Introduc)on: Bacterial infections are an important issue in current clinical medicine.

The severity
of infectious diseases has increased dramatically in recent years, which is also due to increasing
numbers of resistant bacteria, including strains producing broad-spectrum beta-lactamases(1).
Antibiotics are among the most frequently used drugs in children(2, 3). Broad-spectrum antibiotic
prescribing in ambulatory pediatrics is extremely common and frequently inappropriate(4).
Knowledge of the pattern of bloodstream infection (BSI) can help determine antibiotic prescribing
policy and infection control procedures(5). The rapid rise in antimicrobial resistance in bacteria has
generated an increased demand for the development of novel therapies to treat contemporary
infections, especially those caused by methicillin-resistant Staphylococcus aureus (MRSA)(6). In
pediatrics, in particular, there is no sign of any new antibacterial in the foreseeable future(7).
Bacterial infections account for a huge proportion of neonatal deaths worldwide. The problem of
antibiotic resistance among common bacterial pathogens mainly the gram-negative bacteria is
emerging globally which is of more serious concern in developing countries(8). Repeated and/or
prolonged courses of antibiotic exposure have resulted in an increase in the prevalence of hospitalacquired, antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus,
vancomycin-resistant Enterococcus, and multidrug-resistant Gram-negative rods(9). Hospital-based
data suggest alarming rates of resistance to ampicillin and gentamicin, the first-line antimicrobial
agents recommended by WHO for treatment of serious infections in young infants(10).
All children under 12 years of age enrolled between 1st June, 2012 and 31st July 2012, in the
Outpatient department, Inpatient department of pediatrics section and casualty of hospital, who
presented with acute diarrhoea. Data collected by mean of study questionnaire. Stool sample were
processed for bacteriological analysis. In 280 samples bacteria were isolated with the help of
microscopy, culture and biochemical reactions. The isolates obtained were tested for antimicrobial
sensitivity over Mueller Hinton agar by Kirby Bauer-disk diffusion methodThis study was conducted
for a period of one and a half years from January 2010 to June 2011 in a tertiary care hospital in
Chennai. A total of 182 blood samples were collected using sterile precautions. They were
processed following standard laboratory protocol. Antibiogram was done using appropriate
antibiotics by Kirby-Bauer disc diffusion method. Isolated Staphylococcus aureus were tested for
methicillin resistance using Cefoxitin disc (30mug), ESBL was detected using combined disc
method, MIC reduction and Polymerase chain reaction, metallobetalactamases using EDTA and
Amp-C beta lactamases using AmpC disc test. C-reactive protein (CRP) was estimated for all the
cases. The present study was conducted in a rural hospital and health center in Burkina Faso, in a
seasonal malaria transmission area. Hospitalized children (<15 years) presenting with T>/=38.0
degrees C and/or signs of severe illness were enrolled upon admission. Malaria diagnosis and
blood culture were performed for all participants, lumbar puncture when clinically indicated. We
assessed the frequency of severe malariaMETHODS: This was a retrospective study of hospital
records of 4 y. From 276 culture positive reports of 226 newborns, organisms, their sensitivity to
different antibiotics were studied and their outcome was compared to 571 culture negative
newborns. Growth detection was done by BacT/ALERT(R)PF system.

Blood cultures were done on 56 infants and children at QPH during October, November,
and December of 2013. Seven (12.5%) blood cultures were posi)ve for pathogens: 4 with
Klebsiella pneumonia, 2 pa)ents had both Pseudomonas aeuroginosa and Staphylococcus
aureus , and one Eschericia coli. An eighth pa)ent had an Enterococcus isolate that, based
on the clinical course, is unlikely to represent a pathogen.
The neonatal protocol called for imperic treatment of suspected sepsis with cefotaxime
and ampicillin and the ITFC protocol called for ceUriaxone. All pa)ents were begun
therapy per protocol in a )mely manner. 2 neonates with K. pneumonia sepsis died withing
48 hours of beginning therapy. Their isolates were resistant to cefotaxime and ampicillin.
A 2 month old infant with SAM and K. pneumonia sep)cemia was started on ceUrixone per
protocol and then changed to gen)mycin aUer 48 hours because she did not respond to
ini)al therapy. The isolate was suscep)ble to gentamycin and the pa)ent survived. The
fourth pa)ent with K. pneumonia sepsis was a 21 day old neonate who was treated with
cefotaxime and ampicillin and survived despite the isolate being resistant to both .
CeUotaxime was probably ac)ve enough against the organism to aord the host an
opportunity to clear the infec)on.
Two infants had both P. aerugenosa and S. aureus isolated from their blood. The P. aerug.
was resistant to both cefotaxime and amp. and was resistant to gentamycin as well. The S.
aureus isolate was resistant to ceUriaxone but suscep)ble to gentamycin. The rst pa)ent
was 11 days old and came from home in suspected sep)c shock and died in less than 48
hours. The second infant arrived on the day of birth and was begun on cefotaxime and
ampicillin. AUer 4 days of treatment the cefotaxime was stopped and gentamycin begun.
The infant expired the next day. The hosptaliza)on of these two infants overlapped by
nearly 2 days and their BCs were sent on the same day. There are at least two explana)ons
for these 2 infaqnts having the same isolates: 1) the second infec)on was nosocomial, or 2)
there was a lab error and the same report was given for 2 babies while only one was a true
posi)ve.
A 3 year old child with SAM presented with suspected sepsis and was started on
ceUriaxone per protocol. E. coli resistant to ceUriaxone was isolated from the blood and
the pa)ent died within 48 hours of beginning threapy.
All of these isolates were from specimens obtained in October 2013. Early in December
2013 emperic therapy in the Neonatal Unit was changed to ampicillin plus gentamycin.
(cefotaxime was to be added for suspected meningi)s) It was also recommended that

