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Neonatal Sepsis and Antibiotic Resistance in Developing Countries

Bates, Matthew PhD; Kabwe, Mwila MSc; Zumla, Alimuddin MD, FRCP

The Pediatric Infectious Disease Journal: October 2014 - Volume 33 - Issue 10 - p 1097
doi: 10.1097/INF.0000000000000388
Letters to the Editor

University of Zambia and University College London Medical School Research and Training Programme, Lusaka, Zambia

Division of Infection and Immunity, Center for Clinical Microbiology, Department of Infection, University College London, UCL Hospitals NHS Foundation Trust, London, United Kingdom

University of Zambia and University College London Medical School Research and Training Programme, Lusaka, Zambia

University of Zambia and University College London Medical School Research and Training Programme, Lusaka, Zambia

Division of Infection and Immunity, Center for Clinical Microbiology, Department of Infection, University College London, UCL Hospitals NHS Foundation Trust, London, United Kingdom

The authors have no funding or conflicts of interest to disclose.

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To the Editors:

Neonatal sepsis and other bacterial infections account for roughly 800,000 neonatal deaths annually, which is more than malaria and HIV combined in all children <5 years of age.1 Standard microbiologic diagnosis by culture and drug-susceptibility testing is unavailable in most health centers and so the available information on prevalence, speciation and drug-susceptibility of the various pathogens that cause sepsis is minimal. Concurrently, World Health Organization guidelines for suspected neonatal sepsis recommend empirical treatment with penicillin or ampicillin and an aminoglycoside (typically, gentamicin) as frontline therapy, with a third-generation cephalosporin such as ceftriaxone or cefotaxime as second line for nonresponders or patients in whom drug-susceptibility testing of bacterial isolates indicates drug resistance to first-line therapy.2 Reductions in price and local clinical experience is leading to third-generation cephalosporins being commonly used as first-line treatment for severe sepsis in many developing countries raising concerns about the spread of bacteria that are dually resistant to both first- and second-line treatment.

Although the data are scant, those centers from which drug-susceptibility studies have been published suggest alarming rates of resistance to the 2 frontline drugs for both hospital- and community-acquired neonatal sepsis (Table 1), as reviewed.3,4 In light of these data, the current World Health Organization guidelines appear to be inadequate for the treatment of drug-resistant infections in neonates in the community and hospital settings.

TABLE 1

TABLE 1

Antibiotic resistance arises from poor infection control practices and gross overuse or inappropriate or prolonged use of antibiotics. Although it may be possible to design novel strategies for more effective antibiotic use, the ultimate solution to the emergence and spread of antibiotic resistant bacterial infections is prevention. Within institutions, multifaceted infection control interventions including provision of consumables, education, internal monitoring and feedback can potentially reduce infection rates, but such strategies require strong leadership and coordination.5 The predominance of home-birthing practices in rural communities in developing countries, and in particular the lack of a skilled birthing attendant, is linked with higher rates of maternal and neonatal mortality.6 In addition to promoting skilled birthing attendant deliveries, improving referral pathways and increasing the overall number of institutional deliveries is thought to improve both maternal and neonatal mortality.6 Although with increasing institutional births, infection control within obstetric theaters and neonatal units that are already overstretched remains a considerable problem.4

In all health care settings in developing countries, even with limited budgets, the rigorous application and promotion of relatively affordable “back-to-basics” infection control practices, at institutions and in the community, could have a substantial impact on reducing neonatal mortality and improving <5 mortality rates overall.

Matthew Bates, PhD

University of Zambia and

University College London Medical School

Research and

Training Programme

Lusaka, Zambia

Division of Infection and Immunity

Center for Clinical Microbiology

Department of Infection

University College London

UCL Hospitals NHS Foundation Trust

London, United Kingdom

Mwila Kabwe, MSc

University of Zambia and

University College London Medical School

Research and

Training Programme

Lusaka, Zambia

Alimuddin Zumla, MD, FRCP

University of Zambia and

University College London Medical School

Research and

Training Programme

Lusaka, Zambia

Division of Infection and Immunity

Center for Clinical Microbiology

Department of Infection

University College London

UCL Hospitals NHS Foundation Trust

London, United Kingdom

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REFERENCES

1. Liu L, Johnson HL, Cousens S, et al.Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379:2151–2161
2. WHO. Integrated Management of Childhood Illness for High HIV Settings. 2008 Geneva World Health Organization
3. Thaver D, Ali SA, Zaidi AK. Antimicrobial resistance among neonatal pathogens in developing countries. Pediatr Infect Dis J. 2009;28(1 Suppl):S19–S21
4. Zaidi AK, Huskins WC, Thaver D, et al. Hospital-acquired neonatal infections in developing countries. Lancet. 2005;365:1175–1188
5. Rosenthal VD, Dueñas L, Sobreyra-Oropeza M, et al. Findings of the International Nosocomial Infection Control Consortium (INICC), part III: effectiveness of a multidimensional infection control approach to reduce central line-associated bloodstream infections in the neonatal intensive care units of 4 developing countries. Infect Control Hosp Epidemiol. 2013;34:229–237
6. Crowe S, Utley M, Costello A, et al. How many births in sub-Saharan Africa and South Asia will not be attended by a skilled birth attendant between 2011 and 2015? BMC Pregnancy Childbirth. 2012;12:4
© 2014 by Lippincott Williams & Wilkins, Inc.