A Systemic Review and Meta-analysis of the Leading Pathogens Causing Neonatal Sepsis in Developing Countries

Abstract

Background. Neonatal sepsis is one of the major public health problems globally, particularly, in developing countries. Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli are the common pathogens for neonatal sepsis in developing countries. However, the pooled estimate of common pathogens causing neonatal sepsis in developing countries is still unknown. Therefore, this study is aimed at computing the pooled proportion of the leading cause of pathogens for neonatal sepsis in developing countries. Methods. We strictly followed the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines to report this systematic review and meta-analysis. PubMed, Cochrane Library, Web of Science, CINAHL, Science Direct, and other search engines such as Google Scholar, Africa Journals Online, and Hinari were used to obtain studies related to the leading cause of pathogens for neonatal sepsis in developing countries. The search was done from October 1 to December 30, 2018, by considering both published and gray literature. Studies were evaluated based on the PRISMA guideline checklist by using their titles, abstracts, and full texts. Studies were extracted using Microsoft Excel spreadsheets, and STATA software version 14 was used to analyze data. Heterogeneity between studies was checked based on Cochran’s $Q$-test and the corresponding $I^2$ statistic test. Results. The pooled prevalence of the leading cause of pathogens of neonatal sepsis in developing countries were Klebsiella (26.36%), Staphylococcus aureus (23.22%), Coagulase-negative Staphylococcus (23.22%), and Escherichia coli (15.30%). Common pathogens were varied across regions; for instance, pooled isolated Coagulase-negative Staphylococcus was 25.98% in Africa, 16.62% in Asia, and 36.71% in Latin America, and Klebsiella was 29.80% in Africa, 23.21% in Asia, and 22.00% in Latin America. Also, Staphylococcus aureus was 27.87% in Africa and 18.28% in Asia, and Escherichia coli was 22.97% in Asia and 9.43% in Africa. Conclusions. This study highlights that the more prevalent common isolated pathogens in developing countries were Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli, Klebsiella, and Staphylococcus aureus pathogens were predominantly high in Africa as compared to other Asian and Latin American countries. At the same time, Coagulase-negative Staphylococcus was more prevalent in Latin America compared to other regions. Escherichia coli is more dominant in Asia as compared to Africa and Latin America.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Background

Despite the lack of consensuses in definitions and variability between regions, neonatal sepsis is defined as a clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first four weeks of life [1–5].

Neonatal sepsis is a major cause of mortality and morbidity in developing countries [6]. An estimated 3 million newborns suffer from sepsis globally every year [7]. A report showed that three out of every ten deaths were due to neonatal sepsis [8]. Globally, 15% of neonatal mortality was related to sepsis in 2016 [9, 10]. From the total mortality, nearly about 1.6 million deaths occur due to neonatal infections worldwide, and 40% of this death was found in developing countries [11]. Neonatal sepsis remains a significant global problem with little progress made despite major efforts [5] especially in developing countries [12]. This causes an annual economic burden ranging from $10 billion to $469 billion in sub-Saharan countries [13].

The common pathogens of early-onset neonatal sepsis in developed countries were Group B Streptococcus (43-58%), Escherichia coli (E. coli) (18-29%), and other gram-negative bacteria (7-8%). Similarly, in late-onset neonatal sepsis, the common pathogens were Coagulase-negative Staphylococcus (39-54%), E. coli (5-13%), Staphylococcus aureus (6-18%), and Klebsiella (4-9%) [14–16]. Hospital-acquired common pathogens of neonatal sepsis in developing countries were Klebsiella (16-28%), Coagulase-negative Staphylococcus (8-28%), Staphylococcus aureus (8-22%), and E. coli (5-16%). Also, community-acquired common pathogens of neonatal sepsis were Staphylococcus aureus, Klebsiella, E. coli, and Group B Streptococcus which accounted for 13-26%, 14-21%, 8-18%, and 2-8%, respectively [17–19].

E. coli is identified as the second leading cause of early-onset neonatal sepsis and accounted for about 24% of early-onset neonatal sepsis episodes and most (81%) infection seen in preterm newborn babies [20]. In very low birth weight babies, E. coli is responsible for 33.4% of the cases of early-onset neonatal sepsis [21, 22]. Similarly, Staphylococcus aureus and CoNS are more frequent causes of late-onset neonatal sepsis particularly in very low birth weight infants. Also, CoNS was commonly associated with neonatal sepsis in preterm infants, which accounts for 60 to 93% of bloodstream infections [23, 24].

International experience showed that the Gram-positive and Gram-negative microorganisms accounted for 44.5% of Staphylococcus aureus, 31.3% for other staphylococci, and 9.3% for E. coli [25]. Similarly, in developing countries, early-onset neonatal sepsis (EONS) is usually caused by Gram-negative pathogens, i.e., E. coli and Klebsiella, while late-onset neonatal sepsis is mainly caused by Gram-positive organisms like CoNS, Staphylococcus aureus, and S. pneumonia, although the percentage of late-onset sepsis caused by Gram-negative organisms are increasing [26–28]. Klebsiella and E. coli, in particular, are responsible for 61% of neonatal infections, and staphylococci are the most common Gram-positive bacteria for neonatal infection [29].

Moreover, Klebsiella, Staphylococcus aureus, E. coli, Group B Streptococcus, S. pneumonia, and Salmonella sp. have a major contribution for community-acquired neonatal sepsis, whereas hospital-acquired neonatal sepsis caused by Klebsiella, Staphylococcus aureus, E. coli, CoNS, Pseudomonas sp., Enterobacter sp., and Candida sp. were the common pathogens [12]. Staphylococcus aureus, E. coli, and Klebsiella are also the major causes of neonatal sepsis in developing countries [18].

Based on the acquisition of infection, neonatal sepsis can be classified as hospital acquired or community acquired [18, 30]. Hospital-acquired neonatal infection is the most common and severe infection among neonates hospitalized in the hospital [31, 32]. Although there is uncertainty on the source of infection, whether “maternally acquired” or “hospital acquired,” any infection associated with birth in a hospital is considered a hospital-acquired neonatal infection [17]. On the other hand, community-acquired neonatal sepsis is defined as “an infection occurring in nonhospitalized infants between the age of 7-90 days with ≥1 positive blood or CSF cultures with a recognized blood pathogen.” A new infection had to be separated by 48 hours from prior hospitalization discharge [30].

