1. Background
The world health organization (WHO) estimates that 130 million neonates are born each year. Of these, eight million do not live till the 1st year of life, and more than 10 million pass away before the age of 5 years (1). Every year, four million infants die during the first month of life. Developing countries give 98% of reported worldwide neonatal deaths (2). Neonatal septicemia cause about 1.6 million deaths per year in the developing world, and the major cause of neonatal mortality is neonatal infections (3, 4). Bacterial sepsis is considered to be an important cause of neonatal mortality in the first month of life) (5, 6). It occurs in a range of 1 - 10/1000 live births and despite advances in perinatal care, neonatal sepsis is still a significant cause of morbidity and mortality in neonates (7). The incidence of sepsis in the neonate is greater than at any other period of life and varies from center to center.
Studies from developed countries demonstrated that the incidence of neonatal sepsis has been reported to be less than five cases per 1000 live births; some other population-based studies from developing countries have reported clinical sepsis rates ranging from 49 - 170 per 1000 live births (8). Neonatal mortality is about 34 per 1000 live births in Asia, 42 per 1000 live births in Africa and 17 per 1000 live births in Latin America and the Caribbean (4). The incidence of neonatal bacterial infections depends on geographic area and may vary from country to country as well as within the same country. Furthermore, neonatal mortality for different African countries ranges from 68 per 1000 live births in Liberia to 11 per 1000 live births in South Africa (9). Reported infection rates in the neonatal intensive care units (NICUs) vary from 3.2 to 30 per 100 admissions or discharges, illustrating the wide variability among centers. The neonatal intensive care units that admit surgery patients may have higher rates (10).
2. Objectives
There are a lot of risk factors that increase the risk of neonatal sepsis; so, we tried to find the risk factors of neonatal infections in this remote area in Asia.
3. Materials and Methods
3.1. Study Design
Descriptive design was used in the study.
3.2. Setting and Sample
This study was a retrospective cross-sectional descriptive study, which was conducted in six hospitals all-over South Sinai Governorate throughout scanning of 1023 files of the patients admitted to NICUs in these hospitals from January 2010 till September 2014.
3.3. Data Collection/Procedure
Scanning patient's records was done for demographic data and potential risk factors including gender, gestational age, birth weight, mode of delivery, site of delivery, presence of twins, presence of congenital anomalies, maternal age, maternal parity, presence of sepsis, age at onset of sepsis, symptoms and signs, perinatal risk factors, and outcome.
A multivariate logistic regression analysis for the significant neonatal and maternal risk factors related to neonatal sepsis was performed to explain the interaction between these risk factors and order these risk factors regarding statistical significance.
3.4. Data Analysis
Data were analyzed using descriptive statistics (percentages, frequencies, also mean and standard deviations), student's t-tests and Mann-Whitney U tests with the SPSS software version 18.0 (SPSS Inc, Chicago, Illinois, USA).
3.5. Ethical Consideration
Ethical approval which agreed with the principles in the declaration of Helsinki was obtained from the local university ethical council prior to the study. The patients gave their written informed consent to participate in this study.
4. Results
The current study aimed to measure the prevalence of septicemia in the NICUs of South Sinai governorate hospitals, and elicit the risk factors that may be linked to neonatal sepsis in this area.
The number of sepsis cases was 88 (8.6%) and late onset sepsis (5.9%) was more frequent than early onset sepsis (2.7%) (Table 1).
Table 1. Distribution of the Study Population According to the Type of Sepsis
| Parameter | No. (%) |
|---|---|
| No sepsis | 935 (91.4) |
| Early onset sepsis | 28 (2.7) |
| Late onset sepsis | 60 (5.9) |
| Total | 1023 (100) |
A multivariate logistic regression analysis for the significant risk factors related to neonatal sepsis showed that the highest effect on sepsis was for rupture of membranes > 18 hours then the presence of twin deliveries came next, followed by multipara mothers then normal vaginal delivery came 4th in order followed by male gender, low birth weight babies and preterm neonates which became nonsignificant in this multivariate logistic regression analysis (Table 2).
