| Abstract|| |
Background: Increasingly, women in rural areas in Sudan reported to hospital with puerperal sepsis. Aims: This study was design to identify the common pathogens causing puerperal sepsis and their susceptibility to current antibiotics. Materials and Methods: We prospectively studied 170 women from January 2011 through December 2012 who attended Hussein Mustafa Hospital for Obstetrics and Gynecology at Gadarif State, Sudan. We included patients if they met the criteria proposed by the World Health Organization (WHO) for definition of puerperal sepsis. Results: Out of the 170 patients, 124 (72.9%) were pathogen-positive samples. Out of 124 positive isolates, aerobes were the predominant isolates 77 (62.1%) which included Staphylococcus aureus 49 (39.5%), Staphylococcus epidermidis 7(5.6%), and Listeria monocytogenes 21 (16.9%). The anaerobe isolates were Clostridium perfringens 34 (27.4%) and Enterobactor cloacae 13 (10.5%). Standard biochemical test were for bacterial isolation. Higher rate of infections followed vaginal delivery compared to Cesarean section, 121 (97.6%) and 3 (2.5%), respectively. All strains of Staph were sensitive to vancomycin, gentamicin, and ceftriaxone. C. perfringens were sensitive to ceftriaxone, penicillin, vancomycin, and metronidazole, while E. cloacae was sensitive to gentamicin and ceftriaxone. Conclusion: In this study, the main bacteriological isolates were S. aureus, S. epidermidis, L. monocytogenes, C. perfringens, and E. cloacae. Despite the limited resources in the developing countries, treatment based on cultures remains the only solution to reduce maternal morbidity and mortality rates following puerperal sepsis.
Keywords: Antibiotic susceptibility, bacterial pathogens, maternal sepsis, morbidity, mortality, puerperal sepsis, Sudan
|How to cite this article:|
Ahmed MI, Alsammani MA, Babiker RA. Microbial profile in women with puerperal sepsis in Gadarif State, Eastern Sudan. Ann Trop Med Public Health 2013;6:460-4
|How to cite this URL:|
Ahmed MI, Alsammani MA, Babiker RA. Microbial profile in women with puerperal sepsis in Gadarif State, Eastern Sudan. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Jan 25];6:460-4. Available from: http://www.atmph.org/text.asp?2013/6/4/460/127801
| Introduction|| |
Puerperal sepsis is still a significant cause of morbidity and mortality among women in the developing countries. The Millennium Development Goal 5 (MDG5)  of reducing the maternal mortality ratio by 75% between 1990 and 2015 is unlikely to be achieved in Africa, because there was no progress that has been made to achieve such goals. Most of the current strategies in the developing world are focusing on emergency obstetric care. In Sudan, the mortality rate was 1,363 per 100,000 during 1995-1999 and sepsis was found to be the main cause of death in one-third of cases. Furthermore, it was the leading cause of maternal mortality during 1985-2000.  Those who survive may develop serious complications as a result of puerperal sepsis, such as infertility and chronic pelvic pain. , It is a common practice in the developing world to give antibiotics empirically. However, treatment based only on symptoms and clinical diagnosis can be misleading, and it can result in serious complications. , The importance of bacteriological studies of the causative agents in puerperal sepsis can lead to much reduction of morbidity and mortality from this sepsis. The present study was conducted to determine the exact pathogenic infections in women with puerperal sepsis, and their susceptibility test to the currently used antimicrobial therapy in a rural hospital in Sudan.
| Materials and Methods|| |
This prospective cross-sectional study was conducted at Hussein Mustafa Hospital, Department of Obstetrics and Gynecology in Gadarif State, Eastern Sudan, during the period from January 2011 to December 2012. Hussein Mustafa Hospital is a governmental teaching hospital, located in the center of the Gadarif city. The study was approved by the Hospital Ethical Committee and an inform consent was obtained from each patient. Hundred and seventy patients who had puerperal sepsis (World Health Organization (WHO) definition) were included in this study. Puerperal sepsis was defined as infection of the genital tract occurring at any time between the rupture of membranes or labor, and 42 days postpartum in which two or more of the following are present: 1) Pelvic pain; 2) fever, that is, oral temperature 38°C or higher on any occasion; 3) abnormal vaginal discharge, for example, presence of pus; 4) abnormal smell/foul odor of discharge and delay in the rate of reduction of the size of uterus (<2 cm/day during the first 8 days).  To ensure avoiding concomitant infections, the blood samples were collected by trained laboratory technicians. Patients included were admitted in within the first 2 weeks after delivery.
