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Trend of antimicrobial susceptibility in a neonatal and pediatric intensive care unit

How to cite this article: Vázquez-Solís MG, Villa-Manzano AI,Medina-García LH,Zamora-López XX,Pulido-Galaviz C,Zamora-López DF. Trend of antimicrobial susceptibility in a neonatal and pediatric intensive care unit. Rev Med Inst Mex Seguro Soc. 2016;54(1):8-15.


Received: March 8th 2014

Accepted: September 1st 2015


Trend of antimicrobial susceptibility in a neonatal and pediatric intensive care unit

María G. Vázquez-Solís,a Alberto I. Villa-Manzano,b Luis H. Medina-García,c X. Xitlalli Zamora-López,d Carlos Pulido-Galaviz,e Daniel F. Zamora-Lópezf

aServicio de Pediatría, Hospital General Regional 110, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

bUnidad Médica de Medicina Ambulatoria 52, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México

cDepartment of Infectology, University of Arizona Medical Center, Phoenix, Arizona, Estados Unidos

dPosgrado en Ciencias Médicas, Universidad de Colima, Colima, Colima, México

eCentro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México

fUnidad de Medicina Familiar 46, Culiacán, Sinaloa, México

Communication with: Alberto I. Villa-Manzano

Thelephone: (33) 3629 5079


Background: Nosocomial infections in intensive care units are a health problem worldwide due to their incidence, prevalence and clinical impact. The objective of this article was to describe the trend of antimicrobial susceptibility during a 10-years period in both a pediatric and a neonatal intensive care unit.

Methods: This is a follow-up cohort study. In 10 years of follow-up, the antimicrobial used was considered the independent variable, and the antimicrobial susceptibility as the dependent variable. By using chi squared with Fisher exact test, the initial and final susceptibilities were compared, and also the most prevalent diagnoses and the antimicrobials. A two-tailed p value < 0.05 was considered statistically significant. SPSS 8 and Epi-Info 0.6 were used for statistical analysis.

Results: Antimicrobial susceptibility decreased from 66 to 45 % in 10 years, representing a global loss of 13 % (p = 0.002). The most affected antimicrobials were first-generation cephalosporin (p = 0.02), ciprofloxacin (p = 0.05), erythromycin (p = 0.001), imipenem (p = 0.001), and trimethoprim/sulfamethoxazole (p = 0.05).

Conclusion: There is an alarming loss of effectiveness in antimicrobial agents.

Keywords: Microbial drug resistance; Anti-infective agents; Microbial sensitivity tests; Intensive care units; Pediatrics.

The treatment of common infections is based on subjective judgments, and the use of antimicrobials is supported by the diagnosis, epidemiology, the most likely etiology, and the antimicrobial sensitivity profile of the pathogen involved, which varies widely depending on geographic region, and even between hospitals in the same country and city.1 This, combined with the lack of research, obscures the prospects for resolving community- and hospital-acquired infections, and increases bacterial resistance. The World Health Organization (WHO) considers antimicrobial resistance as a priority problem and proposes continuous updates according to reports from epidemiological surveillance systems.2,3

Infection in intensive care units represents a global public health problem due to its incidence, prevalence, and clinical impact; it is therefore one of the leading causes of death worldwide. Mortality is between 14 and 80% depending on the source of infection, the pathogen responsible, the site of acquisition, and antimicrobial sensitivity. Patients admitted to intensive care units are between five and 10 times more at risk for nosocomial infection than patients in other areas.4,5

Identifying pathogens in hospitals is part of the measures to reduce antimicrobial resistance in these centers.6 The epidemiological profile of infections in intensive care units has changed in recent years, and it is related to host characteristics and associated risks that predispose patients to severe infections caused by opportunistic and multidrug-resistant pathogens.7

Antimicrobial sensitivity is variable, and periodic studies must be conducted to support their use. There are few studies, so the prescription of antimicrobials remains empirical and based on information from studies that do not correspond to local reality.


The Hospital General Regional 110 of the Instituto Mexicano del Seguro Social is a hospital of reference in western Mexico. The pediatrics department has a neonatal intensive care unit (NICU) admitting 249 patients on average annually, and a pediatric intensive care unit (PICU) admitting 179 patients on average annually. The NICU admits only babies born at the hospital and that have had no contact with the community, and the PICU admits patients from 0 to 15 years from the pediatric emergency department at the same hospital and other hospitals; these patients are mostly neonates and infants.

The study was designed as a cohort follow-up based on results from the microbiology laboratory of the hospital mentioned, in the period from the opening of the hospital in November 2000 through December 2010. The results were collected from all cultures made on children admitted to the pediatric and neonatal intensive care units.

Positive cultures were identified by conventional biochemical tests. From November 2000 to October 2003, samples were made through the process of dilution with manual adjustment of inoculum to reach the standard turbidity equivalent to 0.5 on the McFarland scale.8 Starting in November 2003, the automated system MicroScan® Walkaway 96SI was used, and sensitivity results were determined by microdilution using the Prompt-D inoculation system, considering strains to be sensitive or resistant based on the minimum inhibitory concentration, determined by NCCLS parameters (National Committee on Clinical Laboratory Standards).9

For statistical analysis, the etiologic agent, the most prevalent diseases, and the antimicrobial used were considered as independent variables. The three main admission diagnoses were considered for analysis by pathology, as well as the 10 major etiologic agents found (four Gram positive bacteria and six Gram negative bacteria), and the total of antimicrobials reported in sensitivity testing.

The dependent variable was antimicrobial sensitivity at the beginning and end of 10 years of follow-up.

Gram sensitivity was determined by grouping the first five years compared with the last five years of follow-up. The data from the two ICUs were analyzed separately and jointly.

The incidence of initial and final sensitivity of the etiologic agent, and the most prevalent diseases and antimicrobial were compared using chi-squared with Fisher’s exact test. Statistical significance was considered with two-tailed p of 0.05. Analyses were made using SPSS statistical software version 8 and Epi-Info version 0.6.

The work was approved by the hospital’s research committee (register R-2009-1303-8), and the use of information was strictly for scientific purposes, maintaining at all times the patient’s right to anonymity and confidentiality.


In the period from November 2000 to December 2010, 2739 patients were admitted to the NICU, with an admission rate of 2.2% of all births, and 1969 patients to the PICU. 1683 samples were processed for culture and sensitivity, obtaining 47% (n = 794) positive microbiological cultures (537 Gram positive, 245 Gram negative, and 12 Candida albicans).

Table I shows that the main pathogens isolated in order of frequency were: S. epidermidis (26%), S. aureus (20%), E. coli (10%), S. haemolyticus (10%), Pseudomonas aeruginosa (6%), Klebsiella pneumoniae (4%), Enterobacter cloacae (4%), Enterococcus faecalis (3%), Acinetobacter baumannii (2%), Citrobacter freundi (1.5%), and Candida albicans (1.5%). Gram positive predominated in both care units: in the NICU 71% (n = 352) and in the PICU 65% (n = 185), but the PICU showed higher incidence of Gram negative with 35% (n = 100) of isolates, showing a significant difference with the NICU, which had only 29% Gram negative (n = 145) with a p of 0.05.

Table I Most common microorganisms isolated by treatment
NICU (n = 497) PICU (n = 285) p*
n % n %
Gram positive bacilli 352 71 65 185 0.05 *
Staphylococcus epidermidis 127 26 29 83 0.01 *
Staphylococcus aureus 108 20 18 52 0.25
Staphylococcus haemolyticus 56 10 7 21 0.05 *
Enterococcus faecalis 12 2 3 7 0.84
Other 13 49 8 22
Gram negative bacilli 29 145 35 100 0.05 *
Escherichia coli 43 8 32 11 0.23
Pseudomonas aeruginosa 26 5 19 7 0.40
Klebsiella pneumoniae 19 4 11 4 0.97
Enterobacter cloacae 13 3 17 6 0.01 *
Acitenobacter baumannii 7 1.5 6 2 0.46
Citrobacter freundii 7 1.5 1 0.3 0.26
Other 30 6 14 5
There were 12 cultures of Candida albicans
* Chi-squared was applied with Fisher's exact test. NICU = neonatal intensive care unit;
PICU = pediatric intensive care unit

Sensitivity analysis for diagnosis

Diagnoses in order of frequency corroborated by positive culture in the NICU were sepsis 51% (n = 260), pneumonia 34% (n = 172), urinary tract infection 11% (n = 58), omphalitis 3% (n = 13), and meningitis 1% (n = 1). In the PICU, diagnoses were similar: sepsis 55% (n = 158), pneumonia 30% (n = 86), urinary tract infection 10% (n = 29), omphalitis 4% (n = 12), and meningitis 1% (n = 3).

