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Table of Contents
LETTER TO EDITOR
Year : 2018  |  Volume : 17  |  Issue : 3  |  Page : 159-161  

Shobowale EO, Solarin AU, Elikwu CJ, Onyedibe KI, Akinola IJ, Faniran AA. Neonatal sepsis in a Nigerian private tertiary hospital: Bacterial isolates, risk factors, and antibiotic susceptibility patterns. Ann Afr Med 2017;16:52-8


Infectious Diseases Unit, Department of Paediatrics, Ahmadu Bello Unversity, Zaria, Kaduna State, Nigeria

Date of Web Publication31-Aug-2018

Correspondence Address:
Dr. Lawal Waisu Umar
Department of Paediatrics, Ahmadu Bello University, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_55_17

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How to cite this article:
Umar LW. Shobowale EO, Solarin AU, Elikwu CJ, Onyedibe KI, Akinola IJ, Faniran AA. Neonatal sepsis in a Nigerian private tertiary hospital: Bacterial isolates, risk factors, and antibiotic susceptibility patterns. Ann Afr Med 2017;16:52-8. Ann Afr Med 2018;17:159-61

How to cite this URL:
Umar LW. Shobowale EO, Solarin AU, Elikwu CJ, Onyedibe KI, Akinola IJ, Faniran AA. Neonatal sepsis in a Nigerian private tertiary hospital: Bacterial isolates, risk factors, and antibiotic susceptibility patterns. Ann Afr Med 2017;16:52-8. Ann Afr Med [serial online] 2018 [cited 2018 Dec 15];17:159-61. Available from: http://www.annalsafrmed.org/text.asp?2018/17/3/159/240191



Sir,

Shobowale et al.[1] in their article on neonatal sepsis, reported about findings suggesting that the prevalence of neonatal sepsis was higher in “out born” neonates, those with prematurity, premature rupture of membranes (PROMs) and those aged <3 days. There are, however, up to 17 notably contentious issues here outlined that cast some doubt about the validity of their findings, which I seek your kind indulgence Sir, to publish these for the authors to clarify.

  1. The abstract stated a study duration as “a 1-year period.” but the methodology stated “from August 2014 to August 2015”, which is a 13-month period
  2. Inclusion criteria: The statement that “All infants satisfying the criteria for sepsis will be subjected to blood culture” suggests a study proposal statement, not what should be used for a completed study being reported
  3. Only blood samples were chosen for analysis; other samples may yieid culture positive when results for blood culture are negative, especially where antibiotics have been previously administered before presentation. Furthermore, standard protocol for sepsis evaluation is inclusive of other samples such as cerebrospinal fluid, urine, stools, aspirates, wound, and mucosal swabs [2],[3]
  4. The researchers did not address the possible compounding effect of prior antibiotic use for the subjects or their mothers before presentation to hospital
  5. It was not clear whether just one or all of the criteria for sepsis had to be present or a combination of a number of them occurring for a clinical diagnosis of neonatal sepsis to be made
  6. The statement that “parents who refuse to provide informed consent shall be excluded…….” is suggestive of a study proposal statement
  7. There is no statement on whether ethical approval for the study was sought for or obtained from an appropriate body
  8. A certain formula (“Kish;” with no reference of its source), was used to obtain a sample size of 120; but only the results of 100 neonates were analyzed, and no account was made of the difference
  9. There is a disparity between the list of antibiotics tested for sensitivity as stated in the methodology and what was displayed as shown in [Figure 1] of this letter (captioned as Figure 2 in Shobowale, et al).[1] The list included ampicillin, vancomycin, erythromycin, gentamicin, and oxacillin, but these were not represented on the chart [Figure 1]; rather strangely, the chart has bars for 6 other antibiotics that were not listed in the methodology (clindamycin, piperacillin/Tazobactam, cefuroxime, colistin, ampicillin/sulbactam, and cefepime)
  10. Results:


    1. The last sentence of the opening paragraph of “Results” stated that “Sepsis was equal in incidence in both early and late-onset variants [Table 1].” However, the table has no data to support this statement, and it is not clear where the basis for this statement came about
    2. It was stated that “majority of parents were in the low socioeconomic bracket, n = 48 (38.9%),” but this is contrary to what is in [Table 2], where 52 were majority (high 16, plus middle 36); the percentages were also incorrect
    3. It was also stated that “Ten of the neonates had preterm PROMs (10%).” It is not clear what “preterm PROMs” mean; the term does not represent a recognized entity.


