Original article 31

Multidrug-resistant organisms in neonatal sepsis in two tertiary

neonatal ICUs, Egypt
Hesham A. Awada, Maha H. Mohameda, Nabil F. Badranc, Manal Mohsenb and
Al-Sayed A. Abd-Elrhmana

Departments of aNeonatology, bClinical Pathology, Background

Ain Shams University and cDepartment of
Neonatology, Al-Azhar University, Cairo, Egypt
Correspondence to Maha H. Mohamed, MD, 4/6
Elesawy Street, Elnozha Elgadida, Cairo 16088, Egypt
Tel: + 20 100 528 7175; fax: + 20 226 201764;
e-mails: dr_mhassan21@med.asu.edu.eg,
dr_mhassan21@yahoo.com
Received 27 June 2015
Accepted 22 September 2015
Journal of the Egyptian Public Health
Association 2016, 91:31–38
Neonatal sepsis remains a serious problem in any neonatal intensive care unit (NICU).
Bacterial organisms have developed increased resistance to commonly used
antibiotics. Because not enough data are available from Egypt, the aim of the present
study was to determine the causative bacteria and the level of their resistance to
commonly used antibiotics in tertiary NICUs in Cairo, Egypt.
Materials and methods
A 3.5-year retrospective study was carried out at NICUs of the Children’s Hospital of
Ain Shams University and that of El-Hussein Hospital, Al-Azhar University, Egypt.
Records of neonates were reviewed. All neonates with culture-proven sepsis were
included in the study.
Results
Almost one-third of the admitted neonates (33.4%) were diagnosed as having
neonatal sepsis, 32.25% of them culture-proven. Early/late onset sepsis was found in
35.4 and 64.6%, respectively. Gram-negative/gram-positive bacteria was found in 68
to 25.6%. Fungal infection was detected in 9% of the isolates. Escherichia coli was
the main pathogen isolated in both early-onset sepsis (41.2%) and late-onset sepsis
(24.5%). Overall, 77% of the isolates were multidrug-resistant (60% of gram-positive
bacteria and 83.4% of gram-negative bacteria). Nearly 80% (79%) of mortality was
caused by multidrug-resistant organisms. Gram-positive and gram-negative bacteria
showed high resistance against commonly used antibiotics such as ampicillin,
amoxicillin, cefotaxime, ceftriaxone, and gentamicin.
Conclusion and recommendations
There is an alarming increase in antibiotic resistance to the commonly used antibiotics.
Continuous surveillance for antibiotic susceptibility is needed to ensure proper
empirical therapy. Improvement of infection control practices, avoidance of irrational
use of antibiotics, and revision of the protocols are mandatory in the prevention of
neonatal sepsis.

Keywords:
antibiotic resistance, developing countries, gram-negative organisms, gram-positive,
neonatal sepsis

J Egypt Public Health Assoc 91:31–38

& 2016 Egyptian Public Health Association
0013-2446

days of life and is acquired after delivery from the

Introduction
Neonatal sepsis remains a serious problem in neonatal
intensive care units (NICUs) around the world, resulting
in significant morbidity and mortality [1]. Early-onset
sepsis (EOS) is associated with the acquisition of
microorganisms from the mother before or during
delivery. Transplacental infection or an ascending infec-
tion from the cervix may be caused by organisms that
colonize the mother’s genitor-urinary tract; the neonate
acquires the microorganisms as it passes through the
colonized birth canal at delivery. Group B Streptococcus
(GBS), Escherichia coli (E. coli), and Coagulase-negative
Staphylococcus (CONS) are the most common pathogen
causing EOS [2]. Late-onset sepsis (LOS) occurs at 4–90
0013-2446 & 2016 Egyptian Public Health Association
caregiving environment (nosocomial or community
sources). CONS, Staphylococcus aureus (S. aureus), E. coli,
Klebsiella spp., Pseudomonas spp., and Candida spp. are the
main pathogens causing LOS [3].
The overall incidence of neonatal bacterial infections is
between one and eight infants per 1000 live births, and
between 160 and 300 per 1000 very low birth-weight
infants [4]. Epidemiological data from developing coun-
tries show differences in the incidence, risk factors,
pattern, and antimicrobial sensitivities of pathogens and
mortality compared with the developed countries. In
Europe and North America, GBS and E. coli contribute to
70–75% of cases of neonatal septicemia [5]. In most of the
DOI: 10.1097/01.EPX.0000482038.76692.3

