Bacterial Profile, Antimicrobial Susceptibility Patterns, and Associated Factors of Puerperal Sepsis in Asella, Central Ethiopia: A Cross-sectional Study
Sepsis, caused by various bacterial pathogens, is a significant contributor to maternal mortality worldwide. In many developing countries, including Ethiopia, empirical or syndromic treatment is commonly employed for puerperal sepsis, which may promote antimicrobial resistance (AMR). We conducted a cross-sectional study to investigate bacterial pathogens, their antimicrobial susceptibility patterns, and associated factors among women with suspected puerperal sepsis attending Asella Referral and Teaching Hospital from September 2020 to August 2021. A total of 174 participants were enrolled, and the sociodemographic and obstetric data were collected using a pretested structured questionnaire and checklist, respectively. Blood samples (approximately 20 ml) were collected from all study participants and incubated in BacT/ALERT® 3D automated blood culture system. In addition, endocervical swabs were collected in Amies transport media. Bacterial isolation and identification were performed following standard bacteriological methods. Antimicrobial susceptibility profiles of bacterial isolates were determined using the disc diffusion method. Data were entered into EpiData version 4.6 and analyzed using SPSS version 25.0. The overall positivity rate of bacterial isolates among puerperal sepsis-suspected women was 48.9%. Among these, 87.1% of the isolates were Gram-negative bacteria. The most common isolates were Escherichia coli (54.1%), followed by Klebsiella spp. (23.5%) and Staphylococci aureus (10.6%). High resistance rates were observed in E. coli to piperacillin (87%), in Klebsiella spp. to aztreonam (65%) and ceftriaxone (65%), and in S. aureus to trimethoprim-sulfamethoxazole (66.6%). Multidrug-resistant bacterial pathogens accounted for 81.2% of the isolates in this study. Multivariate regression analysis did not reveal any statistically significant association between the presence of bacteria and the sociodemographic and obstetrics factors. Our findings emphasize the urgency of strengthening microbiology services to optimize patient management and combat AMR in puerperal sepsis.
[1] van Dillen, J.; Zwart, J.; Schutte, J.; van Roosmalen, J. Maternal Sepsis: Epidemiology, Etiology and Outcome. Curr. Opin. Infect. Dis., 2010, 23, 249–54.
[2] Say, L.; Chou, D.; Gemmill, A.; Tunçalp, Ö.; Moller, A.B.; Daniels, J.; Gülmezoglu, A.M.; Temmerman, M.; Alkema, L. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet Glob. Health, 2014, 2(6), e323–33.
[3] Bakhtawar, S.; Sheikh, S.; Qureshi, R.; Hoodbhoy, Z.; Payne, B.; Azam, I.; von Dadelszen, P.; Magee, L. Risk Factors for Postpartum Sepsis: A Nested Case-Control Study. BMC Pregnancy Childbirth, 2020, 20(1), 297.
[4] Demissie, D.; Seyoum, B.; Demena, M.; Demissie, D.; Seyoum, B.; Demena, M. Septicemia Bacterial Isolates and Drug Susceptibility Among Women Attending Delivery at Dilchora Hospital, Dire Dawa, Eastern Ethiopia. Ethiop. Med. J., 2019, 1(7), 23–30.
[5] Bloos, F. Diagnosis and Therapy of Sepsis. J. Emerg. Crit. Care Med., 2018, 2, 3.
[6] Burlinson, C.E.G.; Sirounis, D.; Walley, K.R.; Chau, A. Sepsis in Pregnancy and the Puerperium. Int. J. Obstet. Anesth., 2018, 36, 96–107.
[7] Atlaw, D.; Seyoum, K.; Woldeyohannes, D.; Berta, M. Puerperal Sepsis and its Associated Factors among Mothers in University of Gondar Referral Hospital, Ethiopia, 2017. Int. J. Pregnancy Child Birth, 2019, 5(5), 190–5.
[8] Admas, A.; Gelaw, B.; Tessema B, Worku, A.; Melese, A. Proportion of Bacterial Isolates, their Antimicrobial Susceptibility Profile and Factors Associated with Puerperal Sepsis among Post-Partum/Aborted Women at a Referral Hospital in Bahir Dar, Northwest Ethiopia. Antimicrob. Resist. Infect. Control, 2020, 9(1), 14.
[9] Arifin, W.A. Introduction to Sample Size Calculation. Educ. Med. J., 2013, 5(2), e89–96.
[10] Cheesbrough, M. District Laboratory Practice in Tropical Countries. 2nd ed., Vol. 2. Cambridge University Press, New York, 2005. p434.
[11] European Committee on Antimicrobial Susceptibility Testing. Breakpoint Tables for Interpretation of MICs and Zone Diameters. European Committee on Antimicrobial Susceptibility Testing. Vol. 9. Sweden, 2019. p1–99.
[12] Demisse, G.A.; Sifer, S.D.; Kedir, B.; Fekene, D.B.; Bulto, G.A. Determinants of Puerperal Sepsis among Postpartum Women at Public Hospitals in West SHOA Zone Oromia Regional STATE, Ethiopia (Institution BASEDCASE Control Study). BMC Pregnancy Childbirth, 2019, 19, 95.
[13] Kiponza, R.; Balandya, B.; Majigo, M.V. Laboratory Confirmed Puerperal Sepsis in a National Referral Hospital in Tanzania: Etiological Agents and their Susceptibility to Commonly Prescribed Antibiotics. BMC Infect. Dis., 2019, 19, 690.
