Research Journal of Recent Sciences ________________________________________________ ISSN 2277 - 2502
Vol. 1(ISC-2011), 275-280 (2012)
Res.J.Recent.Sci.

Emergence of multi-drug-resistant Klebsiella pneumoniae in Neonatal
Intensive Care Units: concern about antimicrobial policies
Shah Manisha N. and Desai Pratibha B
Department of Microbiology, Shree Ramakrishna Institute of Computer Education and Applied Sciences, M.T.B. college campus, Athwalines,
Surat-395 001, Gujarat, INDIA

Available online at: www.isca.in
(Received 29th October 2011, revised 1st January 2012, accepted 5th March 2012)

Abstract
Antimicrobial abuse is a serious risk factor for the emergence of multi-drug-resistant (MDR) pathogens. Multidrug resistant
(MDR) Klebsiella pneumoniae is an increasing cause of neonatal infections in India and in other developing countries.
Objective of this study was designed to monitor temporal change in prevalence of K. pneumoniae as a causative organism for
neonatal infections and its antimicrobial sensitivity pattern. Neonatal infections are clinical syndromes characterized by signs
and symptoms of infections in the first month of life. 550 blood cultures were studied from suspected babies and the
prevalence of K. pneumoniae among them was checked with its antimicrobial susceptibility and case fatality rate at
Department of Microbiology, SRICEAS, Surat, Gujarat. Among 550 suspected neonates in the study period, positivity was
found in 110 cases. Among them, 23 cases were found due to Klebsiella pneumoniae infections, 60.86% of them were fatal.
High degree of resistance to many antibiotics can be seen(%). Most of our strains were shown their resistance to most of the
third generation of cephalosporins used. The incidence of neonatal infections due to K. pneumoniae was higher. All spp. of
K. pneumoniae found as M.D.R., which was in co relevance with the mortality caused by them which knocking and shocking
data, indicating the emergence to check on the cruelty use of antimicrobials in NICUs.
Key words: Multi drug resistant, neonatal infections, klebsiella pneumoniae, case Fatality

Introduction
Neonatal deaths account for over a third of the global burden
of child mortality1. In many developing countries neonatal
mortality rates (deaths in the first 28 days of life) are as high
as 40–50 per 1000 live births2,3, with infections being the
major cause of death4,5. Sepsis is a significant cause of
morbidity and mortality in neonates6.
Neonatal sepsis is defined as a disseminated disease with
positive blood culture during the first month of life7, and is
more common in developing countries compared with
developed countries8. Sepsis with Gram negative
microorganisms is increasingly reported nowadays
particularly in Asian countries9,10. The inadvertent use of
broad-spectrum antibiotics has led to the emergence of
multidrug resistant Gram-negative bacteria11. Klebsiella
species are of significant importance in this regard12. The
most common pathogens of bacterial sepsis and antibiotic
sensitivity patterns vary in different parts of the world13-15.
The potential for antimicrobial resistance is particularly
important for the treatment of systemic infections as initial
antimicrobial chemotherapy is almost invariably empiric and
must be based on knowledge of the most frequently isolated
etiological agents and their antimicrobial susceptibility
patterns. Early initiation of appropriate antimicrobial

treatment is critical in decreasing morbidity and mortality
among patients with bloodstream infections.
Knowledge of local epidemiology is required for optimal
management of neonatal sepsis. This study was undertaken
to monitor temporal change in prevalence of K. pneumoniae
as a causative organism for neonatal infections and its
antimicrobial sensitivity patterns from blood cultures of
neonates admitted to neonatal care unit, Surat, Gujarat, India.

Material and Methods
Blood samples were collected from 550 clinically suspected
neonates (<30 days) admitted to the Neonatal Intensive Care
Unit (N.I.C.U.), Surat, Gujarat, India over a period of 10
months. Their blood samples were inoculated into previously
sterilized Brain Heart Infusion Broth (BHI, Himedia, and
Mumbai, India) in ratio of 1:10. The inoculated blood culture
bottles were incubated at 37oC for 24 hours and the growth
of the microorganisms was observed. The culture bottles
showing turbidity were used for the isolation and cultivation
of bacteria using generalized, enriched and selective media.
Isolates were identified using standard biochemical tests.
Antimicrobial
susceptibility
tests:
Antimicrobial
susceptibility tests were performed using the Kirby Bauer

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Research Journal of Recent Sciences ____________________________________________________________ ISSN 2277 - 2502
Vol. 1(ISC-2011), 275-280 (2012)
Res.J.Recent.Sci
disc diffusion method as per CLSI guidelines. Antimicrobial
used were Amikacin (30μg), Augmentin(50μg), Ceftriaxone
(30μg), Cefotaxime (30μg), Ceftazidime (30μg), Cefazoline
(30μg),
Cefpirome
(30μg),
Cefipime
(30μg),
Cefotaxime/sulbactum (30/15μg), Clindamycin (2μg),
Ciprofolxacin (5μg), Chloramphenicol(25μg), ,Gentamycin
(10μg), Imipenum(10μg), Kanamycin (30μg), Meropenum
(10μg), Methicillin (30μg), Nalidixic acid (30μg),
Netromycin (30μg), Piperacilin / Tazobactum (100/10μg),
Vancomycin (30μg).