Copyright r 2016 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
32 Journal of the Egyptian Public Health Association
developing countries, gram-negative organisms remain the
major cause of neonatal sepsis, particularly of EOS [6].
Bacterial organisms causing neonatal sepsis have devel-
oped increased resistance to commonly used antibiotics,
making its management a challenge for both public and
private health sectors [7].
The epidemiology of neonatal sepsis and antibiotic
resistance patterns may be used to develop guidelines
for the management of neonatal sepsis, including the
choice of empiric antibiotic therapy. We aimed in this
study to evaluate the bacteriological profile, risk factors,
and the outcome of neonatal sepsis, and to examine the
antibiotic sensitivity and resistance patterns of the
isolates in two NICUs of the university hospitals in
Cairo, Egypt.
Materials and methods
This retrospective study, starting from July 2009 to
December 2012, was conducted on patients diagnosed
with neonatal sepsis and admitted to the NICU of the
Children’s Hospital at Ain Shams University, and that of
El-Hussein Hospital at Al-Azhar University, Cairo, Egypt.
This study was approved by the Ethics Committee of
Pediatrics Department, Ain Shams University.
Patients were included in the study if they had clinical
signs of sepsis, positive C-reactive protein (410 mg/dl),
abnormal blood count (total leukocytes counto5000 or
>21 000/mm3, absolute neutrophil counto1500/mm3,
immature to total neutrophil ratio40.2, and low platelet
counto100 000/mm3) [8], and positive culture and
sensitivity.
NICU of the Children’s Hospital at Ain Shams University
is an outborn unit providing level III neonatal care, with
10 incubators and four ventilators. NICU of the El-
Hussein Hospital at Al-Azhar University is an inborn unit
providing level III neonatal care, with 16 incubators and
five ventilators. Neonates were treated by the attending
neonatologists according to their protocols. In both
NICUs, when neonatal sepsis was considered,
ampicillin–sulbactam and amikacin were usually started
till results of cultures and sensitivity were available.
All the records of the study population were carefully
reviewed and data were recorded in data extraction
sheets, including gestational age, birth weight, sex, mode
of delivery, postnatal age at presentation, risk factors for
infections as prematurity, premature rupture of mem-
branes, maternal fever, maternal urinary tract infection,
chorioamnionitis, maternal intake of antibiotics, previous
NICU admission, total parenteral nutrition, exchange
transfusion, use of mechanical ventilation, surgery, dura-
tion of NICU stay, and prognosis. Interventions made to
the patients, including umbilical catheter, central line,
chest tube insertion, and laboratory data, such as
complete blood picture and C-reactive protein, were
recorded.
Copyright r 2016 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Results of cultures from different sites were recorded. In
both NICUs, culturing was carried out for the patients
from different sites, including blood, endotracheal
aspirate, wound swab, urine, and cerebrospinal fluid. In
both NICUs, lumber puncture was not carried out till the
stabilization of the patient was not achieved and after
correction of his bleeding tendency. Blood cultures were
routinely withdrawn for any patient with suspected or
with any risk factor for sepsis. For all patients, under
complete aseptic precautions, 1 to 2 ml of blood were
collected from a peripheral vein for blood cultures using
BACTEC PEDs PLUS/F culture vials (soybean-casein
digest broth with resins) and incubated in BACTEC
(9050) blood culture instrument (Beckton-Dickenson,
New Jersey, USA). Enriched and selective media,
including blood, MacConkey, and chocolate agar plates,
were inoculated, incubated at 371C, and examined for
growth at 24–48 h. Isolates, if any, were identified by
using the standard microbiologic techniques. Bacterial
isolates were identified and antimicrobial susceptibility
tests were carried out using the Kirbey–Bauer disc
diffusion method.
EOS was considered when clinical and laboratory
evidence of sepsis were obtained within 72 h of birth;
LOS was considered when clinical and laboratory
evidence of sepsis were obtained after 72 h of birth. An
isolate was defined as multidrug-resistant if it was found
to be resistant to representative antibiotics of at least two
classes of antimicrobial agents [9].
Statistical analysis
Data were analyzed using the statistical package for social
science, version 16 (SPSS Inc., Chicago, Illinois, USA).
Quantitative data were described using mean ± SD;
qualitative data were described as numbers and percen-
tages. The w2-test was used for the comparison of
qualitative variables. P value less than 0.05 was con-
sidered significant, and P values less than 0.01 and 0.001
were considered highly significant [10].
Results
A total of 704 patients were admitted to the NICU of the
Children’s Hospital at Ain Shams University during the
study period, out of which 232 (232/704 or 32%) were
clinically diagnosed with neonatal sepsis. In 114 patients
(114/232 or 49.2%), 131 cultures showed sepsis, whereas
118 (118/232 or 50.8%) cultures did not show any
bacterial growth. Eight patients of the 114 (7%) grew
multiple organisms in their blood cultures, and thus these
patients were not included as their cultures may have
been contaminated during sample withdrawal [11]. Seven
patients (6.6%) had different organisms isolated on
repeating the culture a few days later; these organisms
were included in the study. Therefore, from this NICU,
106 patients with 123 positive cultures were included in
the study.
A total of 1533 patients were admitted to the NICU of
Hussein Hospital at Al-Azhar University during the study
 Multidrug-resistance in neonatal sepsis Awad et al. 33