Despite the high burden of neonatal sepsis observed worldwide, there is no clear evidence on the rank of common pathogens leading to neonatal sepsis particularly in developing countries [33]. Gaps were identified on the current knowledge of common pathogens causing neonatal sepsis in low-income countries [34]. Current evidence on the leading cause of neonatal sepsis is varied across developing countries [35]; this may be due to the presence of heterogeneous population and healthcare settings [36]. Based on these regional variations, reporting a pooled analysis stratified by region is essential to synthesize recent evidence. Therefore, the ultimate aim of this systematic review and meta-analysis was to generate updated evidence on common pathogens causing neonatal sepsis in developing countries and to compute a single estimated proportion of common pathogens causing neonatal sepsis in developing countries. This may be important to choose appropriate antibiotics as an empirical treatment in low-income settings

2. Methods

2.1. Eligibility Criteria

We restricted our search to studies published in English. Obtained studies that cover pathogens causing neonatal sepsis in developing countries were carefully assessed whether they fulfilled our criteria or not. We only included observational studies that had full text and information on neonatal sepsis caused by common pathogens such as Klebsiella and/or Coagulase-negative Staphylococcus and/or Staphylococcus aureus and/or E. coli and neonatal sepsis diagnosed according to standard laboratory methods, i.e., blood culture, and supported with clinical presentations to diagnose Coagulase-negative Staphylococcus because of false-positive blood cultures due to contamination. The gold standard for diagnosis of neonatal sepsis, however, remains blood culture [37, 38]. In this study, we included studies from developing countries. For this study, we defined developing countries as “countries in the process of change with economic growth that increases in production, per capita consumption, and income.” Studies were excluded if the age of the study population was beyond the neonatal period (28-day-old infants) and had low sample sizes of less than 60 subjects. Also, we excluded studies that have methodological problems and flaws (lack of clear measurement, incomplete diagnostic criteria in choosing, selection bias, and unclear presentation of study population). Studies with a case-control study design were also excluded from the study.

2.2. Information Sources

Electronic databases and search engines were used to gather data about common pathogens of neonatal sepsis. The search was done from October 1 to December 30, 2018, which considered both published and gray literature.

2.3. Search Strategy

We strictly followed the Preferred Reporting Items for Systemic Reviews and Meta-analysis (PRISMA) flow diagram [39] to report this study. International electronic databases such as PubMed, Cochrane Library, Web of Science, CINAHL, Science Direct, and other searching engines such as Google Scholar, Africa Journals Online, and Hinari Access to Research for Health program were used to obtain studies related to the leading cause of pathogens for neonatal sepsis in developing countries. Our search protocol was developed using the following keywords: neonatal, neonatal sepsis, sepsis, Klebsiella, CoNS, Staphylococcus aureus, developing countries, developing, countries, developing nations, less developed nations, Africa, Latin America, and Asia. These terms were predefined to have an inclusive search strategy that involved all fields within records and searching medical literature using medical subject headings in the National Library of Medicine to control the vocabulary that indexed articles from the MEDLINE and/or PubMed database (Sup. File).

2.4. Study Selection and Data Extraction

Articles identified by the search were imported into EndNote version 7 to screen for duplication. Initially, the studies were selected by DAZ using their titles based on predefined inclusion and exclusion criteria. The coauthors (GD, EW, and MB) checked the consistency of the selected articles. The disparities between these reviewers were resolved by the other coauthors (SE and MM) through discussions. In the second phase, DAZ, GD, and EW screened articles using their abstracts. In the third phase, full-text articles were screened by DAZ and GD. The disagreements among reviewers during the selection process were resolved by discussion with MB, SE, and MM. Finally, all reviewed studies that fulfill the inclusion criteria were saved.

Studies were extracted by considering the preferred reporting items for systematic reviews and meta-analyses guidelines [40] and evaluated based on the PRISMA guideline. Duplicate studies were removed on the first screening process. Then, titles were carefully assessed and articles irrelevant to our objective were removed from the study. The authors DAZ, GD, and EW extracted data using Microsoft Excel spreadsheets. The extracted data comprised of authors’ names, publication years, sites (institution or community), types of study (cross-sectional, retrospective), and total sample sizes. Discrepancies among reviewers were resolved by discussion and consensus with reviewers (MM, MB, and SE).

2.5. Quality of the Study

The quality of studies was approved using the Newcastle-Ottawa Scale (NOS) [41]. The NOS is designed to evaluate the qualitative evaluation of observational studies. This examines each study by seven items in three groups: selection, comparability, and outcome. Stars were given to each item. Items of good quality received 3 or 4 stars in the selection domain, 1 or 2 stars in the comparability domain, and 2 or 3 stars in the outcome/exposure domain. Items of fair quality received 2 stars in the selection domain, 1 or 2 stars in the comparability domain, and 2 or 3 stars in the outcome/exposure domain. Items of poor quality received 0 or 1 star in the selection domain, 0 stars in the comparability domain, and 0 or 1 stars in the outcome/exposure domain. In general, each item was scored for a maximum of six scores. Publications which scored 0–2, 3, 4, and 5 were classified as “unsatisfactory,” “satisfactory,” “good,” and “very good,” respectively. Finally, studies that had been categorized as low quality were excluded in the study [41].

2.6. Outcome of Interest

The outcome of interest was to determine the leading cause of pathogens (Klebsiella, CoNS, Staphylococcus aureus, and E. coli) for neonatal sepsis in developing countries. The pooled isolated common pathogens were measured as the number of neonates with sepsis caused by each respective pathogen divided by the number of neonates in a study multiplied by 100.

2.7. Statistical Analysis

Microsoft Excel spreadsheet was used to extract data, and STATA software version 14 was used to analyze data. Laird’s random effects model was used to estimate the pooled proportion of common isolated pathogens for neonatal sepsis because a high degree of heterogeneity was observed across studies. Metaregression was employed to identify the source of heterogeneity using the year of publication, study design, and setting, but there was no statistically significant variable. Subgroup analysis was done by study setting to minimize the random variations between the point estimates of the primary studies. A funnel plot was applied to identify the presence of publication bias. Also, we employed Egger’s test and Begg’s statistical test to identify publication bias. Then, the trim and fill analysis was done to approve the presence of publication bias. A sensitivity analysis was performed to investigate how each study affects the estimated pooled prevalence. Statistical tests were significant if the $P$ value was <0.05.

2.8. Publication Bias, Heterogeneity, and Sensitivity Test

Heterogeneity among studies was checked based on Cochran’s $Q$-test and the corresponding $I^2$ statistic test [42]. Continuous and categorical metaregression analyses were done to determine the sources of heterogeneity. Begg’s test and Egger’s test were also used to evaluate the publication bias [43].

3. Results

3.1. Description of the Studies

In the initial search, a total of 2157 potentially relevant studies were identified by searching international electronic databases, and 1232 studies were removed as a result of irrelevance and duplicates. Then, 925 studies were assessed in depth, and finally, a total of 52 studies were eligible for all common pathogens (25 studies for CoNS, 39 studies for Klebsiella, 13 studies for E. coli, and 27 studies for Staphylococcus aureus) (Figure 1) and 152217 infants were eligible for the final systematic review and meta-analysis. Studies involved in this systematic review and meta-analysis included 21 studies from different countries in developing regions. About 21 studies were from Africa, 4 studies were from Latin America, and 12 studies were from Asian countries. The publication year included in this study was from 2005 to 2018; the individual study with the largest sample size had 34362 infants, and the individual study with the smallest sample size had 68 infants.

[figure omitted; refer to PDF]

In the case of the Klebsiella pathogen, Begg’s test and Egger’s test showed that there was no significant publication bias across studies ($P>0.05$). The number of studies missing from a meta-analysis was estimated using the trim and fill method, and there was a significant asymmetric observation. The funnel and filled funnel plot of the pseudo-95% CI showed that there was a significant asymmetric observation. This showed the presence of publication bias because we observed an asymmetric distribution of plots towards the right side of the midline with a random effects model. The model showed that there was symmetry at the top, but it was missing in the middle and bottom of the graph, and the direction of the effect is towards the right then near the bottom of the plot; we also observed a gap on the left (Figure 11). The metatrim test at pseudo-95% CI with a random effects model showed that there was no significant difference from the original pooled prevalence.

