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Epidemiology of Early-onset Bacterial Neonatal Infections in Madagascar

Ranosiarisoa, Zoly Nantenaina, MD*; El Harrif, Sélim, MD; Andrianirina, André Zo, MD; Duron, Sandrine, MD§; Simon-Ghediri, Marie-José, MD; Ramparany, Lova, MD; Robinson, Annick Lalaina, MD, PhD**; Tsifiregna, Rosa, MD; Randrianirina, Frédérique, MD; Ratsima, Elisoa, MD; Raymond, Josette, MD, PhD¶,††; Imbert, Patrick, MD¶,‡‡

The Pediatric Infectious Disease Journal: January 2019 - Volume 38 - Issue 1 - p 76–81
doi: 10.1097/INF.0000000000001993
Maternal-Neonatal Reports

Background: Little is known about early-onset neonatal bacterial infections (EONBI) in Madagascar. Our aim was to determine their epidemiology to improve their management.

Methods: Inborn neonates at risk for EONBI and admitted in the neonatal unit of 2 tertiary hospitals in Antananarivo, Madagascar, were included in a prospective study from April 2012 to March 2013. Using a clinical algorithm, blood culture, gastric fluid culture and C-reactive protein dosage were performed in newborns at high risk of infection, that is, peri partum fever, prematurity <35 weeks’ gestation or birth weight <2000 g, or presenting with clinical signs of infection. EONBI was defined as a bacteremia occurring within the first week of life.

Results: Among 307 neonates, 75 (24.4%) had an EONBI caused by 1 (n = 59) or 2 (n = 16) bacteria (91 isolates). Gram-negative bacteria were predominant (n = 62, 82.7%), including Enterobacter cloacae (n = 26), Klebsiella pneumoniae (n = 14), Escherichia coli (n = 7) and Proteus mirabilis (n = 2). Group B Streptococcus, Acinetobacter baumanii and Enterococcus sp. represented 3.6%, 8.2% and 12.1% of the isolates, respectively. All E. cloacae and 12/14 (85.7%) K. pneumoniae were extended-spectrum β-lactamase producers. At all, 41/91 (45.1%) bacteria were multidrug-resistant (MDR) and 34/75 (45.3%) newborns had an EONBI caused by an MDR bacteria. Neonatal asphyxia was the only factor associated with multidrug resistance (odds ratio: 4.52; CI: 1.20–16.94; P = 0.025). The EONBI-related mortality (n = 20/75, 26.7%) rose up to 38.2% (n = 13/34) in case of MDR bacteria.

Conclusions: The epidemiology of EONBIs in Madagascar is comparable to that found in many low-income countries. Prevention, including improvement of hygiene during resuscitation for neonatal asphyxia, is likely to be more effective in reducing EONBI-related morbidity and mortality than using new antibiotics to counter resistance.

From the *Service de néonatologie, Hôpital Befelatanana, Antananarivo, Madagascar

Service de réanimation pédiatrique, Hôpital Robert Debré, Paris, France

Service de pédiatrie, Centre hospitalier Soavinandriana, Antananarivo, Madagascar

§Centre d’épidémiologie et de santé publique des armées, Marseille, France

Association Jeremi Rhône-Alpes, Lyon, France

Centre de biologie clinique, Institut Pasteur, Antananarivo, Madagascar

**Service de pédiatrie, Hôpital Tsaralanana, Antananarivo, Madagascar

††Université Paris 5, Service de bactériologie, Hôpital Cochin, Paris, France

‡‡Sous-direction Hôpitaux-Recherche, DIrection centrale du service des armées, Paris, France.

Accepted for publication March 9, 2018.

The study protocol was approved by the Ethic Committee of the Health Ministry of Madagascar. Written informed consents were obtained from at least one parent of each child before enrolment.

This study was funded by the Association Jeremi Rhône Alpes, the French Ministry of Foreign Affairs, the French Society of Pediatrics (Groupe de pédiatrie tropicale and Groupe de pathologie infectieuse pédiatrique) and the GEREME Fund.

The authors have no conflicts of interest to disclose.

P.I. and J.R. conceived the study and participated in its design and coordination. Z.N.R., S.E.H., S.D., P.I. and J.R. drafted the manuscript. Z.N.R., A.Z.A., L.R., A.L.R. and R.T. were responsible for coordination and acquisition of data. F.R., E.R. and J.R. carried out the bacteriologic cultures. S.E.H. and S.D. performed statistic analyses. M.J.S.G. was involved in the study conception and manuscript revision. All authors read and approved the final manuscript.

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Address for correspondence: Patrick Imbert, MD, Direction centrale du service de santé des armées, Sous-direction Hôpitaux-Recherche Site de Vincennes 60 boulevard du général Martial Valin, CS 21623 75509 Paris Cedex 15, France. E-mail:

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