period, out of which 512 patients (512/1533 or 33.4%) had LOS, of which 68% were healthcare-associated
were clinically diagnosed with neonatal sepsis (512/1533 infections.
or 33.4%). In total, 134 patients (134/512 or 26.2%) had
culture-proven sepsis (134/512 or 26.2%), whereas 378 Risk factors for sepsis are shown in Table 2. Prematurity
patients (378/512 or 73.8%) did not show any bacterial was the most common risk factor in both EOS and LOS.
growth in their cultures (378/512 or 73.8%). Overall, 35% of the neonates with LOS were mechani-
cally ventilated. Maternal intrapartum intake of anti-
Over the duration of the study (3.5 years), 33.3% of the biotics, in response to the presence of risk factors or
total admissions to both NICUs (744/2237) were evidence of infection, was found in 39.6% of the patients
clinically diagnosed as neonatal sepsis; overall, 32.25% (95/240) (75% of those with EOS, 19% of those with
of them (240/744) had culture-proven sepsis. Table 1 LOS), in response to the presence of risk factor or
shows demographic, clinical, and laboratory characteris- evidence of infection. Amoxicillin–clavulanate was the
tics of neonates with culture-proven sepsis. In total, 85 one given. Figure 1 shows the sites of samples used for
neonates (35.4%) had EOS, and 155 neonates (64.6%) cultures. Overall, 77.4% were from blood culture.
Gram-negative infection was predominant in both EOS
and LOS (84.7 and 66.5%, respectively). Gram-positive
Table 1. Demographic, clinical and laboratory characteristics of
neonates with culture-proven sepsis in two university neonatal organisms were isolated from 20% of the EOS and 31.6%
ICUs, Cairo, Egypt (N = 240) from LOS sepsis. E. coli was the main pathogen isolated in
n (%) both EOS (41.2%) and LOS (24.5%). GBS was the most
common gram-positive organism associated with EOS
Gestational age (10.5%), whereas CONS was the most common gram-
Full term 135 (56.2)
Preterm 105 (43.8) positive organism encountered in LOS (11.6%). Fungal
Body weight (kg) 2.667 ± 0.535a infection was seen in 9% of LOS (Table 3). Frequency of
Mode of delivery hematological abnormalities and need for inotropic drugs
VD 127 (52.9)
LSCS 113 (47.1) among isolated organisms are shown in Table 4. Coagulo-
Sex pathy were significantly more frequent in gram-negative
Male 124 (51.7) sepsis.
Female 116 (48.3)
Postnatal age (days)b 8.435 ± 6.725a
Surgery and procedures
Overall, 60% of the gram-positive bacteria and 83.4% of
No 174 (72.5) the gram-negative bacteria were multidrug resistant
Yes 66 (27.5) (n = 40, and 146 isolates, respectively; in total 186/240
Early-onset sepsisc 85 (35.4)
Late-onset sepsisd 155 (64.6)
or 77%). Total mortality over 3.5 years was 91 (37.5%),
Duration of admission (days) 16.67 ± 13.45a out of which 79.1% was caused by multidrug-resistant
C-reactive protein (mg/dl) 46.83 ± 34.34a organisms, 16.5% were caused by single drug-resistant
TLC (  109/l) 9.467 ± 4.4535a
ANC (  109/l) 4.202 ± 1.7542a
organisms, and 3.3% were caused by fungal infection
PLT (  109/l) 89.96 ± 77.972a (Table 5).
Outcome
Recovery 149 (62.1) Overall, 90% of the isolated E. coli strains and 78.9% of
Death 91 (37.9) the isolated S. aureus were multidrug-resistant organisms;
ANC, absolute neutrophilic count; LSCS, lower segment cesarean 50% of the multidrug-resistant Pseudomonas spp. and
section; PLT, platelet count; TLC, total leukocytic count; VD, vaginal 36.4% multidrug-resistant methicillin resistant Staphylo-
delivery.
a
Mean ± SD. coccus aureus (MRSA) were associated with mortality
b
Mean postnatal age in early-onset sepsis: 1.387 ± 0.681 days, mean (Table 5). The mean duration of hospital stay due to
postnatal age in late-onset sepsis: 13.13 ± 4.36. infection by multidrug-resistant organisms (20.35 ± 15.73
c
Early onset sepsis was seen in 11.3% of patients of Ain Shams
neonatal ICU and in 54.5% of patients of Al-Azhar neonatal ICU. days) was comparable to that due to infection by single-
d
Late onset sepsis was seen in 88.7% of patients of Ain Shams drug resistant organisms (16.39 ± 9.034 days)
neonatal ICU and in 45.5% of patients of Al-Azhar neonatal ICU. (P = 0.487).

