Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 113
Op e n Ac c e s s
F u l l L e n g t h A r t i c l e
Frequency and Antibiotic Resistance Profile of
Escherichia coli in Neonatal Sepsis
Javaid Akhter Hashmi1, Aaliya Javaid2, Agha Syed Ali Haider Naqvi3,*, Muhammad Umer Javaid Hashmi4
1Department of Community Medicine, Shahida Islam Medical and Dental College, Lodhran, Pakistan.
2Department of Gynaecology, Syed Hospital, Bahawalpur, Pakistan.
3Federal Medical and Dental College, Islamabad, Pakistan.
4HBS Medical and Dental College, Islamabad, Pakistan.
A B S T R A C T
Background: In developing countries, the most common cause of neonatal mortality is neonatal sepsis. Currently, the most significant
and common hospital acquired pathogen is Escherichia coli, associated with many problems such as septicemia, pneumonia and
meningitis in the neonates. Due to emerging antibiotic resistance in microorganisms, the current antibiotics which are extensively used
are insufficient to resolve the issues.
Objectives: The aim of the study was to find out the frequency and antibiogram assay of Escherichia coli in neonatal sepsis.
Methodology: The research study was cross sectional study directed by the Department of Neonatology, Bahawal Victoria Hospital,
Bahawalpur. The study duration for the current study was from September 2019 to January 2021. Blood samples were collected from
all the suspected neonates for isolation and identification of E.coli, and standard microbiological protocols were used for the
identification. Further a modified Kirby Bauer method of disk diffusion was used for antibiotic sensitivity testing.
Results: During the defined study duration, total 150 blood cultures were found positive for neonatal sepsis. Prevalence of E.coli in
these 150 positive blood cultures was 70% (n = 105). The most effective antibiotics observed in our study were gatifloxacin, imipenam
and amikacin, while the least effective antibiotics were vancomycin, ampicillin, gentamycin and linezolid. Gatifloxacin shows 100%
sensitivity against all isolates of E.coli, while all E.coli isolates show 100% resistance to vancomycin.
Conclusion: Our study concluded that E.coli is a major cause for neonatal sepsis in neonates admitted at Bahawal Victoria Hospital,
Bahawalpur. The resistance pattern was alarmingly increased as observed in the currently available antibiotics. Therefore, surveillance
of this emerging resistance is needed in these antibiotics. Furthermore, in order to limit the resistant strains of the pathogens, there is
a need of effective infections control program.
Keywords
Antibiotics, Escherichia coli, Frequency,
Neonatal Sepsis, Susceptibility Pattern,
Sepsis.
*Address of Correspondence
aghasyedalihaidernaqvi@gmail.com
Article info.
Received: February 5, 2021
Accepted: November 22, 2021
Cite this article Hashmi JA, Javaid A, Naqvi ASAH, Hashmi MUJ. Frequency and Antibiotic
Resistance Profile of Escherichia coli in Neonatal Sepsis. 2021; 12(2):113-119.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium provided the original work is properly cited.
I N T R O D U C T I O N
Neonatal sepsis denotes to an infection of the bloodstream
in newborn infants of around <28 days old. It is a
disseminated disease with positive blood culture, and
considered more common in underdeveloped countries
than developed countries1. Annually, about 30% to 50% of
the death of neonates occur due to neonatal sepsis, hence
making it renowned as the most common cause of death
in neonates2. Neonatal sepsis has been classified into EOS
(Early Onset Sepsis) and LOS (Late Onset Sepsis). EOS
takes place within first 7 days of life while LOS take place
O R I G I N A L A R T I C L E
Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 114
after first 7 days of life3. The associated risk factors for EOS
include labor and delivery, while the risk factors for LOS
include care providers or hospital staff. Even with the
advancement in the health care system, the significant
cause of neonatal mortality and morbidity remains neonatal
sepsis, instigated by gram-negative bacilli4. Recently in
Nepal, sepsis caused by gram-negative bacteria have
been identified5. Out of total sepsis cases in neonates,
about 18% to 78% of neonatal sepsis has been reported to
be caused by gram-negative bacteria6, 7.
The most common bacteria in under-developed countries,
for EOS are Escherichia coli, Klebsiella species and
Staphylococcus aureus, while S. aureus, Streptococcus
pneumoniae, and Streptococcus pyogenes are common
bacteria that cause LOS8. However, the bacteria causing
sepsis in neonates in underdeveloped countries are
different as compared to developed countries. In well-
developed states, the leading bacteria that cause EOS are
Group B streptococcus and E. coli, while coagulase-
negative staphylococci trailed by Group B streptococcus
and S. aureus are responsible to cause LOS. Additionally,
in developing countries, the bacteria that cause EOS and
LOS sepsis are alike, particularly in the same hospital
setup9, with reported bacteria including Salmonella Spp,
Klebsiella Spp, E. coli, Pseudomonas aeruginosa,
coagulase negative staphylococci, S. aureus, S. pyogenes
and S. pneumonia10, 11.
The reported incidence of neonatal sepsis are 1-8
cases/thousand live births. Among these, meningitis have
been stated to occur in 1/6 neonatal sepsis patients12.
Increased morbidity, mortality, and prolong hospital stay
have been observed in neonates with neonatal sepsis than
neonates having no sepsis13. Due to infections,
approximately 1.6 million neonates die every year in
developing countries14. In Pakistan, approximately 7% of
the global neonatal deaths occur15, out of which 33%
deaths occur due to sepsis infection16. Currently, amongst
these, the most significant and common hospital acquired
pathogen is Escherichia coli, associated with many
problems such as septicemia, pneumonia, and meningitis
in the neonates.
The life of the neonate with neonatal sepsis can be saved
by early diagnosis, early treatment with antibiotics and
proper supportive care. The bacteria responsible for
neonatal sepsis have developed antimicrobial resistance
and therefore cannot be easily treated with the commonly
used antibiotics12. Hence, for the selection of appropriate
antibiotics, it is essential to know the causative agent for
neonatal sepsis which can be determined by the
antimicrobial susceptibility testing. Additionally,
geographical variations have also been reported
depending upon the bacteria causing sepsis and the
antibiotics used for their treatment at that specified
geographical location. Hence, continuous surveillance is
needed to observe the variation in the epidemiology of
microorganisms, sensitivity of antibiotics, and antibiotics
used to determine the emerging resistance13. Since, limited
data is available about the neonatal sepsis, causative
organisms for neonatal sepsis, and their antimicrobial
profile. Therefore, our study was directed to describe the
frequency and antibiotic susceptibility pattern of E. coli for
better management of neonatal sepsis.
M A T E R I A L S A N D M E T H O D S
This research study was cross sectional study, directed by
the Department of Neonatology, Bahawal Victoria Hospital,
Bahawalpur. The duration of this study was from
September 2019 to January 2021. The study was approved
by the Hospital Committee for Research and Ethics for
neonatal sepsis sample collection. A consent form was
also signed from the guardians of all included neonates.
Only the cases having positive blood culture were included
in our study while negative blood culture cases and
premature neonates were excluded from our study. Blood
samples (5ml) were taken from all suspected neonates and
sent to the diagnostic laboratory of the hospital for further
investigation. The reports of blood culture were divided into
positive and negative reports and only positive reports of
blood culture were included in this study. Standard blood
culture bottles were used for inoculation in the same
laboratory and all the samples were incubated for 5 days.
E.coli was isolated from all positive blood culture samples
by standard microbiological procedures. For identification
of the bacteria, Gram staining and biochemical tests were
done. After confirmation of E. coli, all isolates were
processed for antibiogram assay. Modified Kirby Bauer
method of disk diffusion was used for antibiogram assay.
Mueller-Hinton agar was used for disc diffusion method
and different antibiotic discs were used in antimicrobial
sensitivity testing that includes Ciprofloxacin (5µg),
Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 115
Amikacin (30µg), Ampicillin (10µg), Netilmycin (30µg),
Cefotaxime (30µg), Ceftazidime (30µg), Imipenem (10µg),
Piperacillin (100µg), Gatifloxacin (5µg), Gentamicin
(10µg), Tobramycin (10µg), Linezolid (30µg) and
Vancomycin (30µg). The inhibitory zones were measured
according to guidelines of Clinical and Laboratory
Standards Institute (CLSI)17. Data was entered and
analyzed by using SPSS version 23. Mean and standard
deviation were documented for continuous variables while
for categorical data, frequency, and percentages were
reported. All the data were presented in figures and tables.
R E S U L T S
During this one-year study, 150 sepsis positive blood
cultures were found. In 60% (n=90) cases Late Onset
Sepsis (LOS) was observed, while in 40% (n=60) Early
Onset Sepsis (EOS) was observed in our study (Table 1).
Out of 150 positive blood cultures, 53.33% (n=80) were
baby boys, while 46.66% (n=70) were baby girls (Fig. 1).
The prevalence of E.coli in these 150 positive blood
cultures was 70% (n=105) (Fig. 2).
On the basis of antibiotic susceptibility testing, ampicillin &
cefotaxime, currently used as empirical therapy at Bahawal
Victoria Hospital, Bahawalpur were observed resistant in
80% and 65.71% respectively, to most of the E.coli isolates
in our study. The most effective antibiotics observed in our
study were gatifloxacin, imipenem, and amikacin and these
were effective against E.coli as 100%, 80% and 80%,
respectively. While, the antibiotics to which E.coli shows
more resistance were vancomycin, gentamycin and
linezolid and resistance observed in these antibiotics was
100%, 80% and 80%, respectively. In other antibiotics like
piperacillin, ciprofloxacin, netilmycin, and tobramycin the
resistance observed was 40%, 60%, 65.71% and 31.42%,
respectively (Table 2).
Table 1. Distribution of Patients on the Basis of Types of Sepsis.
Type of Sepsis Number of Patients (n) Percentage (%)
Early Onset Sepsis 60 40%
Late Onset Sepsis 90 60%
Figure 1. Gender-wise distribution of neonates.
Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 116
Table 2. Antibiotic Susceptibility Pattern of E.coli in Neonatal Sepsis.
S. No. Antibiotics Used Concentrations Antibiotics Susceptibility E.coli Isolates
1 Ampicillin 10µg
S 21 (20)
R 84 (80)
2 Cefotaxime 30µg
S 36 (34.28)
R 69 (65.71)
3 Ceftazidime 30µg
S 42 (40)
R 63 (60)
4 Piperacillin 100µg
S 63 (60)
R 42 (40)
5 Ciprofloxacin 5µg
S 42 (40)
R 63 (60)
6 Gatifloxacin 5µg
S 105 (100)
R 00 (00)
7 Netilmycin 30µg
S 36 (34.28)
R 69 (65.71)
8 Tobramycin 10µg
S 72 (68.57)
R 33 (31.42)
9 Imipenam 10µg
S 94 (89.52)
R 11 (10.47)
10 Linezolid 30µg
S 21(20)
R 84 (80)
11 Vancomycin 30µg
S 00(00)
R 105 (100)
12 Gentamicin 10µg
S 21 (20)
R 84 (80)
13 Amikacin 30µg
S 94 (89.52)
R 11 (10.47)
Figure 2. Frequency of isolated E.coli in neonatal sepsis.
Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 117
D I S C U S S I O N
In spite of significant progress in hygienic conditions, new
antimicrobial agent introduction and new advanced
techniques for early diagnosis and treatment of neonatal
sepsis is still considered as a major cause of neonatal
mortality and morbidity13. Sepsis of neonate has high
prevalence around the globe and is a leading health issue
in neonates. According to previous studies, neonatal
sepsis incidence were 1-10/thousand normal live births,
while the incidence of neonatal sepsis in premature
neonates is 1/250 premature live births3.
The best technique for sepsis diagnosis is blood culture9.
During one year study, total 150 positive sepsis samples
from blood culture were found. In 60% (n = 90) cases, Late
Onset Sepsis (LOS) was observed, while in 40% (n = 60)
Early Onset Sepsis (EOS) was observed in our study.
These results are in contrast with the studies reported in
other underdeveloped countries like Iran, where the
LOS:EOS is 22.5%:77.5%, and Bangladesh with the ratio
as 29.3%:70%18, 19. Our findings are in accordance with the
previous reports from Saudi Arabia, where the ratio of
EOS:LOS was 39%:61%, Pakistan 42%:58% and in Libya
31%:69% was observed20-22.
Moreover, the prevalence of E.coli in these 150 positive
blood cultures was 70% (n = 105). This finding is consistent
with the early reports from underdeveloped countries
where they reported that the major sepsis causing bacteria
is gram-negative rods. Our results are in accordance with
the earlier research which reported 77.1% prevalence of
E.coli 23. Similarly, in our study, out of 150 positive blood
cultures, 53.33% (n = 80) were baby boys, while 46.66%
(n = 70) were baby girls. This finding is consistent with the
earlier study done in Dow University, Karachi where 1:0.9
male to female ratio was reported24.
Antibiotic susceptibility testing revealed that ampicillin and
cefotaxime, which are presently utilized as empirical
treatment at Bahawal Victoria Hospital in Bahawalpur,
were resistant to 80% and 65.71% of the E.coli isolates in
our study, respectively. Gatifloxacin, imipenem, and
amikacin were the most effective antibiotics in our study,
with 100%, 80%, and 80% efficacy against E.coli,
respectively. Vancomycin, gentamycin, and linezolid were
the antibiotics to which E.coli showed the most resistance,
with resistance rates of 100%, 80%, and 80%, respectively.
Resistance to other antibiotics such as piperacillin,
ciprofloxacin, netilmycin, and tobramycin was found to be
40%, 60%, 65.71 %, and 31.42 %, respectively. Earlier
study which was done by Jhoshi et al., in neonates
reported high resistance in gram negative bacteria to the
majority of penicillin’s and cephalosporin’s, which might be
due to beta-lactamase production25. In this study, all the
E.coli isolates show sensitivity to imipenem. This high
sensitivity of E. coli to imipenem might be due to lack of
selective pressure to rare prescription of this antibiotic.
These findings are in accordance with the study done by
Marzban et al. that high sensitivity of all gram-negative
bacteria to imipenem (95%), with resistance to imipenem
shown by only one E.coli strain26. A previous study done
by Anwer et al. reported the effectiveness of
aminoglycosides against gram negative bacteria and they
suggested the reservation of aminoglycosides only for
severe infections27.
C O N C L U S I O N
Our study concluded that E. coli is a major causative agent
for neonatal sepsis in neonates admitted at Bahawal
Victoria Hospital, Bahawalpur. The resistance pattern was
alarmingly increased which was observed in the currently
available antibiotics. Therefore, surveillance of this
emerging resistance is needed in currently used
antibiotics. Furthermore, in order to limit the resistant
strains of the pathogens, there is a need of effective
infections control program. Our study proposed amikacin in
the empirical antibiotic therapy, to decrease the morbidity
& mortality from neonatal sepsis. To control this
antimicrobial resistance, there should be judicial use of
antibiotics with perfect dosage and duration.
E T H I C A L A P P R O V A L
The study was approved by the Hospital Committee of
Bahawal Victoria Hospital, Bahawalpur, for Research and
Ethics of neonatal sepsis sample collection. A consent form
was also signed from the guardians of all included
neonates.
C O N F L I C T S O F I N T E R E S T
None.
Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 118
F U N D I N G S O U R C E
None.
A C K N O W L E D G M E N T S
None.
L I S T O F A B B R E V I A T I O N S
CLSI
EOS
Clinical and Laboratory Standards Institute
Early Onset Sepsis
LOS Late Onset Sepsis
R E F E R E N C E S
1. Aletayeb SMH, Khosravi AD, Dehdashtian M, Kompani
F, Aramesh MR. Identification of bacterial agents and
antimicrobial susceptibility of neonatal sepsis: A 54-
month study in a tertiary hospital. Afr J Microbiol Res.
2011; 5(5):528-31.
2. Bang AT, Reddy HM, Deshmukh MD, Baitule SB, Bang
RA. Neonatal and infant mortality in the ten years
(1993 to 2003) of the Gadchiroli field trial: Effect of
home-based neonatal care. J Perinatol. 2005;
25(1):92-107.
3. Ansari S, Nepal HP, Gautam R, Shrestha S, Neopane
P, Chapagain ML. Neonatal septicemia in Nepal:
Early-onset versus late-onset. Int J Pediatr. 2015; 1-8.
4. Khanal B, Shariff M, Deb M. Neonatal septicaemia: A
hospital based study in eastern nepal. J Nepal Med
Ass. 2004; 43(155)8-17.
5. Yadav NS, Sharma S, Chaudhary DK, Panthi P,
Pokhrel P, Shrestha A, et al. Bacteriological profile of
neonatal sepsis and antibiotic susceptibility pattern of
isolates admitted at Kanti Children’s Hospital,
Kathmandu, Nepal. BMC Res Notes. 2018; 11(1):1-6.
6. Macharashvili N, Kourbatova E, Butsashvili M,
Tsertsvadze T, McNutt L-A, Leonard MK. Etiology of
neonatal blood stream infections in Tbilisi, Republic of
Georgia. Int J Infect Dis. 2009; 13(4):499-505.
7. Zaidi AK, Thaver D, Ali SA, Khan TA. Pathogens
associated with sepsis in newborns and young infants
in developing countries. Ped Inf Dise J. 2009; 28(1):
10-18.
8. Sundaram V, Kumar P, Dutta S, Mukhopadhyay K,
Ray P, Gautam V, et al. Blood culture confirmed
bacterial sepsis in neonates in a North Indian tertiary
care center: Changes over the last decade. Jpn J Infect
Dis. 2009; 62(1):46-50.
9. Karthikeyan G, Premkumar K. Neonatal sepsis:
Staphylococcus aureus as the predominant pathogen.
Ind J Ped. 2001; 68(8):715-7.
10. Hyde TB, Hilger TM, Reingold A, Farley MM, O’Brien
KL, Schuchat A. Trends in incidence and antimicrobial
resistance of early-onset sepsis: Population-based
surveillance in San Francisco and Atlanta. Ped. 2002;
110(4):690-5.
11. Isaacs D. A ten year, multicentre study of coagulase
negative staphylococcal infections in Australasian
neonatal units. Archives of Disease in Childhood-Fetal
and Neonatal Edition. 2003; 88(2):89-93.
12. Hussain M, Aurakzai AA, Irshad M, Ullah I. Neonatal
sepsis. Prof Med J. 2018; 25(11):1683-8.
13. Aggarwal R, Sarkar N, Deorari AK, Paul VK. Sepsis in
the newborn. Ind J Ped. 2001; 68(12):1143-7.
14. Black RE, Morris SS, Bryce J. Where and why are 10
million children dying every year? Lancet. 2003;
361(9376):2226-34.
15. Jehan I, Harris H, Salat S, Zeb A, Mobeen N, Pasha
O, et al. Neonatal mortality, risk factors and causes: A
prospective population-based cohort study in urban
Pakistan. Bull World Health Organ. 2009; 87:130-8.
16. Jalil F, Lindblad B, Hanson L, Khan S, Yaqoob M,
Karlberg J. Early child health in Lahore, Pakistan: IX.
Perinatal events. Acta Paed. 1993; 82:95-107.
17. Jorgensen JH, Hindler JF, Reller LB, Weinstein MP.
New consensus guidelines from the Clinical and
Laboratory Standards Institute for antimicrobial
susceptibility testing of infrequently isolated or
fastidious bacteria. Clin Infect Dis. 2007; 44(2):280-6.
18. Movahedian A, Moniri R, Mosayebi Z. Bacterial culture
of neonatal sepsis. Iran J Public Health. 2006;
35(4):84-9.
19. Rasul CH, Hassan MA, Habibullah M. Neonatal sepsis
& use of antibiotic in a tertiary care hospital. Pak J Med
Sci. 2007;23(1):78-85.
20. Dawodu A, Al Umran K, Twum-Danso K. A case
control study of neonatal sepsis: Experience from
Saudi Arabia. J Trop Pediatr. 1997; 43(2):84-8.
21. Aftab R, Iqbal I. Bacteriological agents of neonatal
sepsis in NICU at Nishtar Hospital Multan. JCPSP.
2006; 16(3):216-9.
Frequency & Antibiotic Resistance of E. coli in Neonatal Sepsis Vol. 12 (2), Dec 2021
ISSN (Print): 2305 – 8722 ISSN (Online): 2521 – 8573
R A D S J . B i o l . R e s . A p p l . S c i . 119
22. Misallati A, El Bargathy S, Shembesh N. Blood-culture-
proven neonatal septicaemia: A review of 36 cases.
EMHJ. 2000; 6(2-3):483-6.
23. Aurangzeb B, Hameed A. Neonatal sepsis in hospital-
born babies: Bacterial isolates and antibiotic
susceptibility patterns. JCPSP. 2003; 13:629-32.
24. Rao MH, Khan S, Waseem T, Naeem S, Sabir S.
Sepsis in infants: Analysis of bacterial pathogens and
their antibiotic susceptibility, a study at Government
Tertiary Care Hospital, Karachi. JDUHS. 2013;
7(1):35-40.
25. Joshi S, Ghole V, Niphadkar K. Neonatal gram-
negative bacteremia. Ind J Ped. 2000; 67(1):27-32.
26. Asghart M, Samaee H, Hossein PM, Amir V. Neonatal
late-onset sepsis in a NICU: Analysis of causative
organisms and antimicrobial susceptibility Ali Asghar
children hospital from (2004/5-2007/5), Tehran, Iran.
Res J Biol Sci. 2010; 5(5):376-9.
27. Anwer SK, Mustafa S, Pariyani S, Ashraf S, Taufiq K.
Neonatal sepsis: An etiological study. JPMA. 2000;
50(3):91-3.