Mysore Medical College and Research Institute

From Dr. VEDAVATI B. I. Post Graduate in Microbiology Department of Microbiology Mysore Medical College and Research Institute Mysore

To Registrar (Evaluation) Rajiv Gandhi University of Health Sciences Bangalore.

THROUGH PROPER CHANNEL

Respected Sir,

Subject: Submission of Synopsis titled: “STUDY OF THE BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA AND ASSOCIATED RISK FACTORS”

I am hereby submitting the above titled synopsis (4 copies) as mentioned above, so kindly accept my application and do the needful.

Thanking you,

Yours faithfully,

(Dr. VEDAVATI)

Forwarded to The Dean and Director, Mysore Medical College and Research Institute, Mysore for further needful action.

PROFESSOR AND HOD Date : Department of Microbiology Mysore Medical College and Place : Mysore Research Institute Mysore. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE : Dr.VEDAVATI B.I. AND ADDRESS POST GRADUATE STUDENT DEPARTMENT OF MICROBIOLOGY MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE – 570 001.

2. NAME OF THE : MYSORE MEDICAL COLLEGE AND INSTITUTION RESEARCH INSTITUTE, MYSORE 3. COURSE OF STUDY AND : M.D. (MICROBIOLOGY) SUBJECT 4. DATE OF ADMISSION TO : 30th JULY 2013 THE COURSE 5. TITLE OF THE TOPIC : “ STUDY OF THE BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA AND ASSOCIATED RISK FACTORS”

6. BRIEF RESUME OF THE INTENDED STUDY

6.1 Introduction

Neonatal sepsis is one of the major causes of morbidity and mortality among the newborns in the developing countries. Neonatal sepsis can be defined as "a clinical syndrome characterized by systemic signs and symptoms and bacteremia during the first month of life". Neonatal sepsis is broadly divided into two types according to age of onset: Early-onset sepsis (<72 hrs) and late-onset sepsis (≥72 hrs-28 days).1

Studies show that incidence of neonatal septicemia varies from 7.1 to 38/1000 live births in Asia and from 0.1% to 4.5% in India.2

The various predisposing neonatal factors like sex, gestational age, birth weight, outborn or inborn status of babies and maternal factors like illness during pregnancy, prolonged rupture of membranes( >18 hrs )and difficult labor with instrumentation.2,3

2 The clinical diagnosis of neonatal sepsis is difficult because the signs and symptoms are not always specific. There is no laboratory test with 100% sensitivity and specificity. Blood culture has been considered the gold standard for confirmation of diagnosis but the results are available only after 48-72 hours. Moreover, in many cases blood culture fails to detect the offending organism/bacteria.3 Hence, high index of suspicion is necessary for early diagnosis of sepsis, and when blood culture tests are negative, a battery of sepsis screen tests may help in the diagnosis.4

Periodic evaluation of organisms responsible for neonatal sepsis is essential for the appropriate management of neonates. Therefore, this study is undertaken to determine the profile and antibiotic sensitivity patterns of aerobic isolates from blood cultures of neonates.5

6.2 Review of literature

In a study conducted at a tertiary care hospital in Orissa(2002), out of the 120 blood cultures, 48 were bacteriologically positive among which 43 were pathogenic and 5 were either skin or external contaminants. Of the 43 pathogens isolated 38 were gram-negative bacilli and 5 were gram-positive cocci. Among the gram-negative bacilli all belonged to family Enterobacteriaceae except 3, which were nonfermenters (Acinetobacter spp.). Enterobacter cloacae was isolated in 39.5% followed by Klebsiella pneumoniae in 23.2%, E.coli in 11.6% and others ( C.freundii 4.6%, P.mirabilis 2.3%). All Gram negative isolates showed 100% susceptibility to amikacin except in case of E.cloacae where 85% of the isolates were sensitive.6

A retrospective study conducted in Manipal(2010), 1291 neonates were screened for Early Onset Sepsis, 212 (16.4%) had positive blood cultures. The male to female ratio was 1.08:1. Preterm, small for gestational age and symptomatic newborns constituted 33.9%, 17.9% and 39.2% of the total number of neonates respectively. Coagulase Negative Staphylococcus, klebsiella and Pseudomonas were the predominant isolates. Among the haematological parameters, the positivity was best with micro-ESR 44.8%.7

3 Bacteriological profile of septicemia and the risk factors in neonates and infants in Sikkim(2011) was evaluated. Blood culture was positive in 22% of cases. Gram- negative septicemia was encountered in 61% of the culture-positive cases. Pseudomonas spp. and Enterobacter species were the predominant pathogens amongst gram-negative organisms. Most gram-negative organisms were sensitive to amikacin, ciprofloxacin, and co-trimoxazole. The most common gram-positive organism isolated was Staphylococcus aureus 97%. More than 70% of Staphylococci isolated were resistant to Penicillin, but were sensitive to clindamycin 70% and vancomycin 40%. The most important risk factors of septicemia were preterm birth 31%, followed by respiratory distress 5% and low birth weight 4%.8

