This study revealed that women who were suspected of having sepsis were included at five tertiary hospitals in three-fourths of the country during the study period. These hospitals serve as referral centers for three-fourths of the population of 125 million people. The study revealed that 97% of women who had experienced sepsis were unaware of the harmful symptoms and potential risks of this illness to the developing fetus. The awareness of sepsis is low. Studies have shown that 2.6% of the population in Japan, and 4.2% of the population in Singapore [8, 31, 42]. In contrast, studies in Sweden and Germany revealed that the prevalence of population awareness of sepsis was 92% and 88.6%, respectively [2, 9, 41].
In terms of residence, 74.3% of the maternal sepsis patients were from rural areas. A total of 56.8% of maternal sepsis patients had delayed treatment, making it difficult to determine whether symptoms were from infection or pregnancy complications upon arrival at the hospital. Although these suspected cases were treated with carbapenem and vancomycin, the number of patients infected with antibiotics resistant to those last-resort antibiotics has increased, which is unacceptable in the studied hospitals [10, 20, 24]. Clinicians face significant challenges in regard to the early recognition and diagnosis of sepsis in pregnant women. It mimics signs and symptoms of complicated pregnancy and needs urgent work to identify infection before its prognosis is improved to sepsis [4, 7,8,9, 31, 32, 43]. Additionally, alcoholism was associated with sepsis in mothers in this study. Those who frequently consumed alcohol, such as beer and ”Tela”, and were infected with K. pneumoniae had a greater likelihood of developing severe symptoms, accounting for 42.9% of the patients. These findings are consistent with many related studies [1, 3, 6, 16, 17, 34, 36, 39]. The maternal sepsis incidence and treatment of K. pneumoniae vary by region. This could be due to different factors such as sample type, geographic location, patient demographics, immune status, and co-infections, which can affect the magnitude and strain type of this bacterium, which is consistent with our findings in five tertiary hospitals [10, 15, 24, 35, 37].
This study revealed that K. pneumoniae was resistant to a high percentage (39–100%) of the tested antibiotics, including last-resort options such as carbapenems and tigecycline. These findings suggest that carbapenem and cephalosporin antibiotics have become less effective in treating superbugs. Without addressing the rapid spread of CRKP strains, alternative treatments may not be available in the near future. These findings are consistent with many studies carried out in other counties [34,35,36,37]. On the other hand, this bacterium is one of the most commonly acquired bacteria in both nosocomial and community infections and is highly spreading and developing antimicrobial resistance worldwide [10,11,12,13,14, 23, 24].
The prevalence of MDR K. pneumoniae was high at 93.9% (ranging from 91.4 to 98.2%). This finding is consistent with those of studies carried out by Tsegaye et al. 86.5% [34], Aberaet al. 45.2% [35], Belay et al. 84% [36], Beyene et al. 94.5% [46], and Awoke et al. 98.5% [37]. Overall, those studies demonstrated that the number of isolates evaluated for each study, the geographic variation, the studied population, and the test method used all affect the prevalence of MDR-K. pneumoniae. Another study by Cassini et al. reported various prevalences of antimicrobial-resistant infections across Europe [19]. Similarly, Lee et al. reported that there was variation in the strains, prevalence, and burden of carbapenemase-producing K. pneumoniae that disseminated worldwide [18]. Forero-Hurtado et al. reported antimicrobial resistance via blaKPC genes and other genes, such as blaNDM-1, and plasmid-mediated quinolone resistance [13, 22] cross-transmitted from K. pneumoniae to different species [15]. Similarly, this could involve vertical or horizontal genome transfer [17, 20, 21, 28]. We are actively working toward addressing the challenge of multidrug-resistant strains, including K. pneumoniae, which pose a significant obstacle to achieving our goal of reducing maternal and newborn morbidity and mortality rates in a sustainable manner [7, 18, 19, 27]. In the present study, the prevalence of XDR K.pneumoniae was 28.1%, which is higher than the rates reported in studies by Abera et al. 7.7% [35], and Beyene et al. 8.8% [46]. The percentage obtained in this study is slightly lower than that reported by Tsegayeet al. 43.3% [34]; similarly, the prevalence of PDR K. pneumoniae was 28.1%, which is higher than that reported in studies performed by Beyene et al.. 0.8%[ 46], Awoke et al.. 1.5% [37] and Tsegayeet al. 1.8% [34].