Table 2. Multivariate Logistic Regression Analysis for the Significant Neonatal and Maternal Risk Factors Related to Neonatal Sepsis
| Parameter/Variables | Suspected Sepsis, No. (%) | Total Cases | Statistical Significance | ||
|---|---|---|---|---|---|
| P Value | OR | CI | |||
| Gender | 0.2101 | 1.394 | 0.8292 -2.3435 | ||
| Male | 55 (11.6) | 473 | |||
| Female | 33 (6.9) | 550 | |||
| Gestational age | 0.8885 | 1.0572 | 0.4856 - 2.3018 | ||
| Full term | 44 (6.9) | 638 | |||
| Preterma | 44 (11.4) | 385 | |||
| Birth weight | 0.4106 | 1.3388 | 0.6681 - 2.6830 | ||
| Normal | 39 (6.3) | 616 | |||
| Lowb | 49 (12) | 407 | |||
| Mode of delivery | < 0.00001c | 0.2333 | 0.1341 - 0.4057 | ||
| Normal | 44 (11.6) | 380 | |||
| Caesarean | 44 (6.8) | 643 | |||
| Twin deliveries | < 0.00001c | 7.8585 | 3.6708 - 16.8235 | ||
| Yes | 17 (16.2) | 105 | |||
| No | 71 (7.7) | 918 | |||
| Maternal parity | 0.0448d | 2.0622 | 1.0169 - 4.1821 | ||
| Multipara | 77 (9.6) | 803 | |||
| Primipara | 11 (5) | 220 | |||
| ROM > 18 h | < 0.00001c | 44.4451 | 23.4700 - 84.165 | ||
| Yes | 49 (47.1) | 104 | |||
| No | 39 (4.2) | 919 | |||
Abbreviations: CI, 95% confidence interval; OR, odds ratio.
a< 2.5 kg.
b< 37 weeks.
cP < 0.01: highly significant.
dP < 0.05: Significant.
5. Discussion
Egypt is a developing country where the problem of infection is more evident due to lack of health services and infection control practices. Also, infection control practices are also underdeveloped and are known to contribute to the risk of antibiotic resistance (11). The diagnosis of neonatal infections is difficult because of the similarity between clinical signs associated with physiological disturbances and those of sepsis, bacteremia or fungemia. Earlier diagnosis of neonatal sepsis in critically ill infants would improve timely administration of antibiotics and discontinuation of management in infants with a low probability of sepsis (12).
In the current study, the prevalence rate of septicemia in the NICUs of South Sinai governorate hospitals was 8.6%. The incidence of neonatal sepsis varies greatly between different continents, countries, regions, and hospitals. The reported incidence of neonatal sepsis has recently been reviewed and it varies from 7 to 38 per 1000 live births in Asia and from 6 to 23 per 1000 live births in Africa (4). By comparison, culture proven sepsis in USA and Europe was about two to four per 1000 live births (13). Thapa et al. found that the NICU prevalence rate of sepsis was 37.12% in their cross-sectional study conducted in a NICU of Paropakar Maternity and Women's Hospital in Kathmandu (14). Wu et al. found that the incidence of sepsis was 4.06% among all NICU admissions in a Taiwanese medical center (15).
Results of the current study showed that ROM > 18 hours has a significant effect on sepsis incidence (ROM > 18 hours was highly significant associated with more incidence with sepsis among study population), ROM > 18 hours was the most significant risk factor in a multivariate logistic regression analysis for the significant risk factors related to neonatal sepsis among the study population (odds ratio = 44.4451, 95% confidence interval from 23.4700 to 84.165). Similar to our results, it was found that history of prolonged rupture of membrane (PROM) was common among neonates with sepsis (16). Other studies showed that the duration of PROM ≥ 18 hrs was associated with an increased risk of neonatal sepsis (17). However, in a study conducted in Saudi Arabia no significant role was reported for the duration of premature rupture membranes in the incidence of neonatal sepsis (18).
Results of the current study showed a highly statistical significant difference (P < 0.01) between sepsis and nonsepsis cases regarding the twin deliveries as twin deliveries was significantly associated with more incidence of sepsis among the study population, it came in the 2nd place after ROM > 18 hours as a strong risk factor in a multivariate logistic regression analysis for the significant risk factors related to neonatal sepsis among the study population (odds ratio = 7.8585, 95% confidence interval from 3.6708 to 16.8235). The rate of multifetal pregnancies, specifically twin gestations has risen in recent years, most likely as a result of fertility treatments and delayed childbearing (19). Unlike our results, Boghossian et al. found that the incidence of sepsis among singletons and multiples were similar (20).
5.1. Conclusions
In light of the previously mentioned results the following conclusions were drawn from the study: Prevalence of septicemia in NICUs in South Sinai governorate was about 8.6%. The multivariate logistic regression analysis for the significant risk factors related to neonatal sepsis showed that the highest effect on sepsis was for rupture of membranes > 18 hours then the presence of twin deliveries came next, followed by multipara mothers then normal vaginal delivery came 4th in order followed by male gender, low birth weight babies and preterm neonates, which became nonsignificant in this multivariate logistic regression analysis.
