Various factors could have contributed to the increase in the resistance by day 60. After delivery, exposure related to mothers environment, oral and skin flora provide the major sources of bacteria which may transfer to the neonates by several ways including suckling, kissing and caressing. In addition, breast milk is also a source of bacteria, which contains up to 109microbes/L in healthy mothers . Other sources may be household contact with siblings, pets , as well as horizontal transfer of gene within the commensal flora . In our study acquisition of resistance via GSK1904529A in vitro supplementary food has been ruled out as babies were completely
breast fed. Several studies have shown the prevalence of antibiotic resistance in absence of direct use of antibiotic. Presence of tetracycline resistance bacteria in breastfed infants  and commensal ESBL producers in pre-school healthy children  suggest contamination in the family environment rather than direct exposure to antibiotic. The limitation of our study is that we have not studied the environmental flora and compared it with that of neonatal gut flora. Besides
ESBL, AmpC learn more producing Enterobacteriaceae were also isolated. AmpC producing isolates VX-809 cost were approximately 20% and co-production with ESBL was seen in 11.2% throughout the study period (Table 2). AmpC β-lactamases producers are of major concern as they are resistant to β-lactam and β-lactam inhibitor combination as Casein kinase 1 well as cefoxitin which further narrows down the treatment options. As carbapenems are drug of choice for ESBL and or AmpC producing bacteria, coexistence of these enzymes can pose a threat to the community acquired pathogens as MIC of such strains are 10 fold higher for various carbapenems . The ampC gene showed diverse profile, in contrast CTX-M-15 was predominant ESBL gene in gut flora. Previous studies from India have also shown CTX-M-15 as predominant ESBL from clinical isolate . Approximately, 50% of neonates admitted to neonatal unit in our hospital with early onset sepsis had ESBL producing Enterobacteriaceae
which is strongly supported by early colonization with ESBL producing Enterobacteriaceae in the neonates in the present study. Recent report of isolation of CRE (NDM-1) from environmental samples  and community acquired infections  indicate that CRE producing NDM-1 enzyme may be widely distributed in India. However, there is paucity of data regarding fecal carriage of CRE in the community in absence of antibiotic pressure. Different studies have used different culture based techniques like MacConkey agar plates supplemented with 1 μg/ml imipenem, Chrom Agar KPC, Mac Conkey Agar with imipenem, meropenem and ertapenem disc (10 μg) and two step selective broth enrichment method using 10 μg carbapenem disc to evaluate gut colonization with CRE with good performance . Most of these techniques are validated for KPC detection in organisms with MIC range 0.