The greatest loss of antimicrobial susceptibility over the 10 years was observed in the diagnosis of sepsis, which went from 71.5 to 47% (p = 0.005). For pneumonia, urinary tract infection, and omphalitis there was no significance, nor in the overall diagnostic sensitivity over the 10 years, which went from 71.5 to 66% (p = 0.44).

According to the admission diagnosis, the overall incidence of nosocomial infection was 13% (n = 103). The NICU presented 12% (n = 61) nosocomial infection and the PICU 14% (n = 42), p = 0.32. It was documented that pneumonia was the most frequent nosocomial infection with 42% (n = 73), followed by sepsis with 30% (n = 52). As for the etiology of these nosocomial infections, infections caused by Gram positive pathogens predominated in 68% (n = 70).

Antimicrobial sensitivity analysis

Figure 1 shows a clear decrease in antimicrobial susceptibility, with an initial global average of 66% and a final sensitivity at 10 years of 45%, which represents an overall sensitivity loss of 13% (p = 0.002).

Figure 1 Antimicrobial sensitivity in 10 years in intensive care units (p = 0.002)

The antimicrobials that showed significant sensitivity loss at 10 years were first-generation cephalosporin (p = 0.02), ciprofloxacin (p = 0.05), erythromycin (p = 0.001), imipenem (p = 0.001) and trimethoprim with sulfamethoxazole (p = 0.05).

The antimicrobials that maintained sensitivity were: ampicillin, clarithromycin, erythromycin, penicillin, piperacillin tazobactam, vancomycin, meropenem, and rifampicin, with a p-value that was not significant.

Sensitivity analysis by Gram

When comparing the sensitivities of Gram positive and negative agents, we found no significant changes in the overall sensitivity at 10 years, but it is worrisome that this tended to decrease. Regarding Gram positive cultures, only one in three was antimicrobial-sensitive, and for Gram negative cultures one in two.

In Table II we can see that some antimicrobials showed a marked decrease in sensitivity. Regarding those Gram positive, decrease is observed in first-generation cephalosporins (p = 0.001), as well as in third- (p = 0.001) and fourth-generation (p = 0.015); in dicloxacillin (p = 0.01) in imipenem (p = 0.06), and in piperacillin /tazobactam (p = 0.004). For Gram negative, the following antimicrobials showed decreased sensitivity: amikacin (p = 0.001), aztreonam (p = 0.0001), second-generation cephalosporins (p = 0.01), ticarcillin (p = 0.014), tobramycin (p = 0.2), and trimethoprim-sulfamethoxazole (p = 0.001).

Table II Changes in sensitivity of antimicrobials per Gram at 10 years of follow-up
Gram positive bacilli
Staphylococcus epidermis, Staphylococcus haemolyticus,
Staphylococcus aureus, Staphylococcus hominis,
Staphylococcus simulans, Enterococcus faecalis
2001-2005 2006-2010 p*
% %
Ampicillin 19 20 0.001
First-generation cephalosporin 17 0 0.001
Second-generation cephalosporin 0 3 NS
Third-generation cephalosporin 36 5 0.001
Fourth-generation cephalosporin 54 36 0.015
Clarithromycin 15 21 NS
Dicloxacillin 12 2 0.01
Erythromycin 24 21 NS
Imipenem 55 41 0.06
Meropenem 42 35 NS
Penicillin 19 27 NS
Piperacillin-tazobactam 33 54 0.004
Rifampicin 83 74 NS
Vancomycin 95 96 NS
Total 36 31 NS
Gram negative bacilli
Klebsiella pneumoniae, Enterobacter cloacae, Enterobacter aglomerans, Acitenobacter baumanii, Escherichia coli, Pseudomonas aeruginosa
2001-2005 2006-2010 p*
% %
Amikacin 90 71 0.001
Ampicillin 8 9 NS
Aztreonam 50 23 0.0001
Second-generation cephalosporin 29 67 0.001
Third-generation cephalosporin 72 67 NS
Fourth-generation cephalosporin 58 66 NS
Ciprofloxacin 33 67 0.001
Imipenem 78 77 NS
Meropenem 82 81 NS
Piperacillin-tazobactam 55 60 NS
Ticarcillin 17 33 0.014
Tobramycin 44 61 0.02
Trimethoprim-sulf 100 66 0.001
Total 55 57 NS
* Chi-squared was applied with Fisher's exact test