Table 2. Factors associated with increased risk to neonatal sepsis

Risk factor Total (N = 240) Early onset sepsis (N = 85) Late onset sepsis (N = 155) w2 P

Prematurity 107 58 (68.2) 49 (31.6) 29.8 o0.0001**

Premature rupture of membranes 82 57 (67) 25 (16.1) 63.31 o0.0001**
Low birth weight 102 55 (64.7) 47 (30.3) 26.56 o0.0001**
Assisted ventilation 84 29 (34.1) 55 (35.5) 0.045 0.832
Maternal urinary tract infection 33 20 (23.5) 13 (8.41) 10.62 0.001**
Previous neonatal ICU admission 8 0 (0) 8 (5.1) 4.54 0.033*
Total parenteral nutrition 55 2 (2.3) 53 (34.2) 31.51 o0.0001**
Exchange transfusion 11 4 (4.7) 7 (4.5) 0.005 0.943
Catheter insertiona 31 0 (0) 31 (20) 19.94 o0.0001**
Surgery 59 10 (11.7) 49 (31.6) 11.67 0.0006**
a
Catheters insertion; central venous line, and/or intercostal tube, and/or umbilical catheter and/or peritoneal catheter.
*Statistically significant at Po0.05.
**Statistically highly significant at Po0.01.

Copyright r 2016 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
34 Journal of the Egyptian Public Health Association