In a study conducted at a tertiary care hospital in Pune(2013), out of 115 cases of clinical neonatal sepsis 75 were culture positive. Among isolates, number of gram negative bacilli were 39 was more than gram positive cocci 36. However Staphylococcus aureus 24 was most predominant .Of the 40 culture negative cases 15 neonates were positive for two or more sepsis screen tests.4

A study was conducted to know the Bacterial spectrum of neonatal septicemia with their antibiogram with reference to various predisposing factors in a tertiary care hospital in Southern India(2013). Of 200 cases, 95 were blood culture positive. Of them, 64 were males, 64 were preterm, 41 with birth weight <1.5 kg, 68 outborn neonates and 53 babies died. Gram-negative isolates were 67 and Gram-positive isolates were 28. Enterobacter cloacae and Staphylococcus aureus were commonest isolates in 20% and 11.58% of cases respectively. Gram-negative isolates were sensitive to amikacin, ciprofloxacin, and ofloxacin and least sensitive to ampicillin and amoxyclav.2

A study was conducted to know the bacteriological profile of neonatal septicemia and antibiotic susceptibility pattern of the isolates in Bijapur(2013). 683 clinically diagnosed septicemia cases were included in the study. Blood culture reports were positive in 19.2% cases. Among the culture positive cases, there were 65.5% males and 34.5% females. Early-onset sepsis was present in 74.8% and late-onset sepsis was observed in 25.2% of the cases. Best overall sensitivity among Gram-negative isolates was to imipenem 93%, followed by amikacin 52% and netilmicin 41%. Gram-positive

4 isolates had sensitivity of 91% to linezolid, 68% to tetracycline, 64% to erythromycin, and 52% to ciprofloxacin.5

6.3 Aims and Objectives of the study

1. To study the risk factor associated with septicemia in neonates.

2.To isolate aerobic bacteria causing neonatal septicemia.

3.To study the antibiogram of bacterial isolates.

7. MATERIALS AND METHODS

7.1 Source of data

The present study will be conducted at the Department of Microbiology, Mysore

Medical College and Research Institute, Mysore.

200 clinically suspected cases of neonatal septicemia will be included in the study.

7.2 Method of collection of data

Sample size:

200, clinically suspected cases of neonatal septicemia.

7.3 Method of collection of specimens and processing

The neonates with suspected sepsis will be included in the study. A detailed record of the various predisposing neonatal factors like sex, gestational age, birth weight, outborn or inborn status of babies and maternal factors like illness during pregnancy, prolonged rupture of membranes( >18 hrs) and difficult labor with instrumentation will be made.2,3

5 From neonates with suspected sepsis, 1-2 ml blood of will be collected aseptically and inoculated into 10 ml brain heart infusion broth and incubated at 37° C for 24 h. Subcultures will be done on Blood agar, Chocolate agar and MacConkey agar and incubated aerobically overnight at 37°C. If no growth occurred on plates, subsequent subcultures will be done on 2nd, 3rd, and 7th day. The identification of organisms will be done as per standard protocols.2,4

Antimicrobial susceptibility testing of isolates will be done on Muller-Hinton agar by Kirby-Bauer disc diffusion method, according to the Clinical and Laboratory Standards Institute (CLSI) guidelines.9

A battery of sepsis screen tests like CRP,TLC,Absolute Neutrophil Count will be carried out on the blood samples of all the neonates.4

7.4 Inclusion criteria:

Neonates admitted with signs and symptoms of septicemia.

7.5 Exclusion criteria

Neonates with no clinical evidence of sepsis.

7.6 Statistical methods

Descriptive statistics will be measured by calculating proportions

(proportion of different organism from the isolate). Chi Square test will be done to compare the above proportions.

7.7 Does the Study Require any Investigation / Intervention to be Conducted on

Patients or Other Humans or Animals?

7.8 Has Ethical Clearance Been Obtained from your Institution?

Yes (copy enclosed).

6 8. LIST OF REFERENCES

1. Shah AJ, Mulla SA, Revdiwala SB. Neonatal sepsis: High antibiotic resistance of the bacterial pathogens in a neonatal intensive care unit of a tertiary Care hospital. J Clin Neonatol 2012;1:72-5

2. Rajendraprasad BM, Basavaraj KN, Antony B. Bacterial spectrum of neonatal septicemia with their antibiogram with reference to various predisposing factors in a tertiary care hospital in Southern India. Ann Trop Med Public Health 2013;6:96-9

3. Mondal SK, Nag DR, Bandyopadhyay R, Chakraborty D, Sinha SK. Neonatal sepsis: Role of a battery of immunohematological tests in early diagnosis. Int J App Basic Med Res 2012;2:43-7

4. Misra RN, Jadhav SV, Ghosh P, Gandham N, Angadi K, Vyawahare C.Role of

sepsis screen in the diagnosis of neonatal sepsis. Med J DY Patil Univ 2013;6:254-7