Some antimicrobials increased their sensitivity; among them were ciprofloxacin (p = 0.001), moxifloxacin (p = 0.001), ofloxacin (p = 0.001), piperacillin (p = 0.04), and amoxicillin-clavulanate (p = 0.001).


The present study documented a worrying loss of antimicrobial effectiveness to the agents causing infection.

The most common causes of infection documented in the NICU and PICU were: sepsis, pneumonia, urinary tract infection, omphalitis, and meningitis. The incidence and frequency order of the main causes of admission to the pediatric intensive care units vary in different reports, but sepsis and infections of the respiratory tract, central nervous system, surgical, and urinary tract remain constant.10,11   

The greatest loss of sensitivity was observed in the antimicrobials used to combat sepsis (the primary diagnosis in our study). This coincides with multiple publications, which also state that the pathogens causing sepsis are a rare mixture of microorganisms, observed both in developed and developing countries, and that this pathology’s resistance to first-line antibiotics has increased considerably.12

The incidence of nosocomial infections in the PICU varies between 11 and 35% in our country and the world.13-15 The present study showed that 13% of cultures with confirmed positive diagnoses were for nosocomial infection, a result within the expected parameter.

S. epidermidis was the most frequent pathogen. Some authors report that in Mexico it represents one of the main etiological agents of nosocomial infections in pediatric services and the PICU.16-18

Other significant pathogens identified were S. aureus, S. haemolyticus, Enterococcus faecalis, and Gram negative pathogens such as E. coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter cloacae, Citrobacter freundii, and Acinetobacter baumannii. This great variety coincides with the epidemiology reported in PICUs.19 Gram negative agents are identified as causing the greatest incidence of infections in PICUs in developing countries,20,21 unlike developed countries where Gram positive agents cause infections more frequently in these areas.22 However, it is striking that in our country there is evidence of increased incidence of Gram positive agents,16 as also documented in our study. One could consider that the increase in Gram positive agents could be explained by the fact that invasive procedures often are carried out in ICUs.

Although there are changes in the frequency of these microorganisms, there are constants like Gram positive bacteria such as coagulase negative S. aureus and enterococci, and Gram negative such as E. coli, Pseudomonas, Klebsiella pneumoniae, and Acinetobacter baumannii; the latter is emerging as a cause of bacteremia associated with the use of contaminated fans and humidifiers.23 Candida has been identified with some frequency. This variability in results could be due to the geographical region studied, the characteristics of the population itself, and the hospital environment.24,25 The pathogens identified in our study did not differ greatly from what has already been reported. 

We documented that the sensitivity of some antimicrobials significantly decreased over the 10 years. Such is the case of first-generation cephalosporins (ciprofloxacin, erythromycin, imipenem, and trimethoprim with sulfamethoxazole). These results are analogous to previous reports that showed considerable and significant reduction in sensitivity to sulfamethoxazole, erythromycin, and first-generation cephalosporins.26-28

In our study when making a Gram analysis, some antimicrobials significantly decreased sensitivity. In the Gram negative, reduced sensitivity was identified in amikacin and trimethoprim with sulfamethoxazole; these results confirm the statements in previous reports.21,29

Ticarcillin, tobramycin, and second-generation cephalosporins, as well as carbapenems maintained adequate sensitivity for Gram negative microorganisms.

