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In Dhaka, Bangladesh, in the month of December 2021, Mukta gave birth to a son, and it was immediately apparent to the attending medical staff that the newborn required immediate medical attention. After 11 years of trying to conceive, the 32-year-old woman (who only wants to be referred to by her first name) and her husband are now expecting their first child. It was necessary to perform an emergency caesarean delivery on her 32-week-old baby because of problems throughout her pregnancy.
Her baby was just 3 pounds when he was born and had to be placed on a ventilator. Antibiotics were also put into him to protect against neonatal sepsis, which is a potentially fatal bloodstream infection caused by germs.
Her son's health seemed to improve at first, but at 11 days old, he suddenly started to deteriorate. His blood oxygen levels dropped, making him feel sluggish. A blood test confirmed he had neonatal sepsis, but the doctors were at a loss to identify the offending microbe. No positive findings were found from a blood culture. Another injection of antibiotics, this time different from the previous, looked to be their best shot. This helped him until he had another bout of sepsis from the bug Serratia marcesens, which is a frequent cause of newborn illnesses. Sadly, there was no chance this time. No amount of medication seemed to help against the illness. Mukta lost the baby her much-anticipated child less than a month after giving birth to her heartbreakingly premature child.
It is believed that between 15% and 24% of all newborn fatalities are caused by sepsis over the globe. The terrible ailment, which might at first seem to be innocuous but then swiftly develop, is more frequent in newborns than it is in any other age group, and it is believed that three million infants all over the globe are afflicted with it. They have the potential to get contaminated with hazardous germs before, during, or after the birthing process, for example if the mother has an illness that may be passed on to their kid or if the environment is not sterile enough. Babies may have difficulty fending off the infection because their immune systems are not yet completely grown and have not had enough time to mature.
Particularly vulnerable are the newborns of less developed nations, who often have less access to medical treatment as well as clean medical equipment and facilities. It is projected that the incidence of newborn sepsis is 1.8 times greater in countries with a moderate income and 3.5 times higher in countries with a low income when compared with countries with more wealth. South Asia has one of the largest burdens of this life-threatening condition: 39% of all fatalities caused by neonatal sepsis occur in this area of the world.
Superbugs, or germs that have developed resistance to antibiotics, have emerged as a new threat, compounding the severity of infant sepsis. A phenomenon known as antimicrobial resistance, or AMR, may render medical professionals impotent in the face of rampant illnesses. Formerly helpful medications are now ineffective, and the patient's life continues to deteriorate despite everyone's best efforts to save it.
Professor of neonatology at Bangladesh's Bangabandhu Sheikh Mujib Medical University, Mohammed Shahidullah, has observed that "increasing antibiotic resistance in underdeveloped nations is making the issue of newborn sepsis more worse." In addition to his work as the head of the Bangladeshi medical team trying to preserve Mukta's newborn, he also serves as the leader of the country's National Technical Working Committee (NTWC) on Newborn Health. "One of the leading reasons for newborn hospitalization and mortality in Bangladesh is currently neonatal sepsis. Experiencing such a loss is really painful."
How, however, could the overuse of antibiotics—which have saved countless lives since their introduction in the 1940s—accidentally generate a super-threat to the world's most vulnerable infants?
The isue of superbugs
Sheikh Hasina, prime minister of Bangladesh, cautioned global leaders in 2021 that if antimicrobial resistance wasn't tackled, it might become an even worse public health problem than Covid-19. Scientists had been sounding the alarm for years before to then about how antibiotic overuse was becoming a concern.
Superbugs are a serious problem for hospitals throughout the globe since they are resistant to several antibiotics. Antibiotics are able to eradicate the vast majority of germs, but certain strains are able to persevere thanks to antibiotic-resistant genes. They proliferate, and via a process called horizontal gene transfer, the drug-resistance genes they carry may be passed on to other bacteria, even other species of bacteria, in the area.
Because of this, hospitals risk becoming incubators for drug-resistant strains, and potent medications gradually lose their potency. Because of this, adds Shahidullah, germs causing sepsis in newborns in a hospital are far more likely to be resistant to the current treatments than bacteria causing the same illness in a child after he or she returns home.
To prevent this resistance, experts advise only taking antibiotics when absolutely necessary, rather than liberally doling them out and therefore essentially teaching germs to survive them.
Yet, in the meanwhile, superbugs that are a result of antibiotic misuse are already causing havoc. Urinary tract infections, sepsis, and other illnesses are becoming more difficult to treat, placing at risk those who are already weak. And babies make up an especially susceptible population in this regard.
The "invisible" infant
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A research from the Global Antibiotic Research and Development Partnership found that although children under age 5 death has decreased dramatically over the last several decades, "neonatal survival has lag. The risk of sepsis is high and may be fatal: "An infant with sepsis may be in immediate danger if not treated. A baby's chances of surviving neonatal sepsis are further diminished by drug resistance "says the paper. It may mean that physicians attempt every possible medicine, as they did with Mukta's kid, only to discover that nothing helps.
