ORIGINAL ARTICLE Incidence, aetiology and resistance of late-onset neonatal sepsis: A five-year prospective study Majeda S Hammoud, 1 Abdullah Al-Taiar, 2 Lukman Thalib, 2 Noura Al-Sweih, 3 Seema Pathan 4 and David Isaacs 5 Departments of 1 Pediatrics, 2 Community Medicine and Behavioural Sciences and 3 Microbiology, Faculty of Medicine, Kuwait University, 4 Department of Microbiology, Al-Sabah Maternity Hospital, Kuwait, Kuwait and 5 Department of Infectious Diseases and Microbiology, Children’s Hospital at Westmead, Sydney, New South Wales, Australia Aim: Investigate the incidence, etiological pattern and the antimicrobial resistance of late-onset neonatal infections over a period of 5 years. Methods: Longitudinal audit of neonatal sepsis from January 2005 to December 2009, in the main maternity hospital in Kuwait. Late-onset neonatal infection was defined as the culture of a single potentially pathogenic organism from blood or cerebrospinal fluid from an infant older than 6 days in association with clinical or laboratory findings consistent with infection. Results: The overall incidence was 16.9 (95% confidence interval: 15.8–18.0) episodes per 1000 live births. The commonest pathogen was coagulase-negative Staphylococcus, 339 (35.7%), while Klebsiella was the most common gram-negative infection, 178 (18.8%). Escherichia coli, Enterococcus and Enterobacter spp were each responsible for 6% of all infections. Candida caused 104 (11.0%) infections. The general pattern of infection remained unchanged over the study period. Case fatality was 11.7% (95% confidence interval: 9.7–13.9%) and was high for Pseudomonas (18.4%) and Candida (22.1%) infections. Approximately 24 and 20% of Klebsiella infections were resistant to cefotaxime and gentamicin, respec- tively, while 28 and 24% of Escherichia coli infections were resistant to cefotaxime and gentamicin, respectively. Conclusion: The incidence of late-onset infection in Kuwait is high, resembling that in resource-poor countries. The high incidence coupled with low case fatality provides an example for settings where tertiary care is introduced without strict measures against nosocomial infections. Prevention against nosocomial infections in neonatal units has the potential to further reduce neonatal mortality in these settings. Key words: infection; Kuwait; late-onset; Middle East; neonate. Late-onset neonatal infections remain an important cause of death, morbidity and long-term complications among prema- ture infants. 1–6 Neonatal infections are difficult to diagnose because the symptoms of infection are often non-specific and different from those in older infants. Premature infants are at greater risk of late-onset infection because of their immature immune system and use of invasive devices to sustain life support care. Furthermore, increase in the incidence of preterm births 7 and the survival of these susceptible infants 8 may have contributed to the increase of neonatal septicaemia. Several definitions have been used for late-onset neonatal infections, including infections occurring more than 48 h after birth or infections more than 6 days afterwards. Unlike early- onset neonatal infections, which are acquired mainly from maternal genital tract microorganisms, most late-onset infec- tions are with hospital-acquired organisms. As a result, the spectrum of organisms causing early-onset neonatal sepsis differs from that causing late-onset sepsis, a trend that becomes most obvious 48 h after delivery. 2 Gram-positive bacteria, par- ticularly coagulase-negative staphylococci (CONS), are the most Correspondence: Dr Majeda S. Hammoud, Department of Pediatrics, Faculty of Medicine, Kuwait University, PO Box 24923, Safat, Kuwait 13110, Kuwait. Fax: +965 25338940; email: m.hammoud@hsc.edu.kw Accepted for publication 5 September 2011. What is already known on this topic 1 Late-onset neonatal infections are nosocomial or community- acquired and represent a major cause of neonatal mortality and morbidity in developing countries. 2 The spectrum of organisms causing late-onset neonatal sepsis differs from one place to another and in the same place overtime. 3 Gram-positive bacteria, particularly coagulase-negative staphy- lococci, are the most common cause of late-onset neonatal sepsis in many industrialized and developing countries. What this paper adds 1 Description of the incidence and aetiology of late-onset neona- tal infection in areas where tertiary care is heavily used without strict measures against nosocomial infections. 2 Description of antimicrobial resistance among common neona- tal infections in The Middle East. 3 Demonstration of the role of Klebsiella spp in morbidity and mortality due to late-onset neonatal infections in The Middle East. doi:10.1111/j.1440-1754.2012.02432.x Journal of Paediatrics and Child Health 48 (2012) 604–609 © 2012 The Authors Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians) 604