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Original Article

Correspondence: Dr. Y. R.Khinchi

E-mail: dr_khinchi@yahoo.com

Profile of Neonatal sepsis

Y. R. Khinchi1, Anit Kumar2, Satish Yadav3

1Associate Professor, 2Second year MD resident, 3Third year MD resident; Department of   Pediatrics and Neonatology,

College of Medical Sciences, Bharatpur, Nepal

Abstract

Objective: To study the clinical presentation, investigational profile and outcome of neonatal sepsis in general

and with special reference to inborn (intramural) or out born (extramural), sex and weight of the neonate.

Materials and method: Retrospective descriptive study of neonates admitted during       2 years from July 2007

to June 2009 in special care neonatal unit of the department of Pediatrics, College of Medical Sciences-Teaching

Hospital, Bharatpur, Nepal.

Results: Majority of neonates were out born and referred (72.2%) to this institution. Significant number of

babies was having sepsis in out born group (59%) as compared to inborn (35%). Male sex was found to have

more sepsis as compared to female. Sepsis was observed to be inversely related to birth weight, 65% in low

birth weight (LBW, <2.5Kg) as compared to 42.6% in normal birth weight group (> 2.5kg).

Conclusions: High index of suspicion for diagnosis of neonatal sepsis is required specially in the presence of risk

factors. Prevalence of sepsis is inversely related to birth weight. More number of out born delivered babies

developed sepsis. Neonatal sepsis related morbidity and mortality can be significantly reduced by comprehensive

obstetric and neonatal care at multiple levels right from community to health institutions.

Key words: Neonatal sepsis, Inborn, Out born, Low birth weight (LBW).

Introduction

Neonatal sepsis is the single most important cause

of neonatal deaths in the community, accounting for

half of them. If diagnosed early and treated aggressively

with antibiotics and good supportive care, it may be

possible to save most cases of neonatal sepsis1.

Surviving infants can have significant neurological

sequelae as a consequence of CNS involvement, septic

shock or hypoxemia secondary to severe parenchymal

lung disease2.

Neonatal sepsis is defined as a clinical syndrome

of bacteremia with signs and symptoms of infection in

the first four weeks of life. When pathogenic bacteria

gain access into the blood stream, they may cause

overwhelming infection without much localization

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termed as septicemia or may get predominantly

localized to the lungs resulting in pneumonia, or the

meninges causing meningitis. Early onset and late onset

sepsis are defined on the basis of presentation within

72 hours or after 72 hours of life respectively.

There are many risk factors for development of

neonatal sepsis including low birth weight, unsafe place

of delivery or unclean delivery, prolonged rupture of

membranes more than 24 hours, maternal pyrexia,

chorio-amnionitis, prolonged labor and perinatal

asphyxia.

The present study is carried out to determine the clinico-

investigational profile and outcome of neonatal sepsis

in general and specially in relation to place of delivery

whether inborn or out born, sex, and weight of

neonates admitted in special neonatal care unit of this

institution.

Materials and methods

This study included newborns admitted in special

care neonatal unit of college of medical sciences

teaching hospital, Bharatpur, Nepal  from July 2007

to June 2009.

This is a retrospective descriptive study. The case

records of  411 newborns entitled for the study during

this period was evaluated and categorized on the basis

of septic or non septic; inborn (intramural: delivered in

the study institution) or out born (extramural: delivered

in other heath facility or home); sex and birth weight.

The case records of these newborns was thoroughly

studied and recorded for relevant information including

history, clinical evaluation and available investigation

either favoring primary diagnosis of neonatal sepsis

including with co-morbid conditions or having some

other exclusive alternate diagnosis other than sepsis.

The diagnosis of neonatal sepsis was based on

clinical profile and septic screen, X-ray chest and or

blood culture whenever feasible and ruling out any other

exclusive alternate diagnosis. Neonates diagnosed as

having neonatal sepsis on the basis of clinico-

investigational evaluation with co-morbid conditions

were also included as septic cases in the study.

Neonates taken against medical advice (LAMA)

or referred or taken elsewhere on request or discharged

on request before proper diagnosis were excluded from

the study. All other neonates not fulfilling the diagnosis

of sepsis as mentioned above were considered as

having other alternate diagnosis and put in the category

of non-septic cases. Statistical analysis was done by

evaluating p value.

Results

Total number of cases enrolled for the study was

411 which included 271 male and 140 female patients.

There were 297 out born and 114 inborn neonates.

Clinical and investigational profile of inborn and out

born neonates is shown in the table-1. Septic group

included 215 patients as compared to 196 in non-septic

group (table-2). Neonatal sepsis accounted for 175

(59%) in the out born and 40 (35%) in the inborn

category (p<0.05, table-3). There was significant

difference for prevalence of sepsis between male

(65.1%) and female (34.9%) neonates (p<0.05, table-

2). Early onset sepsis was responsible for 131 cases

whereas late onset sepsis was observed in 84 neonates

(p<0.05, table-4). Sepsis was significantly (p<.000,

table-5) much higher (69.7%) in very low birth weight/

extremely low birth weight (<1.5Kg), followed by

(64.3%) in LBW (< 2.5 kg) than normal birth weight

(>2.5Kg) babies (42.6%).