Our study of K. pneumoniae revealed that various strains that produce enzymes, namely carbapenemase and ESBL, which are responsible for causing antimicrobial resistance, have become resistant to antimicrobial drugs. A total of 41.7% of the K. pneumoniae strains were non-susceptible to carbapenems, and 40.2% produced carbapenemase. The prevalence of carbapenemase-producing strains reported in China ranges from 20.4 to 21.9% [11]. However, this figure is higher than that in the studies conducted by Abera et al., 15.4% [35], and Tsegaye et al., 9% [34]. The percentage obtained in this study is slightly lower than that reported by Beyene et al.., which was 30% [46]. On the other hand, 87.6–93.04% of K. pneumoniae strains were ESBL-producing strains. The highest frequency of this profile was found in hospitals in the central part of the country. Similarly, the western, southern, and eastern regions account for 87.6%, 96.4%, and 95.3%, respectively, of the profile. This study is similar to studies that reported a high percentage of ESBL-producing K. pneumoniae nationwide [3, 34,35,36,37] and even on a global scale [12, 14, 16, 17, 38].
Although sepsis is a significant healthcare problem, comprehensive data on sepsis caused by multidrug-resistant bacteria and the consequences of sepsis leading to exacerbated maternal morbidity and mortality is lacking. In this investigation, we employed binary and multivariate logistic regression models to pinpoint putative risk factors associated with K. pneumoniae-induced maternal sepsis. The findings revealed that women with specific clinical outcomes, such as septic abortion [AOR = 5.3; 95% CI = 2.2–14.4]; P = 0.0001], indwelling catheters[(AOR = 2.1; 95% CI = 1.4–6.2; P < 0.01)], alcoholism alcoholism [(OR = 5.2; 95% CI: 2.9–11.3, P = 0.001], ICU admission[AOR = 4.3; 95% CI = 2.4–11.2; P = 0.01], cesarean delivery[AOR = 4.1; 95% CI = 2.0–9.2]; P = 0.001], a history of not using antimicrobial agents within eight weeks[(AOR = 3.7; 95% CI = 1.6–19.4); P = 0.0001], and recurrent UTIs[AOR = 3.3; 95% CI = 1.6–13.2]; P = 0.01], history of dilatation and curettage [(AOR = 2.2; 95% CI = 1.3–13.4; P = 0.001)] were at greater risk of developing sepsis. These findings are similar to those of studies on the risk factors associated with sepsis, which exacerbates severe morbidity and mortality at community and health facilities (Table 2); these findings have also been reported by many researchers [7, 8, 18, 19, 25, 28, 32, 33, 42]. The occurrence of risk factors associated with maternal factors (host factors) [1, 27, 34, 43] and bacterial factors [8, 29] has led to the widespread spread of highly virulent strains [18, 20, 21, 28] and antimicrobial resistance, which includes strains that are pandrug resistant [8, 11, 26].
The management of sepsis encompasses fluid resuscitation for hypotension, empirical antimicrobial treatment, and vasoactive agents (norepinephrine) to reduce the risk of maternal complications. Although treatments have been used to reduce maternal mortality and morbidity caused by sepsis, an increase in antimicrobial-resistant bacterial infections has had adverse consequences. In this context, sepsis caused by CRKP and ESBL-producing K. pneumoniae has resulted in severe maternal sepsis, leading to millions of deaths, socioeconomic crises, and security issues. Figure 3 shows a high incidence of CRKP and ESBL-producing K. pneumoniae, which compromises the effectiveness of last-resort antibiotics such as carbapenem and tigecycline. These findings are similar to those of previous studies on pulmonary infections (pneumonia), surgical site infections and UTIs associated with CRKP [5, 9, 12, 19].
During the study period, it was observed that there were difficulties in promptly recognizing and treating CRKP because of the delayed reporting of culture results. This delay poses a challenge for gynecologists in reducing the risk of adverse maternal sepsis outcomes. These findings are similar to those of previous studies [3, 5, 11, 22, 30, 34, 37, 38, 40]. Treatment of maternal sepsis with antimicrobial agents involves a general gram-negative bacteremia algorithm, which uses broad-spectrum β-lactam antibiotics such as ciprofloxacin, trimethoprim-sulfamethoxazole, cefepime, aztreonam, ceftriaxone, amoxicillin, gentamicin, clindamycin, vancomycin, and piperacillin-tazobactam as part of empiric antimicrobial therapy. These findings are consistent with those of other studies [1, 21, 44, 47].
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