Figure 1. Table 3. Distribution of the organisms according to the onset of

neonatal sepsis
3.1% 3.1% 2.3% 1.6% Early
3.5%
Blood onset Late onset
4.3%
ETT Total sepsis sepsis
6.2% (% in all (N = 85) (N = 155)
U Catheter isolates) [n (%)] [n (%)] w2 P
Wound
Gram negative
Drain E. coli 73 (28.4) 35 (41.2) 38 (24.5) 7.199 0.007**
77.4% Urine Klebsiella 46 (17.8) 17 (20) 29 (18.7) 0.059 0.808
pneumonia
Sputum
Enterobacter 24 (9.3) 14 (16.4) 10 (6.5) 6.123 0.013*
spp.
Types of samples used for cultures. ETT, endotracheal tube. Acinetobacter 18 (7) 2 (2.4) 16 (10.3) 5.026 0.024*
baumannii
Pseudomonas 14 (5.4) 4 (4.7) 10 (6.5) 0.305 0.581
aeruginosa
All isolated MRSA, CONS, Enterococcus spp., 93.4% of Total 175 (68) 72 (84.7) 103 (66.5) 9.263 0.002**
GBS, and 50% of S. aureus were sensitive to glycopeptide Gram positive
CONS 19 (7.4) 1 (1.2) 18 (11.6) 8.202 0.004**
group (vancomycin and teicoplanin). All enterococci, 68.4 S. aureus 19 (7.4) 6 (7) 13 (8.3) 0.133 0.715
and 57.9% of CONS, 33.3 and 50% of S. aureus, 18 and GBS 15 (5.8) 9 (10.5) 6 (3.8) 4.227 0.039*
45.5% of MRSA, and 13.3 and 53.3% of GBS were MRSA 11 (4.3) 0 (0) 11 (7) 6.322 0.011*
Enterococcus 1 (0.3) 1 (1.2) 0 (0) 1.831 0.176
resistant to aminoglycosides (amikacin and gentamycin) faecalis
and penicillins (ampicillin, ampicillin–sulbactam, amox- Diphtheroid 1 (0.3) 0 (0) 1 (0.6) 0.551 0.458
icillin-clavulonate), respectively. Overall, 63% of E. coli, spp.
Total 66 (25.6) 17 (20) 49 (31.6) 3.713 0.053
80% of Klebsiella spp., 38.9% of Acinetobacter spp., 37.5% of Fungal
Enterobacter spp., and 42.8% of Pseudomonas spp. were Candida spp. 16 (6.2) 2 (2.4) 14 (9) 3.936 0.047*
sensitive to the carbapenem group (imipenam and Total 257 91 166
meropenem). Almost half of the E. coli (47.9%), 87 and CONS, coagulase negative Staphylococcus; GBS, group B Strepto-
65.2% of Klebsiella spp., 88.9 and 94.4% of Acinetobacter coccus; MRSA, methicillin resistant Staphylococcus aureus; S. aureus,
spp., 50 and 41.7% of Enterobacter spp., and 71.4 and Staphylococcus aureus.
*Statistically significant at Po0.05.
64.3% of Pseudomonas spp. were resistant to third- **Statistically highly significant at Po0.01.
generation cephalosporins (cefotaxime, cefoperazone,
ceftazidime, and ceftriaxone) and penicillins, respectively In our study, gram-negative and gram-positive organisms
(Tables 6 and 7). represented 68 and 25.6%, respectively, of all isolates.
Gram-negative organisms were predominant in both EOS
and LOS. E. coli was the main pathogen isolated from all
cultures, in both EOS and LOS, followed by Klebsiella spp.
Discussion and CONS in the isolates in this study. In agreement with
Improvement in outcome and successful treatment of our results, many studies reported the predominance of
neonatal sepsis depends on early initiation of appropriate gram-negative organisms in different areas of the devel-
antibiotic therapy. The pattern of causative organisms has oping world [18–20]. In these studies, either E. coli or
been constantly changing and the frequent emergence of Klebsiella spp. represented the main isolated pathogen. In
resistant bacteria compounds the problem further [8]. Egypt, gram-negative organisms were the most common
In the current study, during the period of 3.5 years, 33.3% bacteria isolated in other tertiary NICUs (86% and 65%,
of the admissions were diagnosed as having neonatal respectively), whereas Klebsiella spp. was the most
sepsis, out of which 33.25% of them had culture-proven common isolated pathogen [21,22] and multidrug-resis-
sepsis. This is comparable to the findings obtained in tant Klebsiella was the main pathogen isolated in
previous studies in developing countries, with incidence nosocomial infection [23]. Similarly, E. coli was the most
of neonatal sepsis ranging from 34.7 to 73.9% [12–15]. common pathogen followed by Klebsiella spp. in studies
Increased rates of neonatal infection in hospitalized from Pakistan [24], India [12], and Iraq [25]. Klebsiella
infants in developing countries were reported to be spp. was the predominant pathogen in studies from
3–20 times higher than those in developed countries. India [20] and Bangladesh [26]. Predominance of gram-
The lower incidence in developed countries reflects negative organisms may be due to the indiscriminate and
higher standards of the health care, with lesser exposure inappropriate use of antibiotics, lack of hygienic practices
of neonates to infections [12]. The incidence of EOS was at the place of delivery, poor cord care, and unhygienic
35.4%, whereas the incidence of LOS was 64.6% in our newborn care practices [27]. Moreover, since the
study. This can be partly attributed to the fact that NICU introduction of GBS intrapartum prophylaxis, several
of the Children’s Hospital at Ain Shams University is an institutions in the United States have reported a shifted
outborn tertiary unit, admitting referred patients from distribution of pathogenic agents responsible for neonatal
other hospitals, many after 3 days of age; overall, 88.7% of sepsis toward a predominance of gram-negative rods,
its patients had LOS. In addition, an increased LOS has specifically E. coli [28]. On the contrary, others studies
been reported in developing as well as developed reported a predominance of gram-positive organ-
countries [16,17]. isms [17,29–31]. This could be because of the fact that