Hundred and seventy blood samples were collected from the admitted cases to the gynecological ward diagnosed as puerperal sepsis. Twenty milliliter of venipuncture blood was drawn into two bottles of blood culture under aseptic condition, and specimens were immediately transferred to the laboratory for bacteriological examination to ensure viability of causative agents.
Two bottles of blood culture (Plasmatic Ltd, UK) were incubated, one aerobically and the other anaerobically at 37°C for 24-48 h. Presumptive turbidity growth in the blood culture bottles were subcultured in aerobic and an anaerobic condition into blood agar and nutrient agar plates (Plasmatic Ltd, UK) at 37°C for 24-48 h before discarding the plates after 3 days as described by Barrow and Feltham. 
Examination of presumptive culture
The presumptive culture of the plate cultures were examined morphologically with the naked eye (size, pigment, edge, etc.) and Gram's stain. Organisms that had pure growth were subjected to subsequent different biochemical tests for species identification, according to methods described previously by many workers ,, (Barrow and Feltham 1993, Ochei and Kolhatkar 2000, Cheesbrough 2000).
Susceptibility to antibiotics
The isolated bacteria were subjected to antibiotics susceptibility test for numbers of antibiotics routinely uses in hospital which including; penicillin (10 mg), ampicillin (10 mg). Vancomycin (30 mg), metronidazole (5 mg), gentamicin (10 mg), methicillin (10 mg), ceftriaxone (30 mg) by disc diffusion technique (Kirby-Bauer method). These antibiotics discs were commercially prepared (Plasmatic Ltd., UK). The result was reported by measured zone of the inhibition growth in millimeter around antibiotic discs according to the National Committee for Clinical Laboratory Standards (NCCLS) for different zone diameter standards to determine sensitive, intermediate, or resistant strains described by Barrow and Feltham,  Ochei and Klhalter,  and Cheesbrough. 
Strips were used to detect the presence of β-lactamase enzyme rapidly. Two to three colonies of the tested organism was taken from the plate performed for antibiotic susceptibility test containing Penicillin G and Cephalosporin as described by Monnet.  Change in color of the test strip from purple to yellow in the area of inoculation within 5-10 min was considered a positive β-lactamase test according to the manufacturer procedure (Abtek Biologicals Ltd, Liverpool).
Methicillin-resistant Staphylococcus aureus (MSRA) strips test: Strips color were used to confirm rapidly MSRA as described by Dominique.  According to the manufacturer procedure (Abtek Biologicals Ltd., Liverpool) change in color from purple to yellow.
The Statistical Package for the Social Sciences (SPSS, version 15 for Windows) was used for data recording and statistical analyses. The descriptive analyses used included the mean, standard deviation (SD), and frequency distribution.
| Results|| |
The total study population comprised 170 women with puerperal sepsis, diagnosed by the clinician according to the history, symptoms, and signs.
The mean maternal age of patients was 25.48 years (range: 17-35). Out of 170 admitted cases, 124 (72.9%) patients had positive bacterial blood culture; whereas in the remaining patients, 46 (27.1%) no potential pathogens were isolated. The majority of these isolates were aerobic bacteria 77 (62.1%), and the anaerobic bacteria were isolated from 34 (27.4%) patients. The age group of 21-25 years had the highest rate of infection (44, 35.5%), followed by the age group of 26-30 years (31, 25%), while those at the extreme of age in 20 or less years were 26 (21%), and 31 years and more had the lowest rate of infection (23, 18.5%) [Table 1].