[figure omitted; refer to PDF]

In the case of Staphylococcus aureus, Begg’s test was applied to determine the publication bias, and statistically, there was no publication bias across studies ($P>0.05$). Egger’s test also showed no publication bias ($P>0.05$). The distribution of plots was asymmetrical with the random effects model, and the majority of the plots were distributed towards the right side (Figure 12).

[figure omitted; refer to PDF]

In the case of E. coli, the funnel plot showed that there is an asymmetric distribution of plots (Figure 13), and Begg’s test showed that there is a significant publication bias. However, Egger’s test showed that there was no significant publication bias.

[figure omitted; refer to PDF]

3.6. Metaregression Analysis

We conducted a metaregression analysis since there was statistically significant heterogeneity across the studies, with $I^2$ test statistics less than 0.05. This analysis is vital to identify the source of heterogeneity; consequently, a corrective measure during the interpretation of findings was made. In this metaregression analysis, the study that we conducted showed that countries and cross-sectional study designs were found to be a significant source of heterogeneity. However, sample size, publication year, study quality score, and subregion were not found significant for the source of heterogeneity (Table 5).

Table 5

Metaregression analysis of Coagulase-negative Staphylococcus, Staphylococcus aureus, and E. coli in developing countries.

Variable	Coefficient	$P$ value
Coagulase-negative Staphylococcus
Years of study	-0.17	0.826
Sample size	-0.23	0.983
Brazil	-35.24	0.027
Ethiopia	-70.95	0.002
India	-61.44	0.000
Jamaica	-59.55	0.001
Jordan	-50.94	0.005
Kenya	-79.15	0.001
Mexico	-0.745	0.956
Nepal	-48.54	0.005
Nigeria	-67.75	0.002
South Africa	-47.81	0.001
Sudan	-76.75	0.001
Tanzania	59.23	0.004
Zambia	-86.55	0.001
Cross-sectional	24.00	0.044
Prospective	1.45	0.813
Staphylococcus aureus
Years of study	-0.48	0.483
Sample size	-0.23	0.654
Ethiopia	49.42	0.134
Gambia	60.00	0.046
Ghana	22.20	0.472
India	18.84	0.406
Indonesia	9.74	0.758
Nepal	23.22	0.466
Nigeria	34.65	0.163
Sudan	21.30	0.437
Tanzania	18.62	0.558
Uganda	34.48	0.236
Zambia	14.62	0.644
Cross-sectional	-21.72	0.149
Prospective cohort	-9.50	0.445
E. coli
Year of study	-0.6604672	0.556
Sample size	0.022806	0.401
Bangladesh	5.2	0.866
Cameroon	18	0.565
Egypt	-0.5400002	0.986
Ghana	0.5999999	0.984
India	28.44278	0.273
Nigeria	1.998955	0.940
Tanzania	11.07911	0.679

4. Discussion

This review was conducted to estimate the pooled isolated common cause of neonatal sepsis in developing countries. In this study, the first most prevalent bacterial pathogen for neonatal sepsis is Klebsiella pneumonia, and the second most prevalent identified pathogen is Staphylococcus aureus. The third and fourth common pathogens are coagulase-negative staphylococci and Escherichia coli, respectively. Another systematic review and meta-analysis study on causative pathogens of neonatal sepsis in low- and middle-income countries demonstrated that the most prevalent bacterial pathogens for neonatal sepsis were Staphylococcus aureus, E. coli, and Klebsiella [44–46]. However, in this study, common pathogens across regions are varied in its proportion. In Africa, Staphylococcus aureus (27.87%) and Klebsiella (29.80%) were common causes of neonatal sepsis. Coagulase-negative Staphylococcus and E. coli are more common in Latin America and Asia, respectively. Similarly, Staphylococcus aureus and Streptococcuspneumoniae were most prevalent in Africa while Klebsiella was highly prevalent in South-East Asia [44]. Bacterial infection was a leading cause of neonatal mortality in low-income countries, and to date, it is a major cause of morbidity and mortality globally, particularly more common in developing countries as compared to developed countries [35, 47, 48] and little progress was noticed [5].

This systematic review and meta-analysis revealed that Klebsiella pneumonia, Staphylococcus aureus, and CoNS are the common causes of neonatal sepsis in developing countries. Similarly, a large-scale survey across the world showed that neonatal sepsis is more common in developing countries than in developed countries, and the causative pathogens were different with a predominance of Gram-negative bacteria and Staphylococcus aureus [35, 49, 50]. The gram-negative organism Klebsiella [49, 50] and the gram-positive microorganisms Staphylococcus aureus [50, 51] and CoNS [52–54] were the most common pathogens of neonatal sepsis in developing countries.

The present study demonstrated that CoNS is ranked as the third common cause of neonatal sepsis with a pooled prevalence of 23.22%. However, in developed countries, Group B Streptococcus and CoNS were the major organisms implicated in early-onset and late-onset sepsis, respectively [53–56], because the risk factors associated with pathogen-specific sepsis are different based on the pathogen [57].

The present study showed that there are pathogen variations across the study setting. For instance, Klebsiella and Staphylococcus aureus are the most common pathogens of neonatal sepsis in Africa, Coagulase-negative Staphylococcus is the predominant pathogen of neonatal sepsis in Latin America, and E. coli is the most common pathogen in Asia. Likewise, another systematic review showed that Klebsiella and Staphylococcus aureus represented 25% and 18% of neonatal sepsis [18]. Other systematic review findings show that Klebsiella is more prevalent as compared to our study, which accounted for 39% to 70% [19]. On the contrary, a systematic review of community-acquired neonatal sepsis revealed that Staphylococcus aureus represented 14.9% which was lower than that in our study [44] and the reason for this discrepancy may be because the pathogens causing neonatal sepsis in the communities are different from those in the health facilities and the bacterial spectrum of neonatal sepsis varies among healthcare settings and communities [35, 57].

About 70% of the cases of early-onset neonatal sepsis in the developed countries are represented by Streptococcus agalactiae and Escherichia coli [20, 58]. The majority of LOS (70%) in the developed world is due to Gram-positive infections [26, 58], Staphylococcus aureus, Enterococcus spp., and GBS, being most common in very low birth weight and preterm infants [26]. The fact is that in low-income countries, CoNS is responsible for the colonization and development of infection especially in low birth weight babies. Exposures to environmental risks and the timing of exposure, access to healthcare, catheter complications, immune status of the infant, and virulence of the causative agent influence the clinical expression of neonatal sepsis [59–61].

This study found that it is important to choose appropriate antibiotics based on the leading common pathogens especially for clinicians who are working in areas where there is a lack of standard laboratory methods such as blood culture. Also, in this study, it may be important to design appropriate protective measures against known germs associated with neonatal infections. It can play an important role in developing better prevention and treatment policies and programs for policymakers and health planners in low-income settings. Since there is a lack of clarity on variations in the distribution of common pathogens of neonatal sepsis in developing and developed countries [35, 49, 50], it can therefore be used as a starting point for future researchers on this topic.

A limitation of this study is a lack of data to display the community-based neonatal sepsis in African, Asian, and Latin American regions. It has also been indicated by a previous study that data on community-acquired neonatal sepsis are limited [44]. This study is also limited to protocol registration and publication. Future research should be focused on systematic review and meta-analysis of randomized clinical trial studies, and pathogen variations across settings may be the other future research area.