Copyright r 2016 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
 Multidrug-resistance in neonatal sepsis Awad et al. 35

Table 4. Frequency of hematological abnormalities and need for inotropes among isolated organisms
Gram-negative (N = 175) Gram-positive (N = 66) Fungal (N = 16) w2 P
Neutropenia 26 (16.5) 9 (15.7) 2 (12.5) 0.601 0.74
Thrombocytopenia 92 (55.1) 33 (57.9) 11 (68.7) 1.703 0.426
Coagulopathy 43 (25) 6 (10.5) 2 (12.5) 7.7 0.021*
Need for inotropes 43 (25) 10 (17.5) 4 (25) 1.667 0.434
Data are expressed as n (%).
*Statistically significant at Po0.05.

Table 5. Distribution of multidrug-resistant and single drug-resistant cultures over the study period 3.5 years (July 2009 to
December 2012)
Number of
multidrug- Mortality from Recovery from
Total resistant Mortality from Recovery from single drug- single drug-
mortality organisms multidrug-resistant multidrug-resistant resistant organisms resistant organisms
Organism Total [n (%)] [n (%)] organisms [n (%)] organisms [n (%)] [n (%)] [n (%)] P

E. coli 73 28 (43.8) 66 (90) 27 (37) 39 (53.4) 1 (1.4) 6 (8.2) o0.0001**

Klebsiella 46 24 (52.2) 38 (82.6) 19 (41.3) 19 (41.3) 5 (10.9) 3 (6.5) o0.0001**
pneumonia
Acinetobacter 18 5 (27.8) 15 (83.3) 5 (27.8) 10 (55.5) 0 (0) 3 (16.7) 0.015*
baumannii
Enterobacter 24 6 (25) 17 (70.8) 3 (12.5) 14 (58.3) 3 (12.5) 2 (8.3) 1
spp.
Pseudomonas 14 9 (64.3) 10 (71.4) 7 (50) 3 (21.4) 2 (14.3) 2 (14.3) 0.043*
aeruginosa
Total 175 72 (41.1) 146 (83.4) 61 (34.9) 85 (48.6) 11 (6.3) 16 (9.1) o0.0001**
CONS 19 5 (26.3) 11 (57.8) 4 (21.1) 7 (36.8) 1 (5.2) 7 (36.8) 0.149
MRSA 11 5 (45.4) 7 (63.6) 4 (36.4) 3 (27.3) 1 (9.0) 3 (27.3) 0.126
GBS 15 2 (13.3) 5 (33.3) 0 (0) 5 (33) 2 (13.3) 8 (53.3) 0.143
S. aureus 19 4 (21.1) 15 (78.9) 3 (15.8) 12 (63.2) 1 (5.2) 3 (15.8) 0.291
Enterococcus 1 0 (0) 1 (100) 0 (0) 1 (100) 0 (0) 0 (0)
faecalis
Diphtheroid 1 0 (0) 1 (100) 0 (0) 1 (100) 0 (0) 0 (0)
spp.
Total 66 16 (24.2) 40 (60.6) 11 (16.8) 29 (43.9) 5 (7.5) 21 (31.8) 0.109
Fungal 16 3 (18.7)
CONS, coagulase negative Staphylococcus, E. coli, Escherichia coli; GBS, group B Streptococcus; MRSA, methicillin resistant Staphylococcus
aureus; S. aureus, Staphylococcus aureus.
Comparison between mortality from multidrug-resistant organisms versus mortality from single drug-resistant organisms using w2-test.
*Statistically significant at Po0.05.
**Statistically highly significant at Po0.01.

