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research letter

Indian Pediatr 2016;53:1109-1110

Profile of Neonatal Sepsis due to Burkholderia capacia Complex


*Aparna Chandrasekaran, #Nivedhana Subburaju, Muzamil Mustafa and #Sulochana Putlibai

Departments of Neonatology and #Microbiology, CHILDS Trust Medical Research Foundation and Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India.
Email: [email protected]

Published online: November 05, 2016. PII:S097475591600027

 


We report the result of retrospective record review of the clinical profile of 59 neonates who presented to a tertiary-care extramural neonatal unit with Burkholderia cepacia complex infection. Among the 3265 admissions over 45 months, incidence of Burkholderia sepsis was 18 per 1000 admissions. Case fatality rate was 17%. Most (95%) isolates were sensitive to cotrimoxazole.

Keywords: Etiology, Infection control, Neonate, Septicemia.

 


I
nfections account for 18% of neonatal deaths globally and 21% of neonatal deaths in India [1]. An increasing proportion of neonatal sepsis is being attributed to non-fermenting gram-negative bacilli (NFGNB), particularly Burkholderia cepacia complex (BCC) [2,3]. Prevention and treatment of BCC is challenging due to the organism’s inherent ability to survive in moist environments and intrinsic antimicrobial resistance [4,5]. We describe the clinical profile, antimicrobial susceptibility pattern and in-hospital mortality of neonates with BCC infection.

After approval from the Institute’s Ethics Committee, we screened blood culture records of outborn neonates admitted to our hospital between October 2011 and June 2015. We retrieved case records of neonates with one or more episodes of BCC sepsis, defined as isolation of Burkholderia cepaciae from blood or sterile body fluids along with clinical signs of sepsis. Positive cultures from neonates whose clinical course was not consistent with sepsis and not treated as culture-positive sepsis by the treating team, were considered as contaminants and excluded from the study. Cultures were performed using BacT/Alert continuous microbial detection system. Positive signals were followed by identification of species using Vitek-2 (Biomerieux, France). Antimicrobial susceptibility pattern was tested as per Clinical and Laboratory Standards Institute (CLSI) guidelines [6]. Intravenous piperacillin-tazobactam and amikacin were used as empirical first line antibiotic in both early- and late-onset sepsis.

Among the 3265 admissions, 65 neonates had positive cultures with BCC. After excluding six contaminants, 59 neonates had BCC sepsis (18 per 1000 admissions). Most neonates (59%) had early-onset sepsis. The most common clinical presentation was respiratory distress (97%), followed by hemodynamic instability (83%). C-reactive protein was elevated (>5 mg/L) in 71% neonates [7]. Highest antimicrobial sensitivity was observed for cotrimoxazole (95%), followed by meropenem (49%), ceftazidime and minocycline (31% each) and levofloxacin (27%). Case fatality rate was 17% (Table I).

TABLE I	Clinical Profile and Laboratory Abnormalities in Neonates with Sepsis due to Burkholderia cepacia (n=59)
Variable
*Gestational Age (wk) 37.0 (2.9)
*Birthweight (g) 2702 (770)
Male gender 44 (75%)
Normal/ assisted vaginal delivery 13 (22%)
Maternal risk factors 17 (29%)
Isolation before 72 h of postnatal age 39 (59%)
#Age at isolation (d) 3.0 (1.5-4.0)
Organism isolated within 48 h of admission 56 (95%)
Associated factors at the referring hospital
  Peripheral intravenous line use 57 (97%)
  Received IV antibiotics prior to admission 56 (95%)
  Central-line use 2 (3%)
Clinical presentation
  $Abdominal distension 29 (49%)
  Vomiting/ Increased (>25%) pre-feed 31 (53%)
  gastric aspirate
  Respiratory distress 57 (97%)
  Apnea requiring  PPV 7 (12%)
  Hemodynamic instability 49 (83%)
Intensive care provided
  Mechanical ventilation 34 (58%)
  Inotrope infusions 49 (83%)
Laboratory Investigations
  #Total leucocyte count,/µL 13500  (9300- 18200)
  #Absolute neutrophil count,/µL 7080 (3570-11856)
  #Platelet  count, ´103/µL 200 (100- 330)
  #C-reactive protein, mg/L 57.0 (21.3- 84.7)
  Elevated C-reactive protein 42 (71%)
Outcome
  Died before discharge 10 (17%)
  #Hospital stay (d)  15 (11-2)
IV: intravenous; PPV: positive pressure ventilation.
Data expressed as number (%) except *mean (standard deviation), #median (interquartile range). $Abdominal distension was defined as increase in abdominal girth by >2cms.

An earlier study from Chandigarh noted an increase in the proportion of neonatal sepsis due to NFGNB, subsequently identified as BCC from 0% in 1998 to 30% in 2006 [2]. Although 59% neonates in our series had early onset sepsis with BCC, only 29% had maternal risk factors. This supports the claim that majority of early-onset infections in hospital-born neonates in the developing world may be hospital-acquired, rather than of maternal origin [8]. Microbiological reports often identify both Pseudomonas species and Burkholderia cepacia as NFGNB, but their antimicrobial susceptibility and treatment options are different. BCC is intrinsically resistant to aminoglycosides, polymyxin (Colistin), and often to piperacillin-tazobactam, while these drugs are useful for infection with Pseudomonas [9].

The limitations of our study include its retrospective design and potential inaccuracy in differentiating neonates truly infected with BCC from contaminants.

References

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