Results and Discussion
Blood samples for culture were obtained from 550 suspected
cases of neonatal infections, of which 110 (20%) were
positive. Table1 shows the gender wise distribution,
indicating the high ratio of male patients (71%) dominating
female (29%), therefore the ratio of male: female is 2.5:1.
The Gram-negative bacterium most commonly isolated was
Escherichia coli (n=35) followed by Klebsiella spp. (n=23).
The positivity as per isolates presented in figure 1. Among
110 culture positive cases, 36 (32.72%) of neonates died.
In our study, mortality caused by neonatal infections had
surprising results. If we see the distribution of isolates, Gram
negative E.coli found as the most prominent organisms among
all Gram negative organisms causing infections, but the
mortality rate was highest in neonates infected with Klebsiella
spp. (14/60,86%) and therefore found Klebsiella sp. as the
most important organisms of concern.
Very different, susceptibility pattern was found in Klebsiella
spp. compare to all other isolates and can be correlated with
its high fatality rate. Table 2 shows antibiogram results and
presence of high frequency of MDR (21/23) knocking the
emergence of prevention of neonatal infections.
Most of the isolates of Klebsiella spp. were found to be more
susceptible
to
Amikacin,
Imipenum,
and
Piperacillin/Tazobactam, but they were resistant to the third
generation of Cephalosporins. Figure 2 shows the
antimicrobial susceptibility test.
Figure 3 represented outcome of cases of neonatal patients, 54
patients were recovered from illness and discharged while 23
patients were discharged against medical advice (DAMA).
Case fatality rate of sepsis was 33 (four cases among these
were due to the infections with C. albicans). A large number
of neonatal deaths are still due to infection etiology and it is
mainly in the premature and low birth weights babies.
Formulation of strict antibiotic-prescription guidelines by the
policy makers and their ground level implementation by the
concerned authorities is the need of the hour for India.
Frequent surveillance studies from different regions across
the world that could help in updating the empirical antibiotic

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regimen for the neonates admitted to NICUs are highly
recommended.
Gram-negative bacilli are frequently associated with
infections in the patients admitted to the intensive care units
of hospitals16, and the incidence of infection is higher in the
neonatal period than at any time of life17. Moreover, the
problem of global antibiotic resistance continues to worsen18.
In this study, the prevalence of documented neonatal
infection with positive blood culture was 20%. This
incidence was lower than the prevalence of positive blood
cultures in Rahman et al.19 study (62.8%) and Bhttacharjee et
al., study (48%)20. The lower prevalence of documented
neonatal sepsis with positive blood culture in our study had
different reasons such as antibiotic administration in mother
or neonate, difficulty in sampling, blood culture technique21
or sepsis due to anaerobic, viral or fungal pathogens22 and
misdiagnosis because of some similarities between the
clinical signs of sepsis with other diseases like metabolic
disorders23.
The mortality was higher in neonates whose blood culture
were positive for isolates as shown above, Similar results
were obtained by many studies in Iraq24-27.
In case of Klebsiella sp., high degree of rrsistance to many
antibiotics can be seen. Most of our strains were shown their
susceptibility to amikacin and to the comnbinstion of
cavulinic acid+ sulbactum and show 100% sensitivity ti
imipenum, while resistance to most of the third generation of
cephalosporins used.
Neonatal infections remain a major cause of mortality in this
age group. As there is a trend of changing pattern of
organisms responsible for bacterial infection in the newborn,
the possible changing nature of the bacterial pathogen at the
neonatal unit needs further monitoring and periodic
surveillance, and there is a need to establish and review local
antibiotic sensitivities of pathogens for optimal therapy. With
early diagnosis and treatment, introduction of new antibiotics
and increased awareness of proper hand washing practice,
the neonatal mortality and morbidity can be reduced
markedly.