should older pa)ents fail to respond to imperic therapy within 48 hours, considera)on be
given to stopping ceUrixone and beginning gentamycin or adding gentamycin.
A look at admissions, deaths a]ributed to sepsis , and total deaths for October, November,
December 2013 and January 2014 is interes)ng:
admissions deaths a]rib. to sepsis total deaths
October: 53 18, 20
November: 43 1 12
December: 62 8 23
January ?? 5 ??
There is a sugges)on from these data that the number of deaths a]ributed to sepsis has
decreased in rela)on to the number of total deaths and the percentage of admissions.
Based on these limited data I would recommend that the guideline for imperic
an)bacterial therapy for suspected neonatal sepsis be formally changed to ampicillin and
gentamycin and that cefotaxime be added only when meningi)s is suspected.
Because at the present )me there is no an)bacterial available should isolates be resistant
to gentamycin as well as all beta lactams I would recommend that a serious eort be made
to have a backup an)bacterial available. My rst choice would be amikacin. An alterna)ve
would be piperacillin/tazobactem. It is not recommended to use imipenem alone to treat
serious gram nega)ve infec)ons.
Although the data are limited I am concerned about the incidence of gram nega)ve sepsis
in children 1month to 59 months of age. Certainly urosepsis is common in this age group
and gram nega)ve enteric organisms are the usual cause. I would certainly add gentamycin
for children with suspected sepsis who fail to show an adequate response to ceUriaxone
within 48 hours. Considera)on should be given to modifying the guideline for suspected
sepsis in ITFC pa)ents to include gentamycin. The concern here would be overuse of
gentamycin.
Thoughbul considera)on should be given to con)nuing to obtain blood cultures on
selected neonates and older children with suspected sepsis. Cultures should be limited to
pa)ents who have not received an)bacterials recently and have not been given
an)bacterials before it is decided to obtain a BC. The number of specimens sent for BC
could be limited by having strict criteria for the diagnosis of suspected sepsis in both age
groups. Obtaining cultures would allow for ongoing informa)on about the organisms
causing sepsis and the suscep)bility of these organisms.
The excessive and irresponsible use of an)bacterial agents in Que]a makes mul)ply
resistant organisms very likely. Although the only S. aureus isolate for BCs was suscep)ble
to oxacillin I would be surprised if MRSA is not wide spread in the community. And, un)l
coverage with PCV10 becomes very high there should be concern about resistant S.
pneumonia
A nal observa)on is that rifampin is frequetly overlooked as the drug of choice for serious
S. aureus infec)ons. MICs are usually <0.001 micrograms per mi and rifamin is ac)ve in
acidic environments like pus, and is ac)ve intracellularly in neutrophils. So, for lung

abscess, osteomyeli)s, sep)c arthri)s , or meningits that is thought to be caused by S.

aureus I would use rifampin as my primary an)bacterial agent. A second agent (like
augmen)n) should be given with rifampin as resistance is likely to develop if used alone. I
would only use rifampin when the index of suspicion for a S. aureus infec)on is very high.

1.
Husickova V, Chroma M, Kolar M, Hricova K, Stosova T, Kantor L, et al. Analysis of ESBLand AmpC-positive Enterobacteriaceae at the Department of Neonatology, University Hospital
Olomouc. Current microbiology. 2011;62(6):1664-70.
2.
Chavez-Bueno S, Stull TL. Antibacterial agents in pediatrics. Infectious disease clinics of
North America. 2009;23(4):865-80, viii.
3.
Barker CI, Standing JF, Turner MA, McElnay JC, Sharland M. Antibiotic dosing in children in
Europe: can we grade the evidence from pharmacokinetic/pharmacodynamic studies - and when is
enough data enough? Current opinion in infectious diseases. 2012;25(3):235-42.
4.
Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in
the United States. Pediatrics. 2011;128(6):1053-61.
5.
Gray JW. A 7-year study of bloodstream infections in an English children's hospital.
European journal of pediatrics. 2004;163(9):530-5.
6.
Haste NM, Thienphrapa W, Tran DN, Loesgen S, Sun P, Nam SJ, et al. Activity of the
thiopeptide antibiotic nosiheptide against contemporary strains of methicillin-resistant
Staphylococcus aureus. The Journal of antibiotics. 2012;65(12):593-8.
7.
Appelbaum PC. 2012 and beyond: potential for the start of a second pre-antibiotic era? The
Journal of antimicrobial chemotherapy. 2012;67(9):2062-8.
8.
Shrestha S, Adhikari N, Rai BK, Shreepaili A. Antibiotic resistance pattern of bacterial
isolates in neonatal care unit. JNMA; journal of the Nepal Medical Association. 2010;50(180):
277-81.
9.
Bizzarro MJ, Gallagher PG. Antibiotic-resistant organisms in the neonatal intensive care
unit. Seminars in perinatology. 2007;31(1):26-32.
10.
Thaver D, Ali SA, Zaidi AK. Antimicrobial resistance among neonatal pathogens in
developing countries. The Pediatric infectious disease journal. 2009;28(1 Suppl):S19-21.