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Neonatal Sepsis Burden


Neonatal sepsis burden 

In the last week of January 2019 a paper ‘Neonatal Sepsis in South Asia: huge burden and spiraling antimicrobial resistance’, in the British Medical Journal has been published by  Doctors of AIIMS . 

It calls for urgent action to improve quality of care at birth and implement it in health facilities in south Asia to reduce neonatal deaths from sepsis.


What is Neonatal Sepsis?
Neonatal sepsis, a system infection in the first 28 days of life, encompasses bloodstream infections, meningitis and pneumonia. It is an invasive infection usually bacterial. It is the third most common cause of deaths among neonates, accounting for 225,000 deaths globally every year.


Neonatal infections are unique in several ways
1 – Infectious agents can be transmitted from the mother to the fetus or newborn infant by diverse modes.

2 – Newborn infants are less capable of responding to infection because of 1 and more immunologic deficiency.

3 – Coexisting conditions often complicate the diagnosis and management of neonatal infections.

4 – The clinical manifestations of newborn infections vary and include subclinical infection, mild to severe manifestations of focal or systemic infection, and rarely, congenital syndromes resulting from in uteri infection.

5 – A wide variety of etiologic agents infect the newborn, including bacteria, viruses, fungi, protozoa, and mycoplasma.



Why the high number of cases of neonatal in south Asia?

South Asia and Sub-Saharan Africa have the highest burden of neonatal sepsis in the world. Of the total sepsis related neonatal deaths in 2013, 38.9% occurred in south Asia. Poverty, low coverage of effective intervention, including facility births and grow inequalities in delivery of healthcare contribute to this situation.

Findings in the research paper

India has a high instance of neonatal sepsis within the first month of birth than anywhere else in the world.
Several of those infected die due to the failure of antibiotics against lethal bugs. 16 per thousand live births in India are infected with confirmed neonatal sepsis and one-third of them die due to unavailability of drugs to fight the infections.

About 62% infections in south Asia occurs within the first 72 hours when compared to an incidence rate 9.8 per thousand live births which are 10-fold higher than in the US.

The cause of worry is the babies acquire these infections from mothers who have been subjected to unhygienic practices in the labour rooms and neonatal intensive units of the hospitals. 
The high instance of neonatal sepsis is attributed to antibiotic overuse. The research paper also notes that poor lab support couples with the difficulty in obtaining adequate blood from babies result difficulty in confirming the presence of infection, as a result of which they fall off the radar.

The study also highlights that south Asia has majority occurrence of gram-negative organisms such as klebsiella, e.coli and Acinetobacter isolated from hospital settings, which are known to cause more deaths than gram-positive organisms found in Western countries.

Drugs of last resort crbapenem and colistin are also failing to deliver due to the rise in resistant bugs.

The study notes that since the choice of drugs for treating babies has increasingly narrowed over the last ten years, it is posing challenge for health care professionals.

Global commitment

The global commitment to reduce child mortality was further augmented in 2000 with the declaration of the millennium development goals. Combined efforts by countries, United Nations organizations, donors, civil society, private sector organization and child health researchers have led to remarkable success in reducing child mortality worldwide. 
The number of under – 5 deaths has been reduced from 12.7  million in 1990 to 6.3 million in 2013, which translates to 17,000 fewer deaths per day in 2013 compared with 1990. The rate of reduction has accelerated over time: 4.0% per year between 2005 and 2013 compared with 1.2% between 1990.

Conclusion

Neonatal sepsis is a major public health problem especially in developing countries. The susceptibility of this naïve population, lack of consensus in the definitions and pathogen variability between different regions isolated the development of clinical trials and practice guidelines increase the risk. 
Physicians taking care of these patients face multiple questions when making diagnosis and treatment decisions. Most of them feel pressured to treat every newborn with suspicion of sepsis aggressively. As a result, many newborns receive prolonged antibiotic therapies without considering the adverse effects of such regimens. 
The management of neonatal sepsis in developing countries is aggravated by increased levels of antibiotic resistance, shortages of medical personnel and high numbers of home-births. 

Some developing countries have started to implement tertiary care units and are now facing challenges of developed countries as well. Given the high incidence and high morbidity and mortality of sepsis in preterm infants, efforts to reduce the rates of infection in this vulnerable population are one the most important intervention in neonatal care. 
Among these preventive interventions, early and exclusive breastfeeding is one of the most important interventions to reduce neonatal sepsis and over mortality.