In Gram positive agents, we identified a significant decrease in the sensitivity of first-, third-, and fourth-generation cephalosporins, which also coincides with reports in the literature.30,31 Some antimicrobials increased their sensitivity, such as piperazine/tazobactam, second-generation cephalosporins, quinolones, piperacillin, and amoxicillin/clavulanate. There are similar studies whose results are consistent with our findings. This may be happening because these antimicrobials are not used frequently in pediatric patients.31-33 The use of quinolones in children is only considered as an alternative for select situations such as infections with P. aeruginosa or multidrug-resistant strains, in which potential benefits and risks are weighed.34 Vancomycin, meropenem, and rifampicin maintained their sensitivity, which could be explained by their use according to established institutional guidelines.

The downward trend in antimicrobial susceptibility is linked to their indiscriminate and inappropriate use.35 There is currently an effort to reduce the phenomenon of antimicrobial resistance through their cyclical use,38,39 analyzing how long their administration lasts,36 and the impact on the health worker who uses them. There is also an effort to raise awareness on the prophylactic use of antimicrobials.37

The scarce use of some antibiotics in pediatrics, such as quinolones, monobactams, and glycopeptides, can become a strategy to increase the sensitivity of other antimicrobials. In addition, as discussed by several authors,40-42 it is advisable to perform blood culture before establishing antimicrobial management; not to use broad-spectrum antimicrobials indiscriminately; to develop national and local policies to restrict the widespread use of antibiotics;43 to have a reliable laboratory verify microbiological cultures; not to diagnose sepsis only with the results of acute-phase reactants; to discontinue the use of an antibiotic on the third day if a blood culture is negative; to avoid antibiotics for long periods; and to remember that health staff is essential for preventing nosocomial infections;44-46 to strengthen infection control; and particularly to encourage hand-washing. 

Doing a prospective study helped us observe the change in antimicrobial sensitivity, which is one of the main strengths of the study and which provides useful information for decision-making on the use of antimicrobials.

