Clinical outcome and risk factors of neonatal sepsis among neonates in Felege Hiwot referral Hospital, Bahir Dar, Amhara Regional State, North West Ethiopia 2016: a retrospective chart review

Neonatal sepsis is a systemic infection occurring in infants within 28 days of life and is a major cause of morbidity and mortality in newborns [1]. According to the international pediatric consensus conference of 2001, neonatal sepsis was defined as systemic inflammatory response syndrome in the presence of or as a result of suspected or proven infection with or without accompanying bacteremia, documented by a positive blood culture in the first 28 days of life [2].

Sepsis encompasses various systemic infections of the new born such as: septicemia, meningitis, pneumonia, arthritis, osteomyelitis and urinary tract infections [3]. Neonatal sepsis is caused by both gram-positive and gram negative bacteria’s [4, 5].

Neonatal sepsis is classified into two major categories based on the time of onset: early-onset neonatal sepsis (EONS) and late onset neonatal sepsis (LONS). Early-onset neonatal sepsis appears within the first seven days of life and most cases appear within 24 h of birth. While late onset neonatal sepsis occurs after 8 days of infants life and is mostly acquired after delivery [5, 6].

Sepsis is diagnosed by: a complete white blood cell count with differential, blood culture, urine cultures, and a lumbar puncture for cell count and culture. To clear the diagnosis of early onset sepsis factors that predispose the neonate for sepsis such as maternal infection and prolonged rupture of membranes, and prematurity are also considered [1, 6].

Signs and symptoms of infection in neonates are subtle and non-specific, may present with one or more of the following: hypothermia or fever, lethargy, poor cry, refusal to suck, poor perfusion, prolonged capillary refill time, hypotonia, absent neonatal reflexes, bulging fontanel, brady/tachycardia, respiratory distress, apnea and gasping respiration, hypo/hyperglycemia, and metabolic acidosis [3, 6, 7].

Risk factors for early onset of sepsis includes premature rupture of membrane (PROM), fever, chorioamnionitis, repeated vaginal examination, meconium stained amniotic fluid, dietary intake of contaminated foods, cervical cerclage, place of birth, prematurity, low birth weight, complicated or instrument-assisted delivery, and low appearance pulse grimace activity respiration (APGAR) scores. Late onset of sepsis acquiring nosocomial infections and invasive procedures during hospital admission [1, 6, 8].

Antimicrobials used to treat sepsis are combinations and in most units are penicillin (Benzyl penicillin, Ampicillin, or Cloxacillin) together with an aminoglycoside, most commonly Gentamicin and is largely preventable by timely recognition, rational antimicrobial therapy and aggressive supportive care [3, 9].

Globally, sepsis is one of the major causes of morbidity and mortality among neonates [4], according to WHO sepsis caused approximately 12% of the 2.9 million neonatal deaths in 2012 [10]. Out these deaths 99% occur in developing countries [11].

In Africa sepsis accounts 28% neonatal deaths [12] and infectious causes accounts 68 deaths per 1000 live births [13]. In Ethiopia from prenatal mortalities sepsis covers 5% [14]. In Debrezeyt, Ethiopia the overall poor outcomes of NS were 26% including deaths [8].

Therefore the purpose of this study was to assess clinical outcomes and risk factors of neonatal sepsis in Felege Hiwot referral hospital, Bahir Dar, North West Ethiopia.

Neonatal sepsis is a systemic infection occurring in infants at less than 28 days of life and is an important cause of morbidity and mortality of newborns [1]. It encompasses various systemic infections of the new born such as septicemia, meningitis, pneumonia, arthritis, osteomyelitis and urinary tract infections [3].

Risk factors for early onset of sepsis includes: premature rupture of membrane, fever, chorioamnionitis, repeated vaginal examination, meconium stained amniotic fluid, dietary intake of contaminated foods, cervical cerclage, place of birth, prematurity, low birth weight, complicated or instrument assisted delivery, and low appearance pulse grimace activity respiration (APGAR) scores. Late onset of sepsis acquiring nosocomial infections and invasive procedures during hospital admission [1, 6, 8].

In this study 84% of neonates had good outcome after treatment. This result comparable with a study done in Debrezeyt, Ethiopia favorable outcome of neonatal sepsis were 74% [8] and in Jimma neonatal death due to infections was 34.3% [15], in other studies done in Ethiopia mortalities due to sepsis accounts 5% a hospital based data [14], in Uganda death rates associated with sepsis was 18.1% [16], in Sudan neonatal mortality due to sepsis was found to be 14.5% [13], Egypt mortality rate of neonatal sepsis were 51% for early onset sepsis and 42.9% for late onset sepsis [4], Iran neonatal sepsis was estimated at 27.4% [17], and Latin America: Brazil, Colombia and Mexico mortality rate of neonatal sepsis were 56, 36 and 28% respectively [18].

In this study respiratory distress syndrome was identified as the determinant factor for poor clinical outcome neonatal sepsis. Neonates with history of respiratory distress syndrome were 74.2% more likely to develop poor neonatal outcome. This result comparable with studies done Uganda [16] in which tachypnea (AOR 1.07: 0.65, 1.77) was the determinant factor for poor outcome of sepsis, and in Sudan [19] where tachypnea results 69.4% for poor outcome of sepsis. This was due to health workers ignorance the syndromes, poor early detection of signs and due to the mothers delay to come in health institution.

Meconium aspiration syndrome history was significantly associated with clinical outcome of sepsis. Neonates with meconium aspiration syndrome history were 80.2% more likely to develop poor outcome. Which is similar with a study in Uganda [16] where neonates with meconium aspiration syndrome were 2.5 times more likely to develop poor outcome than neonates without history of meconium aspiration. This is showed that after meconium aspiration strict follow up is needed. This may be due to health workers poor neonatal performance skill and ignorance of meconium aspiration signs.

In this study the favorable outcomes of neonatal sepsis was 189 (84%). The determinant factors for poor outcome of neonatal sepsis were respiratory distress syndromes and meconium aspiration syndrome. Recommendations to improve neonatal outcome are: performing essential newborn care for all newborns and arranging appropriate follow up until the end of neonatal period and early detection and management of neonatal infections or problems.