the spectrum of different bacteria responsible for
neonatal sepsis varies between countries and between
places in the same country [32].
In the current study, CONS was the most common gram-
positive organism found in LOS (11.6%), and at the same
time the use of intravenous catheters was encountered
among 20% of the neonates with LOS. CONS was
increasingly seen as a cause of nosocomial or LOS,
especially in the premature infants. Its prevalence was
likely related to several intrinsic properties of the
organism that allow it to readily adhere to the plastic
mediums found in intravascular catheters and intraven-
tricular shunts leading to the formation of biofilms, which
provides a barrier to host defense as well as to antibiotic
action [33].
In this study, fungal infection represented about 6.2% of
the total isolates and 9% of LOS. Candida spp. has
remained an important pathogen associated with LOS,
affecting B7% of very low birth weight neonates [34].
The high prevalence of fungal infection seen in our study
necessitates the development of proper preventive
strategies for the high-risk population.
A great burden of drug-resistant organisms was identified
at these two tertiary NICUs. The high prevalence of
multidrug-resistant organisms and the associated high
mortality is alarming to NICUs in Egypt. Multidrug
resistance was not only observed in gram-negative
organisms (83.4%), but also in gram-positive organisms
(60%). The most common multidrug-resistant organisms
were Staphylococcus spp. and E. coli, whereas Pseudomonas
spp., Klebsiella spp., and MRSA were the most common
multidrug-resistant organisms associated with mortality.
This study confirms the urgent need to continuously
perform surveillance programs that monitor trends in
antimicrobial activity and detect the resistance mechan-
isms, and the need to develop antimicrobial stewardship
initiatives.
Unfortunately, the problem is not confined to Egypt.
Many studies have reported the emergence of multiple
drug resistance from different areas of developing
countries [15,16,19,27,35]. Lack of legislation, over the
counter sale of antibiotics, and poor sanitary conditions
may contribute to the problem [36]. On reviewing the
data from developing countries, it was reported that the
increased rates of neonatal infection and B70% of these

Copyright r 2016 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
 36

Table 6. Sensitivity patterns of isolated organisms over the study period in two tertiary neonatal ICUs, Egypt
Glycopeptides Clindamycin Aminoglycoside 3rd C Penicillin Cabipenam Macrolides 4th C Quinolones Anti-Ps Tetracyclin Sulfonamide Chloramphenicol

CONS (n = 19) 19 (100) 5 (26.3) 4 (21.1) 4 (21.1) 2 (10.5) 2 (10.5) 2 (10.5)

MRSA (n = 11) 11 (100) 3 (27.3) 2 (18.1) 1 (9) 4 (36.3)
S. aureus (n = 18) 9 (50) 5 (27.8) 3 (16.6) 8 (44.4) 4 (22.2) 2 (11.1) 3 (16.6) 3 (16.6) 4 (22.2)
GBS (n = 15) 14 (93.4) 8 (53.3) 2 (13.3) 6 (40) 6 (40) 8 (53.3)
Enterococcus faecalis (n = 1) 1 (100) 1 (100) 1 (100)
E. coli (n = 73) 25 (34) 7 (9.5) 9 (12.3) 46 (63) 16 (21.9) 5 (6.8) 38 (52.1) 7 (9.5) 6 (8.2)
Klebsiella pneumonia (n = 46) 14 (30.4) 6 (13) 6 (13) 37 (80) 6 (13) 24 (52.1) 8 (17.4) 1 (2.1)
Acinetobacter baumannii (n = 18) 5 (27.8) 1 (5.6) 1 (5.6) 7 (38.9) 1 (5.6) 3 (16.7) 1 (5.6) 2 (11.1) 6 (33.3) 3 (16.7)
Enterobacter spp. (n = 24) 7 (29.2) 2 (8.3) 3 (12.5) 9 (37.5) 6 (25) 2 (8.3) 5 (20.8) 1 (4.2)
Pseudomonas aeruginosa (n = 14) 8 (57.1) 3 (21.4) 6 (42.8) 3 (21.4) 2 (14.2) 4 (28.5)
Anti-Ps, anti-Pseudomonas penicillin; 3rd C, 3rd generation cephalosporin; 4th C, 4th generation cephalosporin; CONS, coagulase negative Staphylococcus; E. coli, Escherichia coli; GBS, group B Streptococcus;
MRSA, methicillin resistant Staphylococcus aureus; S. aureus, Staphylococcus aureus.
Journal of the Egyptian Public Health Association

Table 7. Resistance patterns of isolated organisms over the study period in two tertiary neonatal ICUs, Egypt
Glycopeptides Aminoglycoside 3rd C Penicillin Cabipenam Macrolides 4th C Quinolones Anti-Ps Tetracycline Sulfonamide