Sally Ellis, the head of GARDP's children's antibiotics program, says, "The main obstacle in treating sepsis in newborns is knowing which organism is causing the infection. In certain circumstances, it is not always feasible to isolate, or even detect whether they have an infection." She explains that the lack of good diagnostic techniques and the prevalence of other illnesses that mimic sepsis make identification difficult, particularly in premature newborns.
According to a different research, bacterial antibiotic resistance will be directly responsible for the deaths of roughly 140,000 newborns throughout the world in 2019. However, the GARDP study states, "babies remain overlooked and unseen within the wider response to antibiotic resistance."
To better comprehend the effects of medicines resistance, GARDP and its colleagues analyzed 3,200 instances of newborn newborns with clinically confirmed sepsis. The primary goal of this study was to determine which antibiotics are now being used to treat sepsis in infants and how much their effectiveness has been diminished due to drug resistance. It included 19 hospitals in 11 nations on 4 continents with varying degrees of wealth.
One major discovery was the widespread use of "rescue" medications in hospitals to treat neonates with sepsis after the first line of treatment failed. Just 13% of the infants received the conventional first-line antibiotics amoxicillin and gentamicin. Surprisingly, 15 percent of the infants were given the very potent antibiotics known as carbapenems, which are only used as a last resort.
"This is frightening and foretells the approaching problem of a scarcity of medicines to treat sepsis caused by multidrug-resistant pathogens," the researchers said.
That is to say, when conventional treatments fail, physicians turn to even more extreme measures, such as the use of so-called "last-resort" medications.
The journey of Sepsis Investigation
Data from the Center for Disease Dynamics, Economics, and & Policy, a public health research organization located in the United States and India, show that around twenty percent of India's annual one million newborn fatalities are attributable to sepsis (CDDEP). An estimated 58,000 of these fatalities may be traced back to the ineffectiveness of antibiotics. Because of gaps or omissions in data, it is difficult to assess the scope of the crisis in certain nations. Neonatologist M. Jeeva Sankar of New Delhi's All India Institute of Medical Sciences said the issue is under-researched even in India.
As of this writing (February 2019), Sankar and coworkers searched two of the most comprehensive databases of scholarly literature for reports on neonatal sepsis. Despite the fact that Asia is home to a sizable fraction of the global populace, they discovered that relatively little information about sepsis is available across the continent.
From January 2000 to August 2018, only 64 studies were conducted on neonatal sepsis, despite the fact that "25 million infants are born in India every year, about the size of Australia's population." "Comparatively, 16 studies were published in Pakistan at that period, 6 in Bangladesh, and 1 in Sri Lanka. Enhanced research necessitates an increase in both data collection and monitoring efforts."
In a study published in the British Medical Journal, they discussed this massive data gap, noting that South Asia and sub-Saharan Africa are especially hard hit by newborn sepsis, making it all the more vital to obtain trustworthy data there. They also point out that "spiraling antimicrobial resistance" is making an already precarious situation even worse, since newborns living in poverty and with limited access to healthcare are more likely to develop sepsis.
Shyam Sundar Budhathoki, a doctor at Imperial College London specializing in public health who formerly worked in Nepal, argues that early diagnosis of sepsis may assist, but that in low-income countries, where the diagnostic facilities are poor, the misdiagnosed and unreported cases remain high. As a result, "goals in public health are defined based on immediate and obvious problem-solving priorities," he argues, which means that drug resistance in these nations may not get the attention it requires. Thus, other risks to babies' health, such as general infections or malnutrition, may seem more serious. This may lead to the "ignorance" of a more complicated causal chain, such as antibiotic resistance leading to newborn fatalities from sepsis.
Fesh information uncovered by the research
Nonetheless, there have been some new, possibly ground-breaking findings discovered by researchers that might aid in the battle against drug-resistant neonatal sepsis. For instance, newborn sepsis bacteria in high-income nations are fundamentally different from those in low- and middle-income regions when it comes to their prevalence and pathogenicity. Since this is the case, how we treat them will change.
To identify bacteria, a test called the Gram stain test is utilized, and Sankar claims that a disproportionate percentage of cases of newborn sepsis in more developed nations are caused by Gram-positive bacteria. Notably, just a few bacterial species, such as particular strains of Streptococcus (normally present in the intestines and the mother's vaginal system) and Staphylococcus (found on the surface of the skin), seem to be responsible for the vast majority of these occurrences.
Infections "caused by Gram-negative bacteria, generally found in the gut," said Sankar, tend to be more common in poor and medium income nations. Inadequate sanitary conditions might play a role in this. These Gram-negative sepsis infections also seem to be caused by a large variety of diverse bacteria, and they often display significant rates of antibiotic resistance.