  11. It is not clear why the percentages of some number of cases in [Table 1] contained decimals (e.g., categories of “Growth” were 34 [34.3%] and 66 [65.7%]), and why some number of cases do not round up to 100 (e.g., categories under “Gestation” had Preterm as 19 and Term as 35, which rounds up to 54). Percentages for “Birth weight” categories (>2500 g and <2500 g), socioeconomic status and Gender were also wrong. Since there were 100 cases, the percentages of any number out of these 100 cases should correspond to the numbers with no decimal places
  12. The categorizations for age (<3 and > 3 days) did not capture age of exactly 3 days at presentation; similarly for “Birth weight,” weight of exactly 2500 g was not included
  13. In [Table 2], the figures and percentages for “Early” and “Late” onset sepsis do not tally for both “Died” and “Discharged” categories
  14. In spite of much higher proportionate mortality among neonates born “Within” the hospital than neonates in the “Out born” category (8 out of 21 or 38.1%, compared to 4 out of 79 or 5.1%), yet the authors stated that delivery outside a tertiary hospital was a risk factor for mortality. This is a total misinterpretation
  15. It was stated that “The risk factors for sepsis in this study was age <3 days and prematurity;” but [Table 3] shows that proportionately more neonates aged >3 days were culture positive compared to those <3 days (17 out of 35 or 48.6% compared to 17 out of 65 or 26.2%). Another misinterpretation
  16. The data for “Birth status” in [Table 3] did not seem to tally correctly; there were 34 “Positive” cases of bacterial isolation, but the table has 15 “Preterm” and 37 “Term” neonates, which gives 52 cases rather than 34. Similarly, the data for “PROM” do not tally correctly to give total of 34 positive bacterial cultures
  17. [Table 3] has “Booking status” but with categories as “In born” and “Out born;” booking status is about antenatal care and not whether a neonate is born in or out of the hospital. Besides, there is no place in the article where antenatal care information was captured in the data for risk factors.
Figure 1: Antimicrobial susceptibility profiles of pathogens isolated in neonatal sepsis

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Table 1: Summary statistics of neonates

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Table 2: Outcome of neonates with bacteriologic sepsis

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Table 3: Risk factors for neonatal sepsis

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   Conclusions Top


  1. There are serious methodological flaws and inconsistencies that need to be clarified to make the findings valid
  2. There are overt disparities and inconsistencies in antibiotic testing and sensitivity results; similarly, the data analysis has lots of calculation errors and misinterpretations resulting in incorrect statements on the conclusions
  3. If the results could be considered based on some of the findings, it seems that with a higher rate of positive blood cultures among neonates >3 days old and higher mortality among inborn neonates, it is possible that nosocomial infection was a significant contributor to this mortality rate in this hospital. This is especially likely with the higher proportion of positive blood cultures found among neonates aged >3 days (late-onset neonatal sepsis), and with isolation of such organisms as Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus aureus plus Coagulase negative staphylococcus (CONS), which are recognized agents known to cause hospital-acquired infection [3],[4],[5],[6]
  4. The validity of findings of this study can only be ascertained if the errors and inconsistencies could be clarified, along with correct interpretation of these findings.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Shobowale EO, Solarin AU, Elikwu CJ, Onyedibe KI, Akinola IJ, Faniran AA, et al. Neonatal sepsis in a Nigerian private tertiary hospital: Bacterial isolates, risk factors, and antibiotic susceptibility patterns. Ann Afr Med 2017;16:52-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Camacho-Gonzalez A, Spearman PW, Stoll BJ. Neonatal infectious diseases: Evaluation of neonatal sepsis. Pediatr Clin North Am 2013;60:367-89.  Back to cited text no. 2
    
3.
Ramasethu J. Prevention and treatment of neonatal nosocomial infections. Matern Health Neonatol Perinatol 2017;3:5.  Back to cited text no. 3
    
4.
Zaidi AK, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA, et al. Hospital-acquired neonatal infections in developing countries. Lancet 2005;365:1175-88.  Back to cited text no. 4
    
5.
Testoni D, Hayashi M, Cohen-Wolkowiez M, Benjamin DK Jr., Lopes RD, Clark RH, et al. Late-onset bloodstream infections in hospitalized term infants. Pediatr Infect Dis J 2014;33:920-3.  Back to cited text no. 5
    
6.
Bagheri Nejad S, Allegranzi B, Syed SB, Ellis B, Pittet D. Health-care-associated infection in Africa: A systematic review. Bull World Health Organ 2011;89:757-65.  Back to cited text no. 6
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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