5. Conclusions

This study highlights that Klebsiella is the leading cause of the pathogen, while Staphylococcus aureus and coagulase-negative staphylococcus are the second leading cause of neonatal sepsis. E. coli is ranked as the least common cause of neonatal sepsis. This systematic review shows that these pathogens are highly prevalent in developing countries compared to the developed world. The pooled prevalence of Klebsiella and Staphylococcus aureus pathogens was predominantly high in Africa compared to other Asian and Latin American countries. Coagulase-negative Staphylococcus was also more prevalent in Latin America as compared to other regions. Escherichia coli was also more dominant in Asia compared to Africa and Latin America. Heterogeneity was identified across the regions and within each region. Since most low-income countries have no laboratory access, this finding helps in the selection of antibiotics for the empirical treatment of neonates with a high risk of sepsis. Governments should take preventive and control measures to reduce the burden of infections due to these pathogens.

Authors’ Contributions

DAZ and GD participated in study conception, data extraction, data analysis, and manuscript writing. EWM, MMM, and MBS participated in data analysis and manuscript writing. SE participated in manuscript writing and editing.

Glossary

Abbreviations

CoNS:Coagulase-negative Staphylococcus

E. coli:Escherichia coli

EONS:Early-onset neonatal sepsis

LOS:Late-onset sepsis.

References

[1] N. Sepsis, Teaching aids: newborn care. Neonatal sepsis, Slide NS-4 Early vs. late, .

[2] S. Rawat, K. Neeraj, K. Preeti, M. Prashant, "A review on type, etiological factors, definition, clinical features, diagnosis management and prevention of neonatal sepsis," Journal of Scientific and Innovative Research, vol. 2 no. 4, pp. 802-813, 2013.

[3] Group WYIS, "Clinical prediction of serious bacterial infections in young infants in developing countries," The Pediatric Infectious Disease Journal, vol. 18 no. 10, pp. S23-S31, 1999.

[4] M. W. Weber, J. B. Carlin, S. Gatchalian, D. Lehmann, L. Muhe, E. K. Mulholland, WHO Young Infants Study Group, "Predictors of neonatal sepsis in developing countries," The Pediatric Infectious Disease Journal, vol. 22 no. 8, pp. 711-717, DOI: 10.1097/01.inf.0000078163.80807.88, 2003.

[5] J. L. Wynn, "Defining neonatal sepsis," Current Opinion in Pediatrics, vol. 28 no. 2, pp. 135-140, DOI: 10.1097/MOP.0000000000000315, 2016.

[6] World Health Organization, "WHO Sepsis Technical Expert Meeting," 2018. https://www.who.int

[7] C. Fleischmann-Struzek, D. M. Goldfarb, P. Schlattmann, L. J. Schlapbach, K. Reinhart, N. Kissoon, "The global burden of paediatric and neonatal sepsis: a systematic review," The Lancet Respiratory Medicine, vol. 6 no. 3, pp. 223-230, DOI: 10.1016/S2213-2600(18)30063-8, 2018.

[8] R. Laxminarayan, P. Matsoso, S. Pant, C. Brower, J.-A. Røttingen, K. Klugman, S. Davies, "Access to effective antimicrobials: a worldwide challenge," The Lancet, vol. 387 no. 10014, pp. 168-175, DOI: 10.1016/S0140-6736(15)00474-2, 2016.

[9] WHO, "WHO Sepsis Technical Expert Meeting-Meeting Report," 2018.

[10] World Health Organization, WHO Recommendations on Intrapartum Care for a Positive Childbirth Experience, 2018.

[11] V. Sundaram, P. Kumar, S. Dutta, K. Mukhopadhyay, P. Ray, V. Gautam, A. Narang, "Blood culture confirmed bacterial sepsis in neonates in a North Indian tertiary care center: changes over the last decade," Japanese Journal of Infectious Diseases, vol. 62 no. 1, pp. 46-50, 2009.

[12] A. Zea-Vera, T. J. Ochoa, "Challenges in the diagnosis and management of neonatal sepsis," Journal of Tropical Pediatrics, vol. 61 no. 1,DOI: 10.1093/tropej/fmu079, 2015.

[13] S. L. Ranjeva, B. C. Warf, S. J. Schiff, "Economic burden of neonatal sepsis in sub-Saharan Africa," BMJ Global Health, vol. 3 no. 1, article e000347,DOI: 10.1136/bmjgh-2017-000347, 2018.

[14] B. J. Stoll, N. Hansen, A. A. Fanaroff, L. L. Wright, W. A. Carlo, R. A. Ehrenkranz, J. A. Lemons, E. F. Donovan, A. R. Stark, J. E. Tyson, W. Oh, C. R. Bauer, S. B. Korones, S. Shankaran, A. R. Laptook, D. K. Stevenson, L. A. Papile, W. K. Poole, "Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network," Pediatrics, vol. 110 no. 2, pp. 285-291, DOI: 10.1542/peds.110.2.285, 2002.

[15] S. Vergnano, E. Menson, N. Kennea, N. Embleton, A. B. Russell, T. Watts, M. J. Robinson, A. Collinson, P. T. Heath, "Neonatal infections in England: the NeonIN surveillance network," Archives of Disease in Childhood-Fetal and Neonatal Edition, vol. 96 no. 1, pp. F9-F14, DOI: 10.1136/adc.2009.178798, 2011.

[16] B. J. Stoll, N. I. Hansen, P. J. Sanchez, R. G. Faix, B. B. Poindexter, K. P. Van Meurs, M. J. Bizzarro, R. N. Goldberg, I. D. Frantz, E. C. Hale, S. Shankaran, K. Kennedy, W. A. Carlo, K. L. Watterberg, E. F. Bell, M. C. Walsh, K. Schibler, A. R. Laptook, A. L. Shane, S. J. Schrag, A. Das, R. D. Higgins, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, "Early onset neonatal sepsis: the burden of group B streptococcal and E. coli disease continues," Pediatrics, vol. 127 no. 5, pp. 817-826, DOI: 10.1542/peds.2010-2217, 2011.

[17] A. K. M. Zaidi, W. C. Huskins, D. Thaver, Z. A. Bhutta, Z. Abbas, D. A. Goldmann, "Hospital-acquired neonatal infections in developing countries," The Lancet, vol. 365 no. 9465, pp. 1175-1188, DOI: 10.1016/S0140-6736(05)71881-X, 2005.

[18] A. K. Zaidi, D. Thaver, S. A. Ali, T. A. Khan, "Pathogens associated with sepsis in newborns and young infants in developing countries," The Pediatric Infectious Disease Journal, vol. 28 no. 1, pp. S10-S18, DOI: 10.1097/INF.0b013e3181958769, 2009.

[19] L. Downie, R. Armiento, R. Subhi, J. Kelly, V. Clifford, T. Duke, "Community-acquired neonatal and infant sepsis in developing countries: efficacy of WHO’s currently recommended antibiotics—systematic review and meta-analysis," Archives of Disease in Childhood, vol. 98 no. 2, pp. 146-154, DOI: 10.1136/archdischild-2012-302033, 2013.