|Table 1: Distribution of women with puerperal sepsis at different age groups (n = 124)|
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Out of 124 of the isolates, S. aureus was the most prevalent organism 49 (39.5%) of which MRSA was 41% (n = 41/49); followed by Clostridium perfringens, which constituted 34 (27.4%); Listeria monocytogenes showed prevalence of 21 (16.9%); Enterobacter cloacae 13 (10.5%); and S. epidermis was identified in 5.6% (n = 7) of cases as shown in [Figure 1].
|Figure 1: Types of bacterial isolates from women with puerperal sepsis (n = 124)|
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The results showed that the highest rate of infection was among women who delivered vaginally (121, 97.6%) compared to those who delivered by Caesarean section (3, 2.5%). Out of the 116 women who delivered vaginally and had a sepsis; 112 (96.6%) of them were home deliveries, whereas only four (3.4%) delivered vaginally at the hospital.
[Table 2] depicts the percentage sensitivity of the different isolates to various antimicrobial agents used in 124 women with puerperal sepsis. The isolated bacteria were subjected to in vitro antimicrobial susceptibility test using the disc diffusion technique (Kirby-Bauer method). The degree of sensitivity, described as sensitive, intermediate, and resistance of the isolated bacteria to antibiotics were recorded.
|Table 2: Antibiotics susceptibility tests for bacterial isolates to common antibiotics in 124 women with positive isolate|
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| Discussion|| |
In the past decade, puerperal sepsis has been a common pregnancy-related event, which could eventually lead to fatal obstetric complications. This study was conducted in response to hospital records what showed an increasing rate of puerperal sepsis. In 2010, the reported hospital rate was as high as 12%.
Our findings do not represent maternal morbidity in Gadarif district because it was a hospital-based study, only patients with severe disease reported to the hospital and most of the deliveries occurred at home due to unavailability of medical care, financial constraints, lack of transportation, and cultural beliefs.
In this study, the highest rate of infection was observed among young females aged 21-25 years (35.5%.), followed by 26-30 years (25%). Previous studies have demonstrated similar findings. , It was reasonable to expect such findings that occurred in old women due to increase in several pregnancy complications including puerperal sepsis. , We speculate that women at this age were likely to be primigravida, with untested pelvises they resort to hospitals when labor became obstructed and infected.
Strikingly, 72.9% (n = 124) of our patients had positive bacterial blood culture and the majority 72.6% (n = 90) of these isolates were aerobic bacteria, which were mainly S. aureus 39.5%, of which MRSA was the predominant isolate 41% (n = 41/49). Traditionally, in the western countries, Streptococcus pyrogen has been a major cause of maternal puerperal sepsis. , Recently, community associated MRSA (CA-MRSA) have become the predominant isolates, it has been described in patients with skin, soft tissue infections, and pneumonia. Carrier may transmit the organism to another person via direct contact with infected hands.  However, this high rate of MRSA, which may indicate community-acquired infection because the majority (96.6%) of our patients delivered at home under unhygienic condition and most of these deliveries were conducted by traditional birth attendant. Such results necessitate urgent tracing of the risks factors by conducting further researches. A similar study was conducted in Nigeria to identify the risk factors and microbial isolates of puerperal sepsis, they reported the commonest microorganism isolated were S. aureus and Escherichia More Details coli seen in 35.4 and 20.9%, respectively. Streptococcus species was found in 6.9%, while 20.3% had polymicrobials isolated. 
In the present study, S. epidermidis was isolated in 5.6% of cases; earlier reports documented that S. epidermidis were the most common bacterial isolates in puerperal sepsis Gerstner et al.,  septicemia caused by S. epidermidis is rarely reported. Although, S. epidermidis is not usually pathogenic, but patients may acquire infection when they have compromised immunity as in pregnancy. These findings may indicate regional variation in isolates as a cause of puerperal sepsis due to differences in geographical locations and immunity. In addition, since the majority of the studied population was home deliveries, the source of infection might be exogenous where pathogens from nearby skin flora or contact with contaminated nonsterilized instruments or frequent vaginal examination with unwashed hands. In addition, the use of local herbal products for proper wound healing and treatment of established wound infections may contribute to increase of infection rate.