Conclusion
Neonatal infection, a clinical syndrome, characterized by
systemic signs and symptoms of first month of life. It
encompasses systemic infections of newborn including
meningitis, pneumonia, arthritis osteomyelitis and urinary
tract infections of the newborn. It is one of the commonest
causes of Neonatal mortality and morbidity and estimated
that 20% of all neonates develop infections, and it is
responsible for 30-50% of total neonatal dearth in developing
countries. As Neonatal infections are a life-threatening
emergency and delays in diagnosis and treatment may have
adverse consequences, surveillance is needed to identify the

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Research Journal of Recent Sciences ____________________________________________________________ ISSN 2277 - 2502
Vol. 1(ISC-2011), 275-280 (2012)
Res.J.Recent.Sci
common symptoms and signs, causative agents and their
antibiotic sensitivity patterns.
In our study, the incidence of culture proven sepsis was
observed to be 20 %. Epidemiologically infections were
predominantly seen in males. Among blood culture isolate,
Gram negative organisms were most common in compare to
Gram positive, fungal sepsis was observed in 9% of the
cases. High degree of antibiotic resistance seen in Klebsiella
isolates and can be correlated with the fatality rate caused by
them.
Most of the isolates of Klebsiella spp. were susceptible to
amikacin, but shown resistant to third generation of
cephalosporins. High prevalence of MDR was the stinking
feature of this study and justifies the purpose of the study.

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Table-1
Gender wise distribution of patients
No of suspected septicemias
550
390
160

Patient’s characteristics
No. of neonates
No. of male
No. of female neonates

No of positive blood cultures
110
78
32

Table-2
Antibiogram of Klebsiella sp.
ISOLATES-NO
Antibiotics
Amikacin
Augmentin
Ceftriaxone
Cefotaxime
Ceftazidime
Cefazoline
Cefpirome
Cefipime
Cefotaxime+sulbactum
Clindamycin
Ciprofolxacin
Chloramphenicol
Gentamycin
Imipenum
Kanamycin
Meropenum
Nalidixic acid
Netromycin
Piperacilin + Tazobactum
Antibiotics
Amikacin
Augmentin
Ceftriaxone
Cefotaxime
Ceftazidime
Cefazoline
Cefpirome

88
S
S
S
S
M
M
M

2
S
R
S
R
R
R
M
S
S
S
R
S
S
S
S
S
R
S
S
89
S
R
R
R
S
R
R

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90
S
R
R
R
S
R
R

12
S
R
R
R
R
R
R
R
S
S
S
S
R
S
R
S
R
M
S
92
S
R
R
R
S
R
R

23
S
R
R
R
R
R
R
R
S
S
S
S
R
S
R
S
R
S
S
93
S
S
S
S
S
S
S

30
S
R
R
R
R
R
R
R
S
S
S
S
R
S
R
S
R
M
S

31
S
R
R
R
R
R
S
S
S
S
S
R
R
S
R
S
R
S
S
95
S
M
S
S
R
R
M

110
R
R
R
R
R
S
R

34
S
R
R
R
R
R
M
M
S
S
S
S
S
S
S
S
R
S
S
125
S
R
R
R
R
R
S

35
R
R
R
R
R
R
S
S
S
M
M
S
S
S
S
R
R
R
R
143
S
R
R
R
R
M
R

45
S
S
S
S
S
S
M
S
S
R
S
S
M
S
S
R
S
R
R
144
S
R
R
R
S
R
R

48
S
S
R
S
R
R
R
S
S
R
M
S
S
S
S
S
M
R
S

54
S
S
S
S
S
S
R
M
S
M
M
S
M
S
S
R
R
R
S
159
S
R
M
R
R
R
R

76
S
R
R
R
S
R
R
M
S
R
S
S
R
S
S
R
S
R
R
193
S
S
R
R
R
R
R

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Vol. 1(ISC-2011), 275-280 (2012)
Res.J.Recent.Sci
Cefipime
Cefotaxime+sulbactum
Clindamycin
Ciprofolxacin
Chloramphenicol
Gentamycin
Imipenum
Kanamycin
Meropenum
Nalidixic acid
Netromycin
Piperacilin + Tazobactum

M
S
S
S
S
M
S
S
R
S
S
S

M
S
M
S
S
R
S
S
R
S
R
R

M
S
M
S
S
R
S
S
R
S
R
S

M
S
M
S
S
R
S
S
R
S
R
S

S
M
R
S
R
S
S
S
R
S
S
M

R
S
R
R
S
R
S
S
R
R
S
R

R
R
R
R
M
R
S
S
R
S
R
S

M
R
R
S
R
R
M
S
R
S
R
S

R
S
R
S
R
R
R
S
R
S
R
S

R
R
R
R
R
R
M
S
R
M
R
S

R
R
S
M
R
R
S
S
R
R
R
R

M
R
R
R
S
R
S
S
R
S
R
M

Figure-1
Positivity rate of each isolate

35
30
25
20
15
10
5
0

Figure-2
Antimicrobial susceptibility Test

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Research Journal of Recent Sciences ____________________________________________________________ ISSN 2277 - 2502
Vol. 1(ISC-2011), 275-280 (2012)
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Figure-2
Outcome of patients of NICU
60
50

40
30

20
10
0
Discharged

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DAMA

Death

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