Abstract
BACKGROUND: Neonatal sepsis is a major cause of morbidity and mortality worldwide. The COVID-19 pandemic has influenced its epidemiology, altering pathogen distribution and antimicrobial resistance patterns, necessitating a reassessment of neonatal infection management. This study aims to evaluate the impact of the COVID-19 pandemic on neonatal sepsis incidence, pathogen distribution, and antimicrobial resistance patterns, providing evidence to inform improved clinical management strategies in neonatal intensive care units. METHODS: This retrospective cross-sectional study analyzed neonatal sepsis cases in a tertiary hospital in Tehran, Iran, comparing pre-pandemic (2017-2019) and pandemic period (2020-2023). Clinical characteristics, pathogen prevalence, and antibiotic resistance patterns were evaluated using logistic regression models. RESULTS: A total of 341 neonates were included (167 pre-pandemic, 174 pandemic period). Early-onset sepsis (0-3 days after birth) significantly declined during the pandemic period (40.4% vs. 12.1%, p < 0.001), while late-onset sepsis increased, particularly between 4 and 10 days (31.0% vs. 21.7%) and beyond 30 days (21.8% vs. 9.0%). Candida and Klebsiella pneumoniae infections surged during the pandemic, contributing to heightened antimicrobial resistance. Ampicillin (OR: 5.30, p = 0.002), Piperacillin (OR: 4.14, p = 0.009), Ciprofloxacin (OR: 2.39, p = 0.027), and Co-trimoxazole (OR: 2.60, p = 0.002) resistance rates increased significantly, while Colistin resistance emerged exclusively during the pandemic period, raising concerns about limited treatment options for multidrug-resistant infections. CONCLUSION: The COVID-19 pandemic significantly altered neonatal sepsis patterns, increasing late-onset infections, shifting pathogen prevalence, and exacerbating antimicrobial resistance trends. Rising resistance to key antibiotics, including Colistin, underscores the urgent need for strengthened antimicrobial stewardship in NICUs. Despite these disruptions, NICU protocols remained effective, ensuring stable neonatal mortality rates.