The worrying loss of utility of antimicrobials should lead us to establish continuous monitoring of susceptibility patterns to determine the trend and implement interventions to achieve the rational use of these medicines.
  1. Turnidge J, Bell J, Biedenbach DJ, Jones RN. Pathogen occurrence and antimicrobial resistance trends among urinary tract infection isolates in the Asia Western Pacific Region; report form the SENTRY Antimicrobial Surveillance Program. 1998-1999. Int J Antimicrob Agents. 2002;20(1):10-7.
  2. World Health Organization. Antimicrobial resistance. Fact sheet N° 194.
  3. Organización Mundial de la Salud. Estrategia Mundial de la OMS de contención de la resistencia a los antimicrobianos. Ginebra. OMS; 2001.
  4. Cordero DM, García AL, Barreal RT, Jiménez J, Rojas N. Comportamiento de la infección nosocomial en las unidades de Terapia en un período de 5 años. Rev Cubana de Hig y Epidemiol. 2002;40(2):79-88.
  5. Sabatier C, Peredo R, Vallés J. Bacteriemia en el paciente crítico. Med Intensiva. 2009;33(7):336-45.
  6. Castañeda NJ, González SN, Vázquez TO, Campos RT, Saldaña MC. Epidemiología de las infecciones nosocomiales en el Instituto Nacional de Pediatría. Rev Enf Inf Ped. 2003;64:128-35.
  7. McGrath EJ, Basim IA. Nosocomial Infection and Multidrug-Resistant Bacterial Organisms in the Pediatric Intensive Care Unit. Indian J Pediatr. 2011;78(2):176-84.
  8. National Committee for Clinical Laboratory Standards 2000. NCCLS approved Standard M7-A5: methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically. National Committee for Clinical Laboratory Standards, 771E. Villanova, Pennsylvania, United States; 2000.
  9. National Committee for Clinical Laboratory Standards 2003. Performance standards for antimicrobial disk susceptibility test. 7th edition. Approved standard M2-A7 NCCLS, Wayne, Pennsylvania, United States; 2003.
  10. Grohskopf LA, Sinkowitz-Cochran RL, Garrett DO, Sohn AH, Levine GL, Siegel JD, et al. A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States. J Pediatr. 2002 apr;140(4):432-8.
  11. Ponce de Leon S, Molinar F, Dominguez G, Rangel MS, Vazquez VG. Prevalence of infections in intensive care units in México: A multicenter study. Crit Care Med. 2000;28:1316-21.
  12. Arredondo JL, Ortiz IF, Solorzano SF, Segura CE, Beltran ZM. Etiología de la septicemia neonatal en una unidad de perinatología. Informe de 7 años. Bol Med Hosp Infant Mex. 1994;51:317.
  13. González N, Castañeda JL, Saltigeral P, Rodríguez MA, López C, Rosas A et al. Infecciones Nosocomiales en la Unidad de Cuidados Intensivos Neonatales del Instituto Nacional de Pediatría. Acta Pediatr Mex. 2011;32(1):28-32.
  14. González N, Castañeda JL, Hernández OH, Saldaña MC, Monroy DA, Lucas RE et al. Informe de 17 años de la vigilancia epidemiológica de las infecciones nosocomiales en el Instituto Nacional de Pediatría. Rev Enf Inf Ped. 2006;20(78):35-9.
  15. Stockwell JA. Nosocomial infections in the pediatric intensive care unit: affecting the impact on safety and outcome. Pediatr Crit Care Med. 2007;8(2):21-37.
  16. Ochoa C, Sangrador MI, Santos MI, Brezmes MF, Marugán V, García MJ et al. Tendencias en la sensibilidad a antimicrobianos de los uropatógenos en la infancia (1995-2001) Bol Pediatr. 2004;44(187):3-8.
  17. Garay UA, Velázquez Y, Anaya V, Valencia JC, López ME. Infecciones nosocomiales en un hospital de alta especialidad. Factores asociados a mortalidad. Rev Med Inst Mex Seguro Soc. 2005;43(5):381-91.
  18. Cornejo P, Velazquez C, Diaz A, Volk P. Tendencia del perfil de sensibilidad antimicrobiana de los aislamientos de sangre en un hospital oncológico (1998-2003). Salud Publica Mex. 2005;47(4):288-93.
  19. Leaños B, Abad M, Solorzano F. Microorganismos aislados de hemocultivos en 10 años en un hospital pediátrico de tercer nivel de atención. Enf Inf Microbiol. 2007;27(1):6-10.
  20. Viswanathan R, Singh AK, Ghosh C, Dasgupta S, Mukherjee S, Basu S. Profile of Neonatal Septicaemia at a District-level Sick Newborn Care Unit. J. Healt Popul Nutr. 2012;30(1):41-8.
  21. Jain A, Roy I, Gupta M, Kumar M, Agarwal S. Prevalence of extended-spectrum B-lactamasa-producing gram negative bacteria in septicaemic neonates in a tertiary care hospital. J Med Microbiol. 2003;52:421-5.
  22. Yapicioglu H, Ozcan K, Sertdemir Y, Mutlu B, Satar M, Narli N, et al. Health care associated infections in a neonatal intensive care unit in Turkey in 2008: Incidence and risk factors, a prospective study. J Trop Pediatr. 2011 Jun; 57(3):157-64.