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Discussion

Sepsis is the commonest cause of neonatal morbidity

and mortality. It is responsible for about 30-50% of

total neonatal deaths3,4. Sepsis related morbidity and

mortality is largely either preventable or treatable with

rational antimicrobial and supportive therapy. LBW is

a strong risk factor for neonatal sepsis due to multiple

reasons. Unsafe delivery or unclean delivery at

inappropriate place is another important predisposing

factor for sepsis.

Earliest clinical features of neonatal sepsis are often

subtle and non specific therefore a high index of

suspicion is needed for early diagnosis specially so if

risk factors are also present. In the present study

majority of neonates presented (table-1) with refusal

to feeds (74%), tachypnea or respiratory distress

(75%) and fever (69%). In a study done in the tertiary

care center in Bangladesh poor feeding, respiratory

distress and fever was reported in 22.2%, 27.8% and

44.4% cases respectively5. In the same study they

documented hypothermia in 11.1%, apnea in 16.7%,

cyanosis in 11.1%, convulsions in 11.1% and jaundice

in 50% as compared to our findings 11.6%, 15%, 41%,

20.4%, and 40% respectively. Clinical features and

further course in neonatal sepsis depends on various

factors like birth weight, place of delivery, age of

newborn, intervention in preventable factors for sepsis,

availability, accessibility, affordability and timely referral

of baby to an appropriate center.  Therefore variation

in different parameters may be observed in various

studies.

Though the gold standard for the diagnosis of sepsis

is positive blood culture but in our setup due to

limitation of affordability, limited blood sample from

newborn, prior use of antibiotics before admission and

other factors, diagnosis is mainly clinical supported by

septic screen and X- Ray chest. CSF examination and

neuroimaging or other relevant investigations were done

whenever clinically indicated.

Neonatal sepsis was diagnosed in 52.6% of

neonates during the previous study done from January

06 to June 07 in this institution which is comparable to

present data (52.3%), reflecting that there is no change

in factors having impact on prevention of neonatal

sepsis in this region at all levels right from community

to health facilities6.

Male neonates were reported to be affected more

with sepsis as compared to females in some studies7,8.

This is in concordance with our study as well (p<0.05,

table-2). Bias for male sex, place of study, sample

including other factors may be responsible for increased

number of male cases in these studies.

There was statistically significant difference

(p<0.05, table-3) in sepsis cases born in the study

institution (inborn) as compared to those brought from

outside (out born). In Inborn category 35% had sepsis

as compared to 59% in out born group. This is because

of the fact that intramural deliveries in the study

institution are conducted with preventive aspects with

adequate perinatal care whereas in extramural including

home deliveries there may be various predisposing and

risk factors including unsafe or unclean environment,

limited skilled manpower and inadequate facilities etc.

Early onset sepsis was documented significantly

more as compared to late onset sepsis (p<0.05, table-

4). Early onset neonatal sepsis in general is more

common because of various high risk perinatal factors

for sepsis operate during this period.

LBW is a strong risk factor contributing to sepsis.

In this study birth weight is inversely related to

Y. R. Khinchi et al, Profile of Neonatal sepsis

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development of sepsis which is statistically highly

significant (p<0.000, table- 4). This is in concordance

with other studies where low birth was found to be

important risk factor for sepsis 6,9. LBW babies are

mostly also premature and are predisposed to sepsis

due to multiple reasons like immune incompetence at

various levels of defense, more subjected to invasive

interventions etc.

Mortality due to sepsis in inborn was 7.5% as

compared to 11% in out born with overall mortality of

10.2% (table-1) which is comparable to other hospital

based study6.  These data are low as compared to

overall mortality which is reported to be in the range

of 30-50% of total neonatal deaths in the community

and rural India3,4. This wide difference in mortality may

be due to the fact that our data are hospital based

where we get selected referred out born babies and

due to less neonatal sepsis in inborn neonates because

deliveries are conducted with proper antenatal and

perinatal services in this institution.

Conclusions

High index of suspicion for diagnosis of neonatal

sepsis is required specially in the presence of risk

factors and baby presenting with non specific clinical

features. Prevalence of sepsis is inversely related to

birth weight. More number of out born delivered cases

develops sepsis due to lack of poor knowledge,

accessibility, affordability or inadequate perinatal

services in the community setup.

Neonatal sepsis related morbidity and mortality can

be significantly reduced with good maternal nutrition

and health status which is known to improve the birth

weight of newborn along with encouraging institutional

deliveries where adequate obstetric and neonatal

services are available.