[20] K. A. Simonsen, A. L. Anderson-Berry, S. F. Delair, H. D. Davies, "Early-onset neonatal sepsis," Clinical Microbiology Reviews, vol. 27 no. 1, pp. 21-47, DOI: 10.1128/CMR.00031-13, 2014.

[21] A. L. Shane, B. J. Stoll, "Recent developments and current issues in the epidemiology, diagnosis, and management of bacterial and fungal neonatal sepsis," American Journal of Perinatology, vol. 30 no. 2, pp. 131-142, 2013.

[22] C. P. Hornik, P. Fort, R. H. Clark, K. Watt, D. K. Benjamin, P. B. Smith, P. Manzoni, E. Jacqz-Aigrain, F. Kaguelidou, M. Cohen-Wolkowiez, "Early and late onset sepsis in very-low-birth-weight infants from a large group of neonatal intensive care units," Early Human Development, vol. 88, pp. S69-S74, DOI: 10.1016/S0378-3782(12)70019-1, 2012.

[23] P. André, B. Thébaud, M. Guibert, F. Audibert, T. Lacaze-Masmonteil, M. Dehan, "Maternal-fetal staphylococcal infections: a series report," American journal of Perinatology, vol. 17 no. 8, pp. 423-428, DOI: 10.1055/s-2000-13455, 2000.

[24] C. T. D'Angio, K. L. McGowan, S. Baumgart, J. S. Geme, M. C. Harris, "Surface colonization with coagulase-negative staphylococci in premature neonates," The Journal of Pediatrics, vol. 114 no. 6, pp. 1029-1034, DOI: 10.1016/S0022-3476(89)80457-3, 1989.

[25] Y. J. Shin, M. Ki, B. Foxman, "Epidemiology of neonatal sepsis in South Korea," Pediatrics International, vol. 51 no. 2, pp. 225-232, DOI: 10.1111/j.1442-200X.2008.02685.x, 2009.

[26] S. Sivanandan, A. S. Soraisham, K. Swarnam, "Choice and duration of antimicrobial therapy for neonatal sepsis and meningitis," International Journal of Pediatrics, vol. 2011,DOI: 10.1155/2011/712150, 2011.

[27] Y. Dong, C. P. Speer, "Late-onset neonatal sepsis: recent developments," Archives of Disease in Childhood-Fetal and Neonatal Edition, vol. 100 no. 3, pp. F257-F263, DOI: 10.1136/archdischild-2014-306213, 2015.

[28] M. Coetzee, N. Mbowane, T. de Witt, "Neonatal sepsis: highlighting the principles of diagnosis and management," South African Journal of Child Health, vol. 11 no. 2, pp. 99-103, DOI: 10.7196/SAJCH.2017.v11i2.1244, 2017.

[29] M. T. Moreno, S. Vargas, R. Poveda, X. Sáez-Llorens, "Neonatal sepsis and meningitis in a developing Latin American country," The Pediatric Infectious Disease Journal, vol. 13 no. 6, pp. 516-520, DOI: 10.1097/00006454-199406000-00010, 1994.

[30] S. Bulkowstein, S. Ben-Shimol, N. Givon-Lavi, R. Melamed, E. Shany, D. Greenberg, "Comparison of early onset sepsis and community-acquired late onset sepsis in infants less than 3 months of age," BMC Pediatrics, vol. 16 no. 1, 2016.

[31] T. G. Emori, D. H. Culver, T. C. Horan, W. R. Jarvis, J. W. White, D. R. Olson, S. Banerjee, J. R. Edwards, W. J. Martone, R. P. Gaynes, J. M. Hughes, "National nosocomial infections surveillance system (NNIS): description of surveillance methods," American Journal of Infection Control, vol. 19 no. 1, pp. 19-35, DOI: 10.1016/0196-6553(91)90157-8, 1991.

[32] R. P. Gaynes, J. R. Edwards, W. R. Jarvis, D. H. Culver, J. S. Tolson, W. J. Martone, National Nosocomial Infections Surveillance System, "Nosocomial infections among neonates in high-risk nurseries in the United States," Pediatrics, vol. 98 no. 3, pp. 357-361, 1996.

[33] C. Oeser, I. Lutsar, T. Metsvaht, M. A. Turner, P. T. Heath, M. Sharland, "Clinical trials in neonatal sepsis," Journal of Antimicrobial Chemotherapy, vol. 68 no. 12, pp. 2733-2745, DOI: 10.1093/jac/dkt297, 2013.

[34] A. C. Seale, M. Mwaniki, C. R. Newton, J. A. Berkley, "Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa," The Lancet Infectious Diseases, vol. 9 no. 7, pp. 428-438, DOI: 10.1016/S1473-3099(09)70172-0, 2009.

[35] S. Vergnano, M. Sharland, P. Kazembe, C. Mwansambo, P. Heath, "Neonatal sepsis: an international perspective," Archives of Disease in Childhood-Fetal and Neonatal Edition, vol. 90 no. 3, pp. F220-f224, DOI: 10.1136/adc.2002.022863, 2005.

[36] M. Ali, R. Salehnejad, M. Mansur, "Hospital heterogeneity: what drives the quality of health care," The European Journal of Health Economics, vol. 19 no. 3, pp. 385-408, DOI: 10.1007/s10198-017-0891-9, 2018.

[37] P.-Y. I. Tam, C. M. Bendel, "Diagnostics for neonatal sepsis: current approaches and future directions," Pediatric Research, vol. 82 no. 4, pp. 574-583, 2017.

[38] F. Cortese, P. Scicchitano, M. Gesualdo, A. Filaninno, E. De Giorgi, F. Schettini, N. Laforgia, M. M. Ciccone, "Early and late infections in newborns: where do we stand? A review," Pediatrics & Neonatology, vol. 57 no. 4, pp. 265-273, DOI: 10.1016/j.pedneo.2015.09.007, 2016.

[39] A. Liberati, D. G. Altman, J. Tetzlaff, C. Mulrow, P. C. Gøtzsche, J. P. A. Ioannidis, M. Clarke, P. J. Devereaux, J. Kleijnen, D. Moher, "The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration," PLoS Medicine, vol. 6 no. 7, article e1000100,DOI: 10.1371/journal.pmed.1000100, 2009.

[40] D. Moher, L. Shamseer, M. Clarke, D. Ghersi, A. Liberati, M. Petticrew, P. Shekelle, L. A. Stewart, PRISMA-P Group, "Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement," Systematic Reviews, vol. 4 no. 1,DOI: 10.1186/2046-4053-4-1, 2015.

[41] G. Wells, B. Shea, D. O’Connell, J. Peterson, V. Welch, M. Losos, P. Tugwell, "Newcastle-Ottawa quality assessment form for cohort studies," Ottawa Hospital Research Institute, vol. 113, pp. 17-18, 2014.

[42] T. B. Huedo-Medina, J. Sánchez-Meca, F. Marín-Martínez, J. Botella, "Assessing heterogeneity in meta-analysis: Q statistic or I 2 index?," Psychological Methods, vol. 11 no. 2, pp. 193-206, DOI: 10.1037/1082-989X.11.2.193, 2006.

[43] L. Lin, H. Chu, "Quantifying publication bias in meta-analysis," Biometrics, vol. 74 no. 3, pp. 785-794, DOI: 10.1111/biom.12817, 2018.