  23. Elward, AM, Warren DK, Fraser VJ. Ventilator-associated pneumonia in pediatric intensive care unit patients: risk factor and outcomes. Pediatrics. 2002;109(5):758-64.
  24. Martínez H, Anaya V, Gorbea M. Infecciones nosocomiales en un servicio de pediatría en un hospital de tercer nivel. Rev Mex Pediatr. 2001;68(2):56-65.
  25. Grohskopf LA, Sinkowitz-Cochran RL, Garrett DO, Sohn AH, Levine GL, Siegel JD, et al. A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States. J Pediatr. 2002;140(4):432-8.
  26. Isaacs D. Unnatural selection: reducing antibiotic resistance in neonatal units. Arch Dis Child Fetal Neonatal. 2006;91(1):72-4.
  27. Bizzarro MJ, Raskind C, Baltimore R, Gallagher PG. Seventy-five years of neonatal sepsis at Yale: 1928-2003. Pediatrics. 2005;116(3):595-602.
  28. Viswanathan R, Singh AK, Mukherjee S, Mukherjee R, Das P, Basu S. Aetiology and antimicrobial resistance of neonatal sepsis at a tertiary care centre in eastern India: a 3 year study. Indian J Pediatr. 2011;78:409-12.
  29. Villa L, Pewzella C, Tosini F, Visca P, Petrucca A, Carattoli A. Multiple antibiotic resistance mediated by structurally relate IncL/M plasmids carrying and extended spectrum B-lactamase gene and a class I integron. Antimicrob Agents Chemother. 2001;44: 2911-4.
  30. Amita J, Rajesh M. Prevalence and antimicrobial resistance pattern of extended spectrum B-lactamase producing Klebsiella spp isolated from cases of neonatal septicaemia. Indian J Med Res. 2007;125(1):89-94.
  31. Rahman A, Hameed A, Roghani MT, Ullah Z. Multidrug resistant neonatal sepsis in Peshawar, Pakistan. Arch Dis Child Fetal Neonatal. 2002;87:52-4.
  32. Agudelo CI, Castañeda E, Corso A, Regueira M, Brandileone MCC, Brandão AP, et al. Resistencia a antibióticos no betalactámicos de aislamientos invasores de Streptococcus pneumoniae en niños latinoamericanos. SIREVA II, 2000–2005. Rev Panam Salud Publica. 2009;25(4):305-13.
  33. Koksal N, Hacimustafaoglu M, Bagci S, Celebi S. Meropenem in neonatal severe infections due to multiresistant gram negative bacteria. Indian J Pediatr. 2001;68:15-9.
  34. Koyle M, Barqawi A, Wild J, Passamaneck M, Furnes P. Pediatric urinary tract infections: the role of fluoroquinolones. Pediatr Infect Dis J. 2003;22:1133-7.
  35. Dowel SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics. 1998;10:163-5.
  36. Demirkol D, Bicer S, Karaböcüoglu M. Prevention of infection and management of multidrug-resistant organisms in the PICU. J Pediatric Infectious Diseases. 2010;5:161-9.
  37. Corral K, Oliveira F, Farinella G, Alvarez E. Infection control strategies in a neonatal intensive care unit in Argentina. J Hosp Infect. 1998;40:149-54.
  38. Gruson D, Hilbert G, Varhas F. Strategy of antibiotic rotation: long-term effect on incidence and susceptibilities of Gram-negatives bacteria responsible for ventilator-associated pneumonia. Crit Care Med. 2003;31:1908-14.
  39. Toltzis P, Dul MJ, Hoyen C, Salvator A, Walsh, M Zett, et al. The effect of antibiotic rotation on colonization with antibiotic-resistant bacilli in a neonatal intensive care unit. Pediatrics. 2002;110(4):707-11.
  40. Solorzano F, Miranda MG, Leanos B. A blood microculture system for the diagnosis of bacteremia in pediatric patients. Scand J Infect Dis. 1999;30:481-3.
  41. Isaacs D, Wilkinson AR, Maxon ER. Duration of antibiotic courses for neonates. Arch Dis Child. 1987;62:727-8.
  42. Kaiser J, Cassat J, Lewno M. Should antibiotics be discontinued at 48 hours for negative late onset sepsis evaluations in the neonatal intensive care unit? J Perinatol. 2002;22:445-7.
  43. Secretaría de Salud México. Lineamientos a lo que estará sujeta la venta y dispensación de antibióticos. Diario Oficial de la Federación. May 27th, 2010.
  44. Zaidi AKM, Huskins WC, Thaver D, Buthta ZA, Abbas Z. Hospital-acquired neonatal infections in developing countries. Lancet. 2005;365(9465):1175-88.
  45. Goldmann DA, Weinstein RA, Wenzel RP. Strategies to prevent and control the emergence and spread of antimicrobial resistant microorganisms in hospitals. A challenge to hospital leadership. JAMA. 1996;275:234-40.
  46. Adams I, Stoll B. Prevention of nosocomial infections in the neonatal intensive care unit. Curr Opin Pediatr. 2002;14:157-64.

Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.

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