5. Jyothi P, Basavaraj MC, Basavaraj PV. Bacteriological profile of neonatal septicemia and antibiotic susceptibility pattern of the isolates. J Nat Sc Biol Med 2013;4:306-9

6. Mahapatra A, Ghosh S K, Mishra S, Pattnaik D, Pattnaik K, Mohanty S K. Enterobacter cloacae: A predominant pathogen in neonatal septicaemia. Indian J Med Microbiol 2002;20:110-12

7. R Bhat Y and Rao A. the performance of haematological screening parameters and CRP in early onset neonatal infections. Journal of Clinical and Diagnostic Research 2010 Dec 10; 4:3331-6. 8. Tsering DC, Chanchal L, Pal R, Kar S. Bacteriological profile of septicemia and the risk factors in neonates and infants in Sikkim. J Global Infect Dis 2011;3:42-5

9. CLSI. Performance standards for antimicrobial susceptibility testing; twenty-third informational supplement. CLSI document M100-S23. Wayne, PA: Clinical And Laboratory Standards Instituite 2013.

10.Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC. Introduction to microbiology. In: Colour Atlas and Textbook of Diagnostic Microbiology. 5 th ed. 7 Philadelphia: Lippincott ;p. 577-699.2009

: 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE :

11. NAME AND DESIGNATION OF (in block letters) 11.1 Guide : Dr.AMRUTHA KUMARI B. ASSOCIATE PROFESSOR DEPARTMENT OF MICROBIOLOGY MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE

11.2 Signature :

11.3 Head of the Department : Dr. D. VENKATESHA M.D. PROFESSOR AND HEAD DEPARTMENT OF MICROBIOLOGY MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, MYSORE

11.4 Signature :

12. 12.1 Remarks of the : Director and Dean

12.2 Signature :

ETHICAL COMMITTEE CLEARANCE

1. Title of Dissertation INFORMED CONSENT: STUDY FORM OF THE BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA AND ASSOCIATED RISK FACTORS

2. Name of the Candidate : Dr. VEDAVATI B.I.

3. Subject : M.D. (MICROBIOLOGY)

4. Name of the Guide : Dr. AMRUTHA KUMARI B. Associate Professor Department Of Microbiology Mysore Medical College and Research Institute, Mysore.

5. Approved / Not Approved :

SUPERINTENDENT SUPERINTENDENT K.R. Hospital Cheluvamba Hospital Mysore. Mysore.

PROFESSOR AND HOD PROFESSOR AND HOD Department of Medicine Department of General Surgery Mysore Medical College Mysore Medical College and Research Institute, and Research Institute, Mysore. Mysore.

SUPERINTENDENT LAW EXPERT PKTB Hospital Mysore.

DIRECTOR AND DEAN Mysore Medical College and Research Institute Mysore 9 Topic title : “STUDY OF THE BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA AND ASSOCIATED RISK FACTORS”

Principal investigator : Dr. VEDAVATI B.I.

Guide : Dr. AMRUTHA KUMARI . B

Associate professor Department of Microbiology Mysore Medical College and Research Institute Mysore

Location of study : Department of microbiology Mysore Medical College and Research Institute Mysore, Karnataka, India

MEDICAL INVESTIGATOR’S COMMITMENT

I, hereby state that the participant has been counselled about the implications of the study and all the details regarding the study and questionnaire have been explained to the candidate in English/ Kannada languages as desired by the candidate and the participant has been given his/her free and informed consent for the study.

I, the post – graduate student will do everything possible to assure that the consent for the study session will be kept inapparent and confidential.

Date : Signature of the Student Place : [Dr. VEDAVATI]

PARTICIPANT’S INFORMED CONSENT

I Mr / Mrs ______have been explained about the purpose of the above stated study, the procedures, possible benefits, and the maintenance of my confidentiality by the Investigator and I voluntarily participate in the study. My signature below attests this.

Date : Participant’s signature/ Place : Thumb impression

Participant’s name:

10 PROFORMA

“STUDY OF THE BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA AND ASSOCIATED RISK FACTORS”

Case No. : OP/ IP No. :

Name of the patient : Ward :

Age : Unit :

Sex : Male / Female Date of admission :

Date of collection Address : of specimen :

Place of Birth : Home/Hospital

Birth weight :

Gestational age :

h/o PROM : h/o instrumental delivery : h/o illness during pregnancy :

Any other history :

Laboratory Diagnosis : Lab no

Absolute Neutrophil Count

Blood Culture

Organism Isolated

Antibiogram

11 DISSERTATION TITLE: “STUDY OF THE BACTERIOLOGICAL PROFILE OF NEONATAL SEPTICEMIA AND ASSOCIATED RISK FACTORS”

DEPARTMENT : M.D.MICROBIOLOGY

NAME OF THE STUDENT: Dr.VEDAVATI B. I.

NAME OF THE GUIDE : Dr. AMRUTHA KUMARI . B

Reviewed and approved by the scientific committee for submission to RGUHS

DATE : Dr M.A SHEKAR

PLACE: Chairman Scientific committee MMC&RI, MYSORE