CONS (n = 19) 2 (10.5) 13 (68.4) 10 (52.6) 11 (57.9) 5 (26.3) 8 (42.1) 2 (10.5) 2 (10.5)
MRSA (n = 18) 2 (18) 7 (63.6) 5 (45.5) 1 (9) 1 (9) 6 (54.5)
S. aureus (n = 18) 5 (27.8) 2 (33.3) 5 (27.8) 9 (50) 7 (38.9) 4 (22.2) 4 (22.2) 9 (50)
GBS (n = 15) 1 (6.6) 2 (13.3) 8 (53.3) 8 (53.3) 6 (40) 3 (20) 2 (13.3)
Enterococcus faecalis (n = 1) 1 (100) 1 (100) 1 (100) 1 (100) 1 (100)
E. coli (n = 73) 21 (28.8) 35 (47.9) 35 (47.9) 11 (15) 15 (21.5) 10 (13.7) 20 (27.3) 2 (2.7) 8 (10.9)
Klebsiella pneumonia (n = 46) 28 (38.4) 40 (87) 30 (65.2) 3 (6.5) 6 (13) 16 (21.9) 3 (6.5) 7 (15.2) 4 (8.7)
Acinetobacter baumannii (n = 18) 15 (83.3) 16 (88.9) 17 (94.4) 13 (72.2) 6 (33.3) 8 (44.4) 2 (11.1) 4 (22.2) 4 (22.2) 3 (16.7)
Enterobacter spp. (n = 24) 1 (4.2) 12 (50) 12 (50) 10 (41.7) 5 (20.8) 5 (20.8) 8 (33.3) 11 (45.8)
Pseudomonas aeruginosa (n = 14) 8 (57.1) 10 (71.4) 9 (64.3) 2 (14.2) 2 (14.2) 5 (35.7)
Anti-Ps, anti-Pseudomonas penicillin; 3rd C, 3rd generation cephalosporin; 4th C, 4th generation cephalosporin; CONS, coagulase negative Staphylococcus; E. coli, Escherichia coli; GBS, group B Streptococcus;
MRSA, methicillin resistant Staphylococcus aureus.

Copyright r 2016 Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.

infections would not be susceptible to conventional
empirical antibiotic regimens, such as ampicillin with
gentamicin. There is also evidence of emerging resistance
to third-generation cephalosporins and quinolones [37].
As a consequence, a myriad of problems result; the
inability to adequately treat infection caused by these
organisms is likely linked to the high rates of morbidity
and mortality at these units; the use of broad-spectrum
antibiotics is expensive. These pathogens can spread to
other patients, and the need to empirically use broad-
spectrum antibiotics can itself further contribute to an
epidemic of multidrug-resistant pathogens within these
units [38].
In our study, gram-positive organisms were mostly
resistant to aminoglycosides and penicillin, whereas
gram-negative organisms were mostly resistant to third-
generation cephalosporin and penicillin. This was asso-
ciated with high mortality. In addition, E. coli and
Pseudomonas spp. showed resistance to aminoglycosides
as well. Acinetobacter spp. was resistant to most of the
commonly used antibiotics. Similarly, previous studies
reported that E. coli and Pseudomonas spp. developed high
degree of resistance to commonly used antibiotics
(ampicillin, augmentin, and gentamicin), a moderate
degree of resistance to cephalosporins, and low resistance
to drugs not used for newborn babies (ofloxacin,
ciprofloxacin, andnoxabid) [19,22–25,29,39]. This world-
wide spread of multidrug-resistant organisms is a ticking
bomb and presents a great challenge for any proposed
antimicrobial stewardship program.
Limitations of the study
One of the limitations of the study was its retrospective
design. The pattern of antibiotic resistance (for example,
extended spectrum b-lactamase enzyme) was not identi-
fied. Another limitation was that our data represented only
two NICUs in two university hospitals in Cairo. Data from
other tertiary NICUs were not included in our study.
Conclusion and recommendations
There is an alarming high rate of antibiotic resistance to
the commonly used drugs for the treatment of neonates
in Egypt. Most of the gram-positive organisms were
resistant to aminoglycosides and penicillins, whereas
most of the gram-negative organisms were resistant to
third-generation cephalosporin and penicillins. Contin-
uous surveillance for antibiotic susceptibility is needed
to ensure proper empirical antibiotic therapy. Improve-
ment of infection control practices, avoidance of
irrational use of antibiotics, and revision of the protocols
for treatment are mandatory to prevent further resis-
tance. Continuous quality improvement programs and
auditing are crucial.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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Multidrug-resistance in neonatal sepsis Awad et al. 37
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