High Incidence of Bacteria Resistant to Recommended Empiric Antibiotics for Neonatal Sepsis at a Tertiary Level Neonatology Unit in Rwanda

Background: In Western countries, one of the leading causes of neonatal sepsis is Group B streptococcus (GBS), which appears to be different from resource-limited countries, where gram negative bacilli (GNB) have been reported to be more common. Anecdotally, Klebsiella species have been reported to be a frequent cause of bacterial sepsis in the neonatology unit of the University Teaching Hospital of Kigali (UTHK) but there have been no formal studies. In addition, frequently reported multi-drug resistant (MDR) GNB have prompted pediatricians to use ciprofloxacin empirically, instead of or in addition to ampicillin combined with gentamicin as recommended by WHO and Rwanda national neonatology protocols. The aim of this study is to describe the bacterial causes of neonatal sepsis in the neonatology department of UTHK, and their antibiotic sensitivities.

Methods: A retrospective review was done of neonates admitted for sepsis in 2013. Data collected included demographics, risk factors for sepsis, and microbiologic results of cultures.

Results: Files were reviewed for 128 neonates; 52% (66/128) were male; 59% (75/128) had low or extremely low birth weight; 82% (105/128) had early neonatal sepsis. Ninety-four percent (120/128) had positive blood cultures, 5% (6/128) positive urine, and 2% (2/128) positive CSF. GNB caused 54% (69/128) of infections, and Klebsiella spp. were the most frequent bacteria isolated 37% (47/128). GBS was only isolated in one case. Among Klebsiella spp., 100% were resistant to ampicillin, 86% to gentamicin, 67% to cefotaxime, and 59% to ciprofloxacin. E. coli was 100% resistant to ampicillin, gentamicin, and ciprofloxacin, and 67% resistant to cefotaxime. 

Conclusion: Empiric treatment of neonatal sepsis with ampicillin and gentamicin provided poor coverage of gram negative infections (which account for over half of all positive cultures) in the neonatology unit in this tertiary teaching hospital in East Africa. The high incidence of MDR gram negative infections is concerning in a setting in which carbapenems are not readily available.