[14] Majangara, R.; Gidiri, M.F.; Mike, Z. Microbiology and Clinical Outcomes of Puerperal Sepsis: A Prospective Cohort Study. J. Obstet. Gynaecol., 2018, 38(5), 635–41.
[15] Wilkie, G.L.; Prabhu, M.; Ona, S.; Easter, S.R.; Tuomala, R.E.; Riley, L.E.; Diouf, K. Microbiology and Antibiotic Resistance in Peripartum Bacteremia. Obstet. Gynecol., 2019, 133(2), 269–75.
[16] Tamboli, S.S.; Tamboli, S.B.; Shrikhande, S. Puerperal Sepsis: Predominant Organisms and their Antibiotic Sensitivity Pattern. Int. J. Reprod. Contracept. Obstet. Gynecol., 2016, 5(3), 762–5.
[17] Alsammani, M.A.; Babiker, R.A.; Ahmed, M.I. Microbial Profile in Women with Puerperal Sepsis in Gadarif State, Eastern Sudan. Ann. Trop. Med. Public Health, 2019, 6(4), 460–4.
[18] Bako, B.; Audu, B.M.; Lawan, Z.M.; Umar, J.B. Risk Factors and Microbial Isolates of Puerperal Sepsis at the University of Maiduguri Teaching Hospital, Maiduguri, North-Eastern Nigeria. Arch. Gynecol. Obstet., 2012, 285, 913–7.
[19] Kajeguka, D.C.; Mreme, N.R.; Mawazo, A.; Malya, R.; Mgabo, M.R. Factors and Causes of Puerperal Sepsis in Kilimanjaro, Tanzania: A Descriptive Study among Postnatal Women who Attended Kilimanjaro Christian Medical Centre. East Afr. Health Res. J., 2020, 4(2), 158–63.
[20] Elliyas, S.; Gaind, R.; Kanwal, S.K.; Singh, S.; Arya, S. Bacterial Colonization of Vagina in Indian Women during Labor and its Association with Puerperal and Neonatal Sepsis: A Tertiary Hospital Study. Cureus, 2021, 13(3), e13943.
[21] Ononuju, C.N.; Nyeugidiki, T.K.; Ugboma, H.A.A.; Bassey, G. Risk Factors and Antibiogram of Organisms Causing Puerperal Sepsis In A Tertiary Health Facility In Nigeria. Trop. J. Obstet. Gynaecol., 2015, 32(2), 73–82.
[22] Akerele, J.; Abhulimen, P.; Okonofua, F. Prevalence of Asymptomatic Genital Infection among Pregnant Women in Benin City, Nigeria. Afr. J. Reprod. Health, 2002, 6(3), 93–7.
[23] Kaur, T.; Mor, S.; Puri, M.; Sood, R.; Nath, J. A Study of Predisposing Factors and Microbial Flora in Puerperal Sepsis. Int. J. Reprod. Contracept. Obstet. Gynecol., 2016, 5(9), 3133–6.
[24] Abbas, M. Bacteriological Study of Puerperal Sepsis in Al-Najaf City. Al-Kufa Univ. J. Biol., 2016, 8(2), 143–51.
[25] Sokhn, E.S.; Salami, A.; El Roz, A.; Salloum, L.; Bahmad, H.F.; Ghssein, G. Antimicrobial Susceptibilities and Laboratory Profiles of Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis Isolates as Agents of Urinary Tract Infection in Lebanon: Paving the Way for Better Diagnostics. Med. Sci. (Basel), 2020, 8, 32.
[26] Effah, C.Y.; Sun, T.; Liu, S.; Wu, Y. Klebsiella pneumoniae: An Increasing Threat to Public Health. Ann. Clin. Microbiol. Antimicrob., 2020, 19(1), 1.
[27] Ingole, K.V.; Shendre, P.P. Study of Bacterial Isolates in Puerperal Sepsis & its Antibiotic Sensitivity Pattern. J. Med. Sci. Clin. Res., 2017, 5(3), 18563–8.
[28] Tong, S.Y.C.; Davis, J.S.; Eichenberger, E.; Holland, T.L.; Fowler, V.G. Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management. Clin. Microbiol. Rev., 2015, 28(3), 603–61.
[29] Mohsen, L.; Ramy, N.; Saied, D.; Akmal, D.; Salama, N.; Haleim, M.M.A. Emerging Antimicrobial Resistance in Early and Late-Onset Neonatal Sepsis. Antimicrob. Resist. Infect. Control, 2017, 6, 63.
[30] Bebell, L.M.; Ngonzi, J.; Bazira, J.; Fajardo, Y.; Boatin, A.A.; Siedner, M.J.; Bassett, I.V.; Nyehangane, D.; Nanjebe, D.; Bangsberg, D.R.; Riley, L.E.; Boum, Y.; 2nd. Antimicrobial- Resistant Infections among Postpartum Women at a Ugandan Referral Hospital. PLoS One, 2017, 12(4), e0175456.
[31] Östholm-Balkhed, Å.; Tärnberg, M.; Nilsson, M.; Johansson, A.V.; Hanberger, H.; Monstein, H.J.; Nilsson, L.E. Prevalence of Extended-Spectrum Betalactamase-Producing Enterobacteriaceae and Trends in Antibiotic Consumption in a County of Sweden. Scand. J. Infect. Dis., 2010, 42:831–8.
[32] Khaskheli, M.N.; Baloch, S.; Sheeba, A. Risk Factors and Complications of Puerperal Sepsis at a Tertiary Healthcare Centre. Pak. J. Med. Sci., 2013, 29(4), 972–6.