[44] D. Waters, I. Jawad, A. Ahmad, I. Lukšić, H. Nair, L. Zgaga, E. Theodoratou, I. Rudan, A. K. Zaidi, H. Campbell, "Aetiology of community-acquired neonatal sepsis in low and middle income countries," Journal of Global Health, vol. 1 no. 2, pp. 154-170, 2011.

[45] Z. Akbarian-Rad, S. M. Riahi, A. Abdollahi, P. Sabbagh, S. Ebrahimpour, M. Javanian, V. K. R. Vasigala, A. Rostami, "Neonatal sepsis in Iran: a systematic review and meta-analysis on national prevalence and causative pathogens," PLoS One, vol. 15 no. 1, article e0227570,DOI: 10.1371/journal.pone.0227570, 2020.

[46] D. Amare, M. Mela, G. Dessie, "Unfinished agenda of the neonates in developing countries: magnitude of neonatal sepsis: systematic review and meta-analysis," Heliyon, vol. 5 no. 9, article e02519,DOI: 10.1016/j.heliyon.2019.e02519, 2019.

[47] A. C. Seale, H. Blencowe, A. Zaidi, H. Ganatra, S. Syed, C. Engmann, C. R. Newton, S. Vergnano, B. J. Stoll, S. N. Cousens, J. E. Lawn, on behalf of the Neonatal Infections Estimation Team, "Neonatal severe bacterial infection impairment estimates in South Asia, sub-Saharan Africa, and Latin America for 2010," Pediatric Research, vol. 74 no. S1, pp. 73-85, DOI: 10.1038/pr.2013.207, 2013.

[48] World Health Organization, "WHO sepsis technical expert meeting," 2018.

[49] S. S. Tallur, A. Kasturi, S. D. Nadgir, B. Krishna, "Clinico-bacteriological study of neonatal septicemia in Hubli," The Indian Journal of Pediatrics, vol. 67 no. 3, pp. 169-174, DOI: 10.1007/BF02723654, 2000.

[50] G. Karthikeyan, K. Premkumar, "Neonatal sepsis: Staphylococcus aureus as the predominant pathogen," The Indian Journal of Pediatrics, vol. 68 no. 8, pp. 715-717, DOI: 10.1007/BF02752407, 2001.

[51] E. K. Mulholland, O. O. Ogunlesi, R. A. Adegbola, M. Weber, B. E. Sam, A. Palmer, M. J. Manary, O. Secka, M. Aidoo, D. Hazlett, H. Whittle, B. M. Greenwood, "Etiology of serious infections in young Gambian infants," The Pediatric Infectious Disease Journal, vol. 18, pp. S35-S41, DOI: 10.1097/00006454-199910001-00007, 1999.

[52] R. Pennie, A. Malik, "Early onset neonatal septicaemia in a level II nursery," The Medical Journal of Malaysia, vol. 49 no. 1, pp. 17-23, 1994.

[53] E. A. Marchant, G. K. Boyce, M. Sadarangani, P. M. Lavoie, "Neonatal sepsis due to coagulase-negative staphylococci," Clinical and Developmental Immunology, vol. 2013,DOI: 10.1155/2013/586076, 2013.

[54] J.-y. Li, S.-q. Chen, Y.-y. Yan, Y.-y. Hu, J. Wei, Q.-p. Wu, Z.-l. Lin, J. Lin, "Identification and antimicrobial resistance of pathogens in neonatal septicemia in China--A meta-analysis," International Journal of Infectious Diseases, vol. 71, pp. 89-93, DOI: 10.1016/j.ijid.2018.04.794, 2018.

[55] S. Gheibi, Z. Fakoor, M. Karamyyar, J. Khashabi, B. Ilkhanizadeh, F. Asghari-Sana, H. Mahmoudzadeh, A. H. Majlesi, "Coagulase negative Staphylococcus ; the most common cause of neonatal septicemia in Urmia, Iran," Iranian journal of Pediatrics, vol. 18 no. 3, pp. 237-243, 2008.

[56] A. Camacho-Gonzalez, P. W. Spearman, B. J. Stoll, "Neonatal infectious diseases: evaluation of neonatal sepsis," Pediatric Clinics of North America, vol. 60 no. 2, pp. 367-389, DOI: 10.1016/j.pcl.2012.12.003, 2013.

[57] J. Guo, Y. Luo, Y. Wu, W. Lai, X. Mu, "Clinical characteristic and pathogen spectrum of neonatal sepsis in Guangzhou City from June 2011 to June 2017," Medical Science Monitor, vol. 25, pp. 2296-2304, DOI: 10.12659/MSM.912375, 2019.

[58] B. A. Shah, J. F. Padbury, "Neonatal sepsis: an old problem with new insights," Virulence, vol. 5 no. 1, pp. 170-178, DOI: 10.4161/viru.26906, 2014.

[59] A. De Oliveira, P. Sanches, J. C. Lyra, M. R. Bentlin, L. M. S. S. Rugolo, M. D. L. R. D. S. Da Cunha, "Risk factors for infection with coagulase-negative staphylococci in newborns from the neonatal unit of a Brazilian University Hospital," Clinical Medicine Insights: Pediatrics, vol. 6, article CMPed.S7427,DOI: 10.4137/cmped.s7427, 2012.

[60] F. Moges, S. Eshetie, B. Yeshitela, E. Abate, "Bacterial etiologic agents causing neonatal sepsis and associated risk factors in Gondar, Northwest Ethiopia," BMC pediatrics, vol. 17 no. 1, 2017.

[61] A. S. P. LShane, B. J. Stoll, "Neonatal sepsis," The Lancet, vol. 390 no. 10104, pp. 1770-1780, 2017.

[62] A. O. Arowosegbe, D. A. Ojo, I. O. Dedeke, O. B. Shittu, O. A. Akingbade, "Neonatal sepsis in a Nigerian Tertiary Hospital: clinical features, clinical outcome, aetiology and antibiotic susceptibility pattern," Southern African Journal of Infectious Diseases, vol. 32 no. 4, pp. 127-131, DOI: 10.4102/sajid.v32i4.37, 2017.

[63] A. Kheir, R. A. Khair, "Neonatal sepsis; prevalence and outcome in a tertiary neonatal unit in Sudan," Time Journals of Medical Sciences Report and Research, vol. 2, pp. 21-25, 2014.

[64] M. Kabwe, J. Tembo, L. Chilukutu, M. Chilufya, F. Ngulube, C. Lukwesa, M. Kapasa, V. Enne, H. Wexner, L. Mwananyanda, D. H. Hamer, S. Sinyangwe, Y. Ahmed, N. Klein, M. Maeurer, A. Zumla, M. Bates, "Etiology, antibiotic resistance and risk factors for neonatal sepsis in a large referral center in Zambia," The Pediatric Infectious Disease Journal, vol. 35 no. 7, pp. e191-e198, DOI: 10.1097/INF.0000000000001154, 2016.

[65] E. O. Shobowale, F. Ogunsola, O. Oduyebo, V. Ezeaka, "Aetiology and risk factors for neonatal sepsis at the Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria," South African Journal of Child Health, vol. 10 no. 3, pp. 147-150, DOI: 10.7196/SAJCH.2016.v10i3.965, 2016.

