title: Management of neonatal sepsis at Muhimbili National Hospital in Dar es Salaam: diagnostic accuracy of C-reactive protein and newborn scale of sepsis and antimicrobial resistance pattern of etiological bacteria.
abstract: BACKGROUND
  We determined the accuracy of Rubarth's newborn scale of sepsis and C- reactive protein in diagnosing neonatal sepsis and assessed antimicrobial susceptibility pattern of etiological bacteria.
  
  
  METHODS
  This cross sectional study was conducted at Muhimbili National Hospital in Dar es Salaam, Tanzania between July 2012 and March 2013. Neonates suspected to have sepsis underwent physical examination using Rubarth's newborn scale of sepsis (RNSOS). Blood was taken for culture and antimicrobial sensitivity testing, full blood picture and C - reactive protein (CRP) performed 12 hours apart. The efficacy of RNSOS and serial CRP was assessed by calculating sensitivity, specificity, negative and positive predictive values, receiver operating characteristics (ROC) analysis as well as likelihood ratios (LHR) with blood culture result used as a gold standard.
  
  
  RESULTS
  Out of 208 blood samples, 19.2% had a positive blood culture. Single CRP had sensitivity and specificity of 87.5% and 70.9% respectively, while RNSOS had sensitivity of 65% and specificity of 79.7%. Serial CRP had sensitivity of 69.0% and specificity of 92.9%. Combination of CRP and RNSOS increased sensitivity to 95.6% and specificity of 56.4%. Combination of two CRP and RNSOS decreased sensitivity to 89.1% but increased specificity to 74%. ROC for CRP was 0.86; and for RNSOS was 0.81. For CRP the LHR for positive test was 3 while for negative test was 0.18, while for RNSOS the corresponding values were 3.24 and for negative test was 0.43. Isolated bacteria were Klebsiella spp 14 (35%), Escherichia coli 12 (22.5%), Coagulase negative staphlococci 9 (30%), Staphylococcus aureus 4 (10%), and Pseudomonas spp 1 (2.5%). The overall resistance to the WHO recommended first line antibiotics was 100%, 92% and 42% for cloxacillin, ampicillin and gentamicin, respectively. For the second line drugs resistance was 45%, 40%, and 7% for ceftriaxone, vancomycin and amikacin respectively.
  
  
  CONCLUSIONS
  Single CRP in combination with RNSOS can be used for rapid identification of neonates with sepsis due to high sensitivity (95.6%) but cannot exclude those without sepsis due to low specificity (56.4%). Serial CRP done 12hrs apart can be used to exclude non-cases. This study demonstrated very high levels of resistance to the first-line antibiotics.
authors.affiliation: Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania. mmkony@gmail.com.
authors.forename: Martha Franklin
authors.initials: MF
authors.lastname: Mkony
authors.affiliation: Epidemiology Fogarty Fellow, The Dartmouth-Boston University Fogarty AIDS International Training and Research Program, Boston University, Boston, MA, USA. mucho_m2002@yahoo.co.uk.
authors.forename: Mucho Michael
authors.initials: MM
authors.lastname: Mizinduko
authors.affiliation: Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar esSalaam, Tanzania. dr.augustine.massawe@gmail.com.
authors.forename: Augustine
authors.initials: A
authors.lastname: Massawe
authors.affiliation: Department of Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar esSalaam, Tanzania. mateemecky@yahoo.com.
authors.forename: Mecky
authors.initials: M
authors.lastname: Matee
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016470:Bacteremia / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology*; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis*; D003428:Cross Infection / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology*; D024881:Drug Resistance, Bacterial; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008826:Microbial Sensitivity Tests; D011446:Prospective Studies; D012372:ROC Curve; D012680:Sensitivity and Specificity; D013636:Tanzania
chemical_list: D000900:Anti-Bacterial Agents; D015415:Biomarkers; D002097:C-Reactive Protein