Neonatal sepsis: a 6-year analysis in a neonatal care unit in Taiwan

Impact of inborn errors of metabolism on admission in a neonatal intensive care unit--a prospective cohort study

OBJECTIVE

To estimate the incidence of Inborn errors of metobolism (IEM) in Neonatal intensive care unit (NICU) using tandem mass spectrometry and to determine the impact that these disorders have on NICU resources.

METHODS

During the period of study, 724 (81% eligible cases) dried blood filter-paper samples were collected from a NICU. The samples were analysed using tandem mass spectrometry. The diagnosis was further confirmed through clinical symptoms and by gas chromatography-mass spectrometry. The results were also confirmed by clinical follow-up of all positive patients in an overall interval of 1 year. The mean observation period was 11 months per neonate.

RESULTS

In total, 22 cases were screen positive and 8 cases of inborn errors of metabolism were detected. The incidence of IEM in the population of patients admitted to the authors' NICU was 1.1%. The most common inborn error found was methylmalonic acidemia (3 cases, 37.5%), and all of the cases needed aggressive treatment and invasive mechanical ventilation. There were two cases of Tyrosinemia type 1, one case each of Maple Syrup Urine Disease, Propionic Acidemia, and Multiple Acyl-CoA dehydrogenase deficiency (MADD). Five of the eight patients required invasive mechanical ventilation. The median length of NICU stay was 3 days (1~7 days) and early therapeutic intervention was effective for four of them and other four patients (50%) died.

CONCLUSIONS

The incidence of IEM in NICU was 1.1%, indicating an underestimation of the incidence of metabolic disorders prior to implementing screening. Most patients with IEM in the NICU required invasive mechanical ventilation and the mortality was increased due to underlying IEM.

Antibiotic therapy in neonatal and pediatric septic shock

Severe sepsis accounts for nearly 4,500 deaths (mortality rate 10%), and is responsible for nearly $2 billion annual healthcare expenditure in the United States. Early and speedy treatment of critically ill septic patients can halt or reduce the likelihood of physiologic progression to multi-system organ failure. A cornerstone of this therapeutic strategy is antibiotic administration. In this review, we discuss the empirical treatment strategies for the treatment of early and late neonatal sepsis, along with pediatric sepsis. Furthermore, we discuss the rationale that underlies the adoption of such treatment strategies. The present article also discusses the emergence of multi-drug organisms as the causative agents for sepsis, i.e. methicillin-resistant Staphylococcus aureus (MRSA), resistant enterococci and Klebsiella pneumoniae carbapenemases (KPC).

MR imaging of neonatal brain infections

Infections of the brain in the postnatal period differ from those in older children as a result of a combination of distinct epidemiologic factors in general, and immaturity of neonatal brain and immunologic host response in particular. It has been recognized that clinical and neurologic signs are often nonspecific, sometimes scarce, and seldom correlate with the extent of neuroimaging findings, thus warranting an early MR imaging examination in the course of the disease, enabling rapid therapy institution and better clinical outcome. This article reviews most of postnatal pathogen agents involved in neonatal brain infections, related physiopathology, and neuroimaging findings.

The changing face of early-onset neonatal sepsis after the implementation of a maternal group B Streptococcus screening and intrapartum prophylaxis policy--a study in one medical center

BACKGROUND

Early-onset sepsis (EOS) is the major cause of neonatal morbidity and mortality. Maternal group B Streptococcus (GBS) screening and intrapartum antibiotic prophylaxis (IAP) were implemented in our hospital in 2004. Our aim was to evaluate the effectiveness of the program and changes in pathogens and antibiotic susceptibility.

METHODS

The medical charts of mothers and infants with EOS between January 2001 and November 2008 were retrospectively reviewed. EOS was defined as sepsis occurring within 72 hours of birth. Data were pooled and compared for January 2001 through September 2004 (Period 1, without GBS screening) and October 2004 through November 2008 (Period 2, with GBS screening and IAP).

RESULTS

The GBS screening rate increased from 10.11% in 2004 to 65% in 2008 and the IAP rate increased from 40% in 2004 to 90% in 2008. The most common EOS pathogen in Period 1 was GBS (45.4%), which decreased to 20% in Period 2 (p=0.081; trend p=0.009). The percentage of EOS because of Escherichia coli in Period 1 was 40.9% but increased to 70% in Period 2 (p=0.059). E coli EOS increased in extremely low birth weight premature babies weighing 500-1000g from Period 1 to Period 2 (p=0.031). The incidence of ampicillin-resistant E coli EOS was relatively high, but no significant change (88.9% vs. 92.9%) after implementation of GBS screening and IAP was noted.