[66] R. Kumar, R. Musoke, W. Macharia, G. Revathi, "Validation of c-reactive protein in the early diagnosis of neonatal sepsis in a tertiary care hospital in Kenya," East African Medical Journal, vol. 87 no. 6, pp. 255-261, DOI: 10.4314/eamj.v87i6.63084, 2010.

[67] S. El-Din, E. M. Rabie, M. M. A. El-Sokkary, M. R. Bassiouny, R. Hassan, "Epidemiology of neonatal sepsis and implicated pathogens: a study from Egypt," BioMed Research International, vol. 2015,DOI: 10.1155/2015/509484, 2015.

[68] M. M. Lebea, V. Davies, "Evaluation of culture-proven neonatal sepsis at a tertiary care hospital in Johannesburg, South Africa," South African Journal of Child Health, vol. 11 no. 4, pp. 170-173, 2017.

[69] D. E. Ballot, T. Nana, C. Sriruttan, P. A. Cooper, "Bacterial bloodstream infections in neonates in a developing country," ISRN Pediatrics, vol. 2012,DOI: 10.5402/2012/508512, 2012.

[70] T. V. Mhada, F. Fredrick, M. I. Matee, A. Massawe, "Neonatal sepsis at Muhimbili National Hospital, Dar es Salaam, Tanzania; aetiology, antimicrobial sensitivity pattern and clinical outcome," BMC Public Health, vol. 12 no. 1,DOI: 10.1186/1471-2458-12-904, 2012.

[71] M. F. Mkony, M. M. Mizinduko, A. Massawe, M. Matee, "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," BMC Pediatrics, vol. 14 no. 1,DOI: 10.1186/s12887-014-0293-4, 2014.

[72] B. Thapa, A. Thapa, D. R. Aryal, K. Thapa, A. Pun, S. Khanal, K. Mahat, "Neonatal sepsis as a major cause of morbidity in a tertiary center in Kathmandu," Journal of Nepal Medical Association, vol. 52 no. 192,DOI: 10.31729/jnma.2424, 2013.

[73] P. Verma, P. K. Berwal, N. Nagaraj, S. Swami, P. Jivaji, S. Narayan, "Neonatal sepsis: epidemiology, clinical spectrum, recent antimicrobial agents and their antibiotic susceptibility pattern," International Journal of Contemporary Pediatrics, vol. 2 no. 3, pp. 176-180, 2017.

[74] A. J. Shah, S. A. Mulla, S. B. Revdiwala, "Neonatal sepsis: high antibiotic resistance of the bacterial pathogens in a neonatal intensive care unit of a tertiary care hospital," Journal of Clinical Neonatology, vol. 1 no. 2, pp. 72-75, DOI: 10.4103/2249-4847.96753, 2012.

[75] S. Ansari, H. P. Nepal, R. Gautam, S. Shrestha, P. Neopane, M. L. Chapagain, "Neonatal septicemia in Nepal: early-onset versus late-onset," International Journal of Pediatrics., vol. 2015,DOI: 10.1155/2015/379806, 2015.

[76] B. Pokhrel, T. Koirala, G. Shah, S. Joshi, P. Baral, "Bacteriological profile and antibiotic susceptibility of neonatal sepsis in neonatal intensive care unit of a tertiary hospital in Nepal," BMC Pediatrics, vol. 18 no. 1,DOI: 10.1186/s12887-018-1176-x, 2018.

[77] R. S. Sharma, M. Tiwari, R. P. Bansal, "Neonatal septicemia: isolates and their sensitivity pattern with emergence of Citrobacter septicemia," International Journal of Research in Medical Sciences, vol. 4 no. 4, pp. 1128-1131, 2016.

[78] S. M. JS, N. Shree, D. Bhagwani, M. Kumar, "Neonatal sepsis—a prospective study from a tertiary care hospital of North Delhi," International Journal of Microbiology Research, vol. 7 no. 3, pp. 644-647, 2015.

[79] C. M. Sharma, R. P. Agrawal, H. Sharan, B. Kumar, D. Sharma, S. S. Bhatia, "“Neonatal sepsis”: bacteria & their susceptibility pattern towards antibiotics in neonatal intensive care unit," Journal of Clinical and Diagnostic Research, vol. 7 no. 11, pp. 2511-2513, DOI: 10.7860/JCDR/2013/6796.3594, 2013.

[80] M. P. Samaga, "Prevalence of neonatal septicaemia in a tertiary care hospital in Mandya, Karnataka, India," International Journal of Research in Medical Sciences, vol. 4 no. 7, pp. 2812-2816, 2017.

[81] D. Yusef, T. Shalakhti, S. Awad, W. Khasawneh, "Clinical characteristics and epidemiology of sepsis in the neonatal intensive care unit in the era of multi-drug resistant organisms: a retrospective review," Pediatrics & Neonatology, vol. 59 no. 1, pp. 35-41, DOI: 10.1016/j.pedneo.2017.06.001, 2018.

[82] P. Sharma, P. Kaur, A. Aggarwal, "Staphylococcus aureus —the predominant pathogen in the neonatal ICU of a tertiary care hospital in Amritsar, India," Journal of Clinical and Diagnostic Research, vol. 7 no. 1, pp. 66-69, DOI: 10.7860/JCDR/2012/4913.2672, 2013.

[83] K. Dal-Bó, R. M. Silva, T. M. Sakae, "Infecção hospitalar em uma unidade de terapia intensiva neonatal do Sul do Brasil," Revista Brasileira de terapia intensiva, vol. 24 no. 4, pp. 381-385, DOI: 10.1590/S0103-507X2012000400015, 2012.

[84] Y. A. Leal, J. Álvarez-Nemegyei, J. R. Velázquez, U. Rosado-Quiab, N. Diego-Rodríguez, E. Paz-Baeza, J. Dávila-Velázquez, "Risk factors and prognosis for neonatal sepsis in southeastern Mexico: analysis of a four-year historic cohort follow-up," BMC Pregnancy and Childbirth, vol. 12 no. 1,DOI: 10.1186/1471-2393-12-48, 2012.

[85] Y. Bell, M. Barton, M. Thame, A. Nicholson, H. Trotman, "Neonatal sepsis in Jamaican neonates," Annals of Tropical Paediatrics, vol. 25 no. 4, pp. 293-296, DOI: 10.1179/146532805X72449, 2005.

[86] O. Peterside, K. Pondei, F. O. Akinbami, "Bacteriological profile and antibiotic susceptibility pattern of neonatal sepsis at a teaching hospital in Bayelsa State, Nigeria," Tropical Medicine and Health, vol. 43 no. 3, pp. 183-190, DOI: 10.2149/tmh.2015-03, 2015.

[87] A. Chiabi, M. Djoupomb, E. Mah, S. Nguefack, L. Mbuagbaw, J. Zafack, M. Ghoyap, T. Nkoa, P. F. Tchokoteu, "The clinical and bacteriogical spectrum of neonatal sepsis in a tertiary hospital in Yaounde, Cameroon," Iranian Journal of Pediatrics, vol. 21 no. 4, pp. 441-448, 2011.

[88] O. Olatunde, A. Akinsoji, D. Florence, O. Akintunde, A. Ademola, O. Adetutu, O. Akibu, "Neonatal septicaemia in a rural Nigerian hospital: aetiology, presentation and antibiotic sensitivity pattern," British Journal of Medicine and Medical Research, vol. 12 no. 7,DOI: 10.9734/BJMMR/2016/22325, 2016.

[89] W. Babiker, A. Ahmed, T. Babiker, E. Ibrahim, B. Almugadam, "Prevalence and causes of neonatal sepsis in Soba University Hospital, Sudan," Medical Microbiology Reports, vol. 3, pp. 11-13, 2018.

[90] J. Kiwanuka, J. Bazira, J. Mwanga, D. Tumusiime, E. Nyesigire, N. Lwanga, B. C. Warf, V. Kapur, M. Poss, S. J. Schiff, "The microbial spectrum of neonatal sepsis in Uganda: recovery of culturable bacteria in mother-infant pairs," PLoS One, vol. 8 no. 8, article e72775,DOI: 10.1371/journal.pone.0072775, 2013.

[91] B. John, M. David, L. Mathias, N. Elizabeth, "Risk factors and practices contributing to newborn sepsis in a rural district of Eastern Uganda, August 2013: a cross sectional study," BMC Research Notes, vol. 8 no. 1,DOI: 10.1186/s13104-015-1308-4, 2015.

[92] M. T. Magwenzi, M. Gudza-Mugabe, H. A. Mujuru, M. Dangarembizi-Bwakura, V. Robertson, A. M. Aiken, "Carriage of antibiotic-resistant Enterobacteriaceae in hospitalised children in tertiary hospitals in Harare, Zimbabwe," Antimicrobial Resistance & Infection Control, vol. 6 no. 1,DOI: 10.1186/s13756-016-0155-y, 2017.

[93] S. Pius, M. Bello, G. Galadima, H. Ibrahim, S. Yerima, J. Ambe, "Neonatal septicaemia, bacterial isolates and antibiogram sensitivity in Maiduguri North-Eastern Nigeria," Nigerian Postgraduate Medical Journal, vol. 23 no. 3,DOI: 10.4103/1117-1936.190340, 2016.

[94] B. K. Raha, M. A. Baki, T. Begum, N. Nahar, N. Jahan, M. Begum, "Clinical, bacteriological profile & outcome of neonatal sepsis in a tertiary care hospital," Medicine Today, vol. 26 no. 1, pp. 18-21, DOI: 10.3329/medtoday.v26i1.21306, 2014.

[95] B. Hasibuan, "Comparison of microbial pattern in early and late onset neonatal sepsis in referral center Haji Adam Malik Hospital Medan Indonesia," IOP Conference Series: Earth and Environmental Science, .

[96] M. Jajoo, K. Kapoor, L. Garg, V. Manchanda, S. Mittal, "To study the incidence and risk factors of early onset neonatal sepsis in an out born neonatal intensive care unit of India," Journal of Clinical Neonatology, vol. 4 no. 2,DOI: 10.4103/2249-4847.154106, 2015.

[97] P. Panigrahi, D. S. Chandel, N. I. Hansen, N. Sharma, S. Kandefer, S. Parida, R. Satpathy, L. Pradhan, A. Mohapatra, S. S. Mohapatra, P. R. Misra, N. Banaji, J. A. Johnson, J. G. Morris, I. H. Gewolb, R. Chaudhry, "Neonatal sepsis in rural India: timing, microbiology and antibiotic resistance in a population-based prospective study in the community setting," Journal of Perinatology, vol. 37 no. 8, pp. 911-921, DOI: 10.1038/jp.2017.67, 2017.

[98] A. Agrawal, S. Awasthi, P. Ghanghoriya, S. Singh, "Study of current status of bacteriological prevalence and profile in an inborn unit of SNCU in central India," International Journal of Contemporary Pediatrics, vol. 5 no. 3, pp. 764-769, DOI: 10.18203/2349-3291.ijcp20181436, 2018.

[99] P. M. Dharapur, A. R. Kanaki, "Antibiotic sensitivity and resistance pattern for neonatal sepsis in Klebsiella and Pseudomonas isolated pathogens in neonatal intensive care unit at tertiary care hospital," International Journal of Basic & Clinical Pharmacology, vol. 5 no. 5, pp. 2110-2113, 2016.

[100] A. Boulos, K. Rand, J. A. Johnson, J. Gautier, M. Koster, "Neonatal sepsis in Haiti," Journal of Tropical Pediatrics, vol. 63 no. 1, pp. 70-73, DOI: 10.1093/tropej/fmw077, 2017.

[101] A. Roca, A. Bojang, B. Camara, C. Oluwalana, K. Lette, P. West, U. D’Alessandro, C. Bottomley, "Maternal colonization with Staphylococcus aureus and Group B Streptococcus is associated with colonization in newborns," Clinical Microbiology and Infection, vol. 23 no. 12, pp. 974-979, DOI: 10.1016/j.cmi.2017.04.020, 2017.

[102] A.-K. Labi, N. Obeng-Nkrumah, S. Bjerrum, C. Enweronu-Laryea, M. J. Newman, "Neonatal bloodstream infections in a Ghanaian Tertiary Hospital: are the current antibiotic recommendations adequate?," BMC Infectious Diseases, vol. 16 no. 1,DOI: 10.1186/s12879-016-1913-4, 2016.

[103] R. Singh, S. Singh, S. Singh, D. Sachan, "Prevalence and susceptibility pattern of E. coli in low birth weight neonates of early onset sepsis," International Journal of Pharmaceutical Sciences and Research, vol. 2 no. 12, 2011.

[104] F. Y. Aku, P. Akweongo, K. Nyarko, S. Sackey, F. Wurapa, E. A. Afari, D. K. Ameme, E. Kenu, "Bacteriological profile and antibiotic susceptibility pattern of common isolates of neonatal sepsis, Ho Municipality, Ghana—2016," Maternal Health, Neonatology and Perinatology, vol. 4 no. 1,DOI: 10.1186/s40748-017-0071-z, 2018.

[105] K. Iregbu, K. Zubair, I. Modibbo, A. Aigbe, S. Sonibare, O. Ayoola, "Neonatal infections caused by Escherichia coli at the National Hospital, Abuja: a three-year retrospective study," African Journal of Clinical and Experimental Microbiology, vol. 14 no. 2, pp. 95-100, 2013.

[106] A. E. Akindolire, O. Tongo, H. Dada-Adegbola, O. Akinyinka, "Etiology of early onset septicemia among neonates at the University College Hospital, Ibadan, Nigeria," The Journal of Infection in Developing Countries, vol. 10 no. 12, pp. 1338-1344, DOI: 10.3855/jidc.7830, 2016.

[107] M. Afrin, M. A. Siddique, A. A. Ahmed, M. N. Islam, P. C. Sarker, M. S. Showkath, R. Sharmin, A. Aktar, P. Begum, T. Khanom, M. A. Biswas, F. Ahommed, "Neonatal septicemia: isolation, identification and antibiotic sensitivity pattern of bacteria in a tertiary hospital in Bangladesh," Faridpur Medical College Journal, vol. 11 no. 2, pp. 58-61, DOI: 10.3329/fmcj.v11i2.32886, 2016.

[108] R. Kumar, A. Kumari, A. Kumari, N. Verma, "Evaluation of perinatal factors in neonatal sepsis at tertiary centre," International Journal of Reproduction, Contraception, Obstetrics and Gynecology, vol. 6 no. 11, pp. 4981-4985, DOI: 10.18203/2320-1770.ijrcog20175012, 2017.