In this study, 16.9% of the study population was found to have positive blood culture for L. monocytogenes. Vazquez-Boland et al.  reported that pregnant women and immunocompromised patients are predominantly affected with L. monocytogenes. In the past, several outbreaks of food borne diseases were reported, Farber and Peterkin  reported in 1991 outbreaks with mortality of 24%. Our high reported cases of such infection are possible, may be due outbreaks rather than sporadic cases, as there was 12% increase in the rate of sepsis which initiated the idea of this study.
From the total isolates, 27.4% of the recovered species were C. perfringens. Patients who are infected with C. perfringens are not essentially developing gas gangrene; the disease can display a wide spectrum of clinical presentations. , Recently, it has become apparent that the presence of C. perfringens is unusual, but not rare, causes of tissue and bloodstream infections. Studies in which blood samples were obtained from patients in tertiary care facilities have shown that C. perfringens were the most frequently identified pathogens and accounted for 20-50% of isolates.  In La Crosse, Wisconsin, a retrospective study carried from 1990 through 1997 to determine the incidence and clostridium species among the inpatients, the main clostridium species were perfringens with an incidence rate of 21.7%. The main source of the infection was the gastrointestinal tract.  The high rate in our study may be due to the fact that women in rural areas experience unattended labor and during bearing down they soiled the perineum with fecal matter. These organisms may get access to the blood through fecally infected episiotomy and decircumcision and wounds leading to C. perfringens bacteremia.
The present study showed differences in antibiotic susceptibility pattern of the isolates to antibiotics used for the treatment of puerperal sepsis. The isolates of S. aureus were in considerable variation in term of antibiotic susceptibility, in which 83.7% of the isolated strains were identified as MRSA. Similar study as reported by Stone  which showed that 85.5% (55/47) of the isolates were MRSA.
The present study yielded that Ceftriaxone was 100% effective over all isolates. Similar observations had been reported by Pokharel. Less susceptibility was reported by Kankuri et al.  This variation could be ascribed to geographical variation and difference in immune response. Metronidazole was shown to have great affectivity against anaerobic bacteria, and it was ineffective to all aerobic bacteria. Metronidazole is regarded as the drug of choice for the treatment of anaerobic bacteria sepsis Boyanova.  S. aureus and L. monocytogenes were 100% sensitive to vancomycin, while C. perfringens sensitivity to vancomycin was 94.1%. Ampicillin was 100% effective against L. monocytogenes, while it was 88.2% effective against C. perfringens. Penicillin was remarkably effective against L. monocytogenes (100%), but it was ineffective against S. epidermidis and E. cloacae. On the other hand, Gentamicin was more effective against E. cloacae, L. monoctogenes (100%); while 94.1% of C. perfringens were resistant to gentamicin. A previous study demonstrated a similar finding,  which showed that gentamicin is ineffective against anaerobic bacteria, primarily useful in aerobic gram negative bacterial infection such as enterobacter.
The shortcomings of this report was the small number of patients recruited due to our limited resources, it was a hospital-based study which did not reflect puerperal sepsis in the whole community, and we did evaluate maternal fetal outcomes and the source of the infection in the study population.
| Conclusion|| |
In this study, the main bacteriological isolates were S. aureus, S. epidermidis, L. monocytogenes, C. perfringens, and E. cloacae. Despite the limited resources in the developing countries, treatment based on cultures remains the only solution to reduce maternal morbidity and mortality rates following puerperal sepsis. In this study, the rate of sepsis increased with home deliveries, in addition to younger age group. Improving accessibility to in-hospital care and midwife services will reduce morbidity associated with puerperal sepsis in rural areas. Each hospital should implement its standardized guidance for sepsis care. Further community-based research is recommended.
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Mohamed Alkhatim Alsammani
Department of Obstetrics and Gynecology, College of Medicine, Qassim University, Buriadah
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]