CONCLUSION

GBS screening plus IAP is effective in decreasing the incidence of GBS EOS; however, an increase in EOS caused by E coli was noted. Monitoring of pathogens causing EOS is important for effective treatment.

Changing trends in newborn sepsis in Sagamu, Nigeria: bacterial aetiology, risk factors and antibiotic susceptibility

AIM

Sepsis is a major contributor to newborn deaths in the developing world. The objective is to determine the prevalence of newborn sepsis, the bacterial pathogens and antibiotic sensitivity pattern of the isolates.

METHOD

A study of consecutive babies hospitalised in Sagamu, Nigeria, with risk factors for or clinical features of sepsis was retrospectively done between January 2006 and December 2007, and prospectively between January and December 2008. Positive blood culture defined neonatal sepsis, and the antibiotic sensitivity pattern of the organisms was also determined.

RESULTS

There were 1050 admissions, and 174 (16.5%) babies had positive blood culture. Of the 527 babies with risk factors and clinical features of sepsis, 174 (33.3%) had confirmed sepsis: 119 (22.5%) had early-onset sepsis, while 55 (10.4%) had late-onset sepsis. The incidence of neonatal sepsis in the hospital was 51.3/1000 live births. Weight less than 1.5 kg, prolonged labour, prolonged rupture of membranes and lower socio-economic status were risk factors for sepsis. Staphylococcus aureus (31.0%), Klebsiella (23.0%), and coagulase-negative Staphylococcus (12.6%) and Escherichia coli (11.0%) were the leading aetiologies. The isolates were most sensitive to levofloxacin (95.7%), ofloxacin (95.1%), cefotaxime (86.7%) and ceftazidime (81.3%). Their sensitivity was 56.4% to cefuroxime and gentamicin, which are commonly used.

CONCLUSION

The prevalence of sepsis was high in this cohort of high-risk infants. The low in vitro sensitivity of the leading microbes to commonly used drugs is challenging. Guidelines on the reduction of emergence of drug resistance must be provided and instituted in newborn units.

Predictors of mortality in neonatal septicemia in an underresourced setting

OBJECTIVE

To determine the predictors of mortality in neonatal septicemia.

METHOD

The records of babies with culture-proven septicemia managed in a Nigerian newborn unit between 2006 and 2008 were studied using bivariate and multivariate analysis.

RESULTS

Out of 174 babies with septicemia, 56 (32.2%) died. Outborn babies, babies with estimated gestational age (EGA) less than 32 weeks, weight less than 1.5 kg, temperature less than 38 degrees C, respiratory distress, abdominal distension, poor skin color, hypoglycemia, and infection with gram-negative pathogens were significantly associated with death by bivariate analysis. Multivariate analysis of these risk factors confirmed that EGA less than 32 weeks (odds ratio [OR], 5.5), respiratory distress (OR, 3.4), abdominal distension (OR, 2.7), poor skin color (OR, 3.3), and hypoglycemia (OR, 5.2) had significant independent contributions to the occurrence of death among babies with culture-proven septicemia.

CONCLUSION

Most of the identified predictors of mortality are modifiable and can be used to draw up a screening tool to determine the clinical severity among septic babies.

Use of rifampin in persistent coagulase negative staphylococcal bacteremia in neonates

BACKGROUND

Coagulase negative staphylococci (CoNS) are the most common cause of neonatal sepsis in the Neonatal Intensive Care Unit (NICU). A minority of neonates does not respond to vancomycin therapy and develops persistent bacteremia, which may be treated with rifampin. We evaluated the use of rifampin in persistent CoNS bacteremia.

METHODS

Retrospective study of 137 neonates with CoNS bacteremia during admission to a tertiary NICU between July 2006 and July 2009. Main outcome measures were total duration of bacteremia and the adequacy of vancomycin and rifampin therapy.

RESULTS

137/1696 (8.0%) neonates developed a CoNS bacteremia. Eighteen were treated with rifampin because of persistent bacteremia (3 positive blