrhoea), jaundice (early [<24 hours after birth] or prolonged),

• Phase 2: included all neonates retained after the criteria in Phase 1. Samples for complete blood count (CBC), C-reactive protein (CRP), urine, blood and cerebrospinal fluid (CSF) cultures were taken and sent to the laboratory. Chest x-rays were done on those who presented with respiratory symptoms.

The following are considered as signs and symptoms suggestive of sepsis-

General

Hypothermia, Poor feeding, Sclerema, Mottling, Lethargy.

Cardiovascular System

Bradycardia, Tachycardia, CFT>2 second

Respiratory System

Apnoea, RDS, Chest retractions, Cyanosis, Grunting.

Central nervous System

Hypotonia, Irritability, Seizures, High pitched cry.

Gastrointestinal System

Vomiting, Abdominal distension, Hepatomegaly.

All the neonates meeting the inclusion criteria were included in our study. Informed oral and written consent were taken from the parents.

The blood samples from neonates born to mothers with risk factors for neonatal sepsis was collected and sent for analysis. Detailed birth events. Apgar score, sex of the baby, weight of baby was recorded on the predesigned proforma. Gestational age was assessed by using modified Ballard scoring system.

Neonates were followed up for up to 72 hours from the time of birth for the development of any symptoms and signs suggestive of neonatal sepsis and if present were recorded.

Blood samples were collected, and following tests were done-

1. Total count, absolute Neutrophil count and band cell ratio.
2. Procalcitonin levels.
3. CRP levels.
4. Blood culture and sensitivity.

For the purpose of the study, neonates will be divided in 3 groups-

Definite Sepsis

Neonate with signs and symptoms suggestive of sepsis with a positive blood culture.

Probable Sepsis

Will be based on any one of the following-

• Two or more signs suggestive of sepsis with at least one abnormal laboratory parameters.
• One or more signs suggestive of sepsis with two or more abnormal laboratory parameters.

No Sepsis

Any signs of sepsis or abnormal lab parameters.

Once samples were taken, the neonates were placed on antibiotherapy (Ampicillin or Cefotaxime, and Gentamycin). In those with positive cultures, antibiotherapy was re-adjusted according to sensitivity results.

Data Analysis

Data was entered in Epi Info 2000 and analysed with the Statistical Package for Social Sciences version 11.0 (SPSS 11.0) software. Descriptive statistics was used to analyse the collected data.

RESULTS

This descriptive study was conducted in Neonatal Division of Department of Paediatrics, G. B. Pant Hospital Srinagar Kashmir from June 2013 to May 2014. The blood samples from 100 babies meeting the inclusion and exclusion criteria constituted the material for study.

The most frequent clinical findings were thermal dysregulation 66% and respiratory symptoms 54% and gastrointestinal symptoms in 46% babies