Neonatal sepsis is a clinical syndrome in an infant 28 days of life or younger, manifested by systemic signs of infection and isolation of a bacterial pathogen from the bloodstream (1, 2). According to the international pediatric sepsis consensus conference of 2005, neonatal sepsis can also be defined as systemic inflammatory response syndrome in the presence of or as a result of suspected or proven infection in a neonate which presents with clinical features of temperature instability, respiratory problems, feeding intolerance, and isolation of bacteria or other pathogens from the bloodstream(3). Neonatal sepsis occurs when pathogenic bacteria gain access into the blood stream causing overwhelming general infection. The most common isolated bacteria were gram-negative(4).
Neonatal sepsis is classified into two major categories based on the time of onset: Early-onset neonatal sepsis (EONS) and Late-onset neonatal sepsis (LONS). Early onset neonatal sepsis appears within the first seven days of life and is mainly due to bacteria acquired before and during delivery and most cases appear with in the first 24 hours(5). According to the World Health Organization (WHO) report in 2006, out of the 130 million live births every year, 4 million die within the first four weeks of life. Of these deaths, 99% occur in developing countries (6). Neonatal sepsis is accountable for 15% of global neonatal deaths and 30-50% of neonatal deaths in developing countries (7). In sub Saharan Africa, 17% of neonatal deaths are due to neonatal sepsis (8). Around 37% of Ethiopian neonates also died due to neonatal sepsis, which accounts for more than one third of neonatal deaths (9).
Sepsis is still one of the major causes of morbidity and mortality in neonates. In spite of recent advances in health care units, it is an ongoing major global public health challenge leaving the survivors vulnerable to short and long-term neurodevelopmental morbidity (10). Among those who survive, impaired quality of life, increased dependency, re-hospitalization, increase healthcare consumption, and along with increased mortality, all contribute the humanistic and economic burden of sepsis(11). Neonates could also face long-term survival with post infectious hydrocephalus (PIH), which could result in childhood mortality or survival with PIH with resulting neurological impairment and this long-term survival from sepsis with neurodevelopmental impairment could result in cerebral palsy or lifetime neurodevelopmental impairment without cerebral palsy; or uncomplicated recovery following an acute 2-week period of neonatal sepsis (12).
Different studies have been conducted in developed and developing countries to determine incidence density rate of neonatal mortality with sepsis. A study done in Brazil showed that the incidence and the incidence density of sepsis was 22% and 18.6 per 1000 central venous catheter-days, respectively. Considering very low birth weight neonates (VLBW) neonates as the reference group, the hazard ratio (HR) for time to death was 4.06 from day 0 to 60 and for time to the first episode of sepsis was 1.76 from day 0 to 36. Having the heavier neonates group as reference, the HR for time to the first episode of sepsis was 2.94 from day 37 to 90 (13).
A study conducted in Tanzania revealed a mortality rate of 19% in neonates with sepsis and high mortality is seen in early onset neonatal sepsis and showed a survival rate of 47% (14). Another study conducted in Uganda shows that mortality rate due to neonatal sepsis is 18.1% and most of the deaths (84%) occurred in the first 48 hours of admission(15). In Nigeria a study indicate that mortality rate due to sepsis was 15.7%. In this study, low birth weight was 7.2 times more likely to die compared to those who were appropriate for birth weight. Babies that had PROM were 2.5 times more likely to die(16). Another study done in Johannesburg, showed the overall mortality rate for neonatal sepsis was 1.7% (17).
A study done in Sub-Saharan Africa to estimate the incidence density rate of neonatal mortality among neonates the incidence density rate of mortality was significantly high. And the hazard of neonatal mortality in NICUs was increased by comorbidities like sepsis with the hazard of death of neonates with sepsis was 1.94 times than neonates free from sepsis (18).
A study in southern Ethiopia revealed that the incidence rate of mortality among neonates admitted with neonatal sepsis was 14.57 per 1000 neonate days. The cumulative proportion of surviving at the end of the fourth day was 99.5%, and it was 98.2% at the end of the fifth day. In addition, it was 96.6%, 93.5%, and 91.1% at the end of the sixth, seventh, and eighth day, respectively (1).
Prolonged rupture of membrane(>48hrs), maternal fever, and chorioamnionitis were found significant predictors of mortality of neonates with sepsis in a retrospective study conducted in Pakistan (19).
Efforts to reduce hospital acquired late onset infections require much closer attention to appropriate hand washing, infection control, and proper techniques for placement and management of central catheters (20). Antenatal corticosteroid treatment for accelerating fetal lung maturation for women at risk of preterm birth has been shown to reduce birth complications including the risk of neonatal sepsis (21).
Even though the impact of neonatal sepsis remains a public health problem in resource limited settings like Ethiopia, limited evidences exist to show the time to death and predictors of this serious public health problem in different parts of Ethiopia particularly in the study setting. Thus, determining the time to death and identifying its predictors among neonates with neonatal sepsis is very important for optimizing neonatal care.
Though Ethiopia has made considerable achievement in the reduction of under-five mortality rate, the neonatal mortality burden has not experienced the same reduction, which may be attributed to neonatal sepsis. Neonatal sepsis is a relevant public health issue because it consistently emerges as one of the main causes of neonatal morbidity and mortality. Therefore, evidence on time to death of neonates with sepsis and factors that predicts the death of neonates with sepsis in the area will provide knowledge for health professionals in early identification of high-risk neonates with sepsis and timely intervention for their better survival. It also enhances the current neonatal sepsis management strategies by making sure the various determinants contribute to neonatal sepsis. This study will also be used for future researchers as reference. Also identifying the predictors of neonatal sepsis will be helpful in designing strategies to prevent and/or treat neonatal sepsis. Therefore, the aim of this study is to determine time to death and identifying predicting factors for death among neonates admitted with sepsis at public hospitals of Bahir Dar city.