That's why, he adds, "neonatal sepsis mortality is higher in low- and middle-income countries than in wealthy ones." Due to the wide variety of microorganisms, standardizing the treatment approach "the way it is done in the West" is more challenging.
Instead, medical professionals in developing nations must determine what organism caused the sepsis, cross their fingers that it shows up in the tests, and then determine whether or not the condition is curable with the drugs they have available.
The use of many of the existing last-ditch antibiotics is fraught with danger because of the potential for catastrophic adverse effects in patients, especially in infants. However, it is hoped that new strategies for treating drug-resistant bacteria may be developed via the use of combinations of many antibiotics at once that are still safe for infants to take. However, access to these sophisticated alternatives to antibiotics is still restricted in low-resource areas of the world.
The Conquest of Superbugs
Antibiotic resistance is a frightening problem, but physicians and patients have another, more fundamental weapon: excellent hygiene. In the past, it was thought that if a newborn became ill during the first three days of life, it was because of germs they had picked up through their mother's vaginal canal or digestive system. Later-onset sepsis was attributed to improper cleanliness practices in the neonatal intensive care unit or at home. Recent years, however, have shown that this perspective may be more complex.
On the other hand, recent studies, such as one conducted by Sankar and colleagues, have shown that the bacteria responsible for early and late-onset sepsis are not all that dissimilar from one another. It's possible that inadequate cleanliness is a factor in many instances of sepsis, including those that occur shortly after delivery.
As a result, "the requirement for disinfection and maintaining a process that provides a clean, sanitary atmosphere is immensely crucial," adds Sankar. However, a WHO/UNICEF research published in 2022 found that basic soap and water were insufficient in half of the world's healthcare facilities, increasing the risk of infection in pregnant women and infants.
The use of sterile gowns in critical care units, the swabbing and cleaning of surfaces and equipment, and the disinfection of a newborn's skin prior to the administration of injections or drips are all examples of additional easy actions that may assist avoid infection in hospital settings. It is important to inform parents about proper cleanliness, but putting these policies into action also needs training and sufficient manpower, as Shahidullah points out.
While hospitals aren't immune to the threat of superbugs, they do provide a safer choice for mothers in Bangladesh, which is why the country is actively trying to get more women to give birth there. Despite the increased risk of infection, over half of Bangladeshi women still give birth at home. The prevalence of neonatal sepsis among infants delivered to moms in Nepal who did not get prenatal care is more evidence of the need of providing resources to expectant women.
Experts agree that in the end, a diverse set of resources will be necessary to combat the drug resistance challenge.
Abdul Ghafur, a specialist in infectious diseases at the Apollo Cancer Institute in the Southern Indian city of Chennai, says, "For more broad change, we need to address antimicrobial resistance as a socio-political concern and not only a medical one." He is an outspoken advocate for reducing the spread of antibiotic-resistant bacteria with his fellow Indian medical professionals. In order to combat [antimicrobial resistance] and stop re-infection in children, "proper cleanliness at home, in healthcare facilities, and in communities is crucial."
As he puts it, "Covid has showed us that India can be the pharmacy of the world and generate state-of-the-art pharmaceuticals," demonstrating the urgency with which new antibiotics must be developed.
Ghafur recommends prioritizing the development of diagnostics to swiftly determine the infectious agent. "The mortality rate may be drastically reduced if physicians had access to a quick diagnostic test that let them administer the most effective antibiotic within one hour. Although certain germs have become immune to current antibiotics, there is still hope for a cure "I quote what he has to say. He thinks this is something that has to be worked on internationally, with governments and businesses cooperating.
Unfortunately, these developments are too little, too late for families like Mukta's, who lost a kid to sepsis. Yet, addressing the shortage of antibiotics and the associated risk of infection during childbirth might enable more parents to provide a healthy start for their newborns and more physicians to save the lives of their patients.
That brings us to the conclusion. I want to express my gratitude to you for taking the time to read this post, and I pray that God will richly reward you.
Shah, Arpita Jigar, et al. “Neonatal Sepsis: High Antibiotic Resistance of the Bacterial Pathogens in a Neonatal Intensive Care Unit of a Tertiary Care Hospital - PMC.” PubMed Central (PMC), www.ncbi.nlm.nih.gov/pmc/articles/PMC3743139. Accessed 28 Sept. 2022.
Thiagarajan, Kamala. “Neonatal Sepsis: The New Threat Posed by Superbugs.” Neonatal Sepsis: The New Threat Posed by Superbugs - BBC Future, Sept. 2022, www.bbc.com/future/article/20220927-neonatal-sepsis-the-new-threat-posed-by-superbugs.
admin. “Neonatal Sepsis: The New Threat Posed by Superbugs – Health Care Today!” Health Care Today!, 28 Sept. 2022, healthcaretoday.news/news/neonatal-sepsis-the-new-threat-posed-by-superbugs.