Early-Onset Neonatal Sepsis in India — The ‘Elephant’ Remains ‘Unseen’

Excerpt

Systemic infections are the second most common cause of neonatal deaths globally and the most common cause in areas with high neonatal mortality rates [1]. Early-onset neonatal sepsis, manifesting within 72 h of birth, and sometimes within 24 h of birth (very early-onset sepsis) is more common than late-onset sepsis in low-middle income countries (LMIC) [2]. Early-onset sepsis has a high case fatality rate. Identifying at-risk neonates, early diagnosis, and timely antibiotic treatment can improve survival. However, many challenges preclude the optimal strategy to manage early-onset neonatal sepsis. First, the epidemiology of neonatal sepsis is poorly understood in LMIC. A neonate can acquire sepsis before birth i.e., intrauterine infection, during birth on getting colonized with maternal genital tract bacteria, or shortly after birth from the delivery area environment including resuscitation equipment and healthcare providers. It is not known what proportion of early-onset neonatal sepsis in LMIC is attributable to each of these pathways. Second, a similar set of organisms cause very early-onset (within 24 h of birth and therefore likely to be acquired before birth), early-onset (24–72 h of birth), and late-onset sepsis. Combined with poorly understood pathways of sepsis acquisition, designing a specific preventive strategy that is as successful as the Group B streptococcus detection and treatment approach in high-income countries, is difficult. Third, due to a high baseline incidence of sepsis, risk-factors-based sepsis calculators cannot be used without exposing an unacceptably high proportion of neonates to work-up of sepsis and administration of antibiotics. In a research study published in this issue of the journal, Jain et al. have attempted to fill a lacuna in understanding the epidemiology of early-onset sepsis and improve the diagnostic approach [3]. The study included two cohorts of women with preterm delivery — those with preterm premature rupture of membranes (pPROM) of at least 24 h or with suspected chorioamnionitis (exposed cohort) and those without these two risk factors (unexposed cohort). Umbilical venous blood was collected for measurement of immunoglobulin (Ig) A levels and bacterial culture and the neonates were followed for the development of sepsis within three days and death within seven days of birth. …