References

1. Management of neonatal sepsis, IAP-NNF (Indian

Academy of Pediatrics- National Neonatology Forum)

Guidelines 2006 on level II neonatal care: 159-86.

2. Chaiko B and Sohi I, Early onset neonatal sepsis. Indian

Journal of Pediatrics, 72: 2005: 23-6.

3. Bang AT, Bang RA, Bactule SB et al. Effect of home-

based neonatal care and management of sepsis on

neonatal mortality: field trial in rural India. Lancet 1999:

354: 1955-86.

4. Stoll BJ, The global impact of neonatal infection. Clin

Perinatol 1997: 24: 1-21.

5. Ahmed NU, Chowdhary A, Hoque M et al. Clinical and

bacteriological profile of neonatal septicemia in a tertiary

level pediatric hospital in Bangladesh. Indian Pediatrics

2002: 39: 1034-39.

6. Khinchi YR, Shreshta D, Sarmah BK et al. A study of

morbidity and mortality profile of neonates admitted in

tertiary care hospital in central Nepal. Journal of College

of Medical Sciences, Nepal, 2008: 5: 70-5.

7. Jain NK, Jain VM, Maheshwari S. Clinical profile of

neonatal sepsis. KUMJ: 2003: 1: 117-20.

8. WHO young infant study group. Bacterial etiology of

serious infection in young infants in developing countries:

results of multicenter study. Pediatr. Dis. J. 1999: 18 S17-22.

9. Jeeva Sankar M, Agrawal R, Deorari AK et al. Sepsis in

newborn. Indian J Pediatr 2008: 75: 261-66.

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Table-1: Profile of Neonatal sepsis: 

Feature  Inborn 

(40)   

Out born 

(175) 

 Total (215)    

(%) 

Refusal to feeds 28(70%) 132(75%) 160(74%) 

Poor activity and Cry 21(52%) 67(38%) 88(41%) 

Tachypnea / Respiratory distress 32(80%) 129(73%) 161(75%) 

Fever  26(65%) 122(69%) 148(69%) 

Jaundice  28(70%) 59(33%) 87(40%) 

Apnea  9(22%) 24(13%) 33(15%) 

Hypothermia  2(5%) 23(13%) 25(11.6%) 

Cyanosis  12(30%) 78(44.5%) 90(41%) 

CRT(Capillary Refill Time) > 3 Sec 9(22.5%) 82(46.8%) 91(42.3%) 

Bleeding/ Patechie/ Purpura 12(30%) 36(20.5%) 48(22.3%) 

Convulsions  8(20%) 36(20.5%) 44(20.4%) 

Umbilical sepsis / Skin infections 2(5%) 31(17.7%) 33(15.3%) 

Chest X-Ray suggestive of Respiratory infection 24(60%) 68(38.8%) 92(42.7%) 

Clinical and chest X-Ray with empyema - 1(0.57%) 1(0.46%) 

Positive septic screen (CRP/CBC/PBF) 26(65%) 109(62.2%) 135(62.7%) 

Positive blood culture (out of 22 samples sent) - 1(0.57%) 1(0.46%) 

Meningitis (CSF: Cell count/Gram stain/Biochem.) 5(12.5%) 28(16%) 33(15.3%) 

CT scan showing complications (Meningitis cases) - 2(1.14%) 2(0.93%) 

Mortality due to Sepsis 3(7.5%) 19(11%) 22(10.2%) 

 

Table-2: Distribution of cases according to sex and septic/ non-septic: 

Sex  Septic Non-septic Total  

Male  140 (65.1%) 131 (66.8%) 271 

Female  75 (34.9%) 65 (33.1%) 140 

Total  215 196 411 

(p value <0.05) 

 

Table-3: Distribution of cases according to place of delivery: 

Sepsis cases Septic  Non-septic Total 

Out born (Extramural) 175 (59%) 122 (41%) 297 

Inborn (Intramural) 40 (35%) 74 (65%) 114 

Total  215(52.3%) 196(47.6%) 411 

(p value <0.05)  

Y. R. Khinchi et al, Profile of Neonatal sepsis

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Table-4: Distribution of sepsis cases according to onset of Neonatal sepsis: 

Place of delivery Early onset sepsis  Late onset sepsis Total  

Inborn (intramural) 32 (80%) 8 (20%) 40 

Out born (extramural) 99 (56%) 76 (44%) 175 

Total  131(60.9%) 84(39%) 215 

(p value <0.05) 

 

Table-5: Neonatal sepsis according to birth weight: 

Weight group Septic  Non septic Total  

2.5Kg or more 102(42.6%) 137(57.3%) 239 

Low birth weight 

(1.5Kg to < 2.5Kg)  

83(64.3%) 46(35.6%) 129 

Very/extremely low birth weight  

(<1.5 Kg) 

30(69.7%) 13(30.2%) 43 

All weight group 215(52.3%) 196(47.6) 411 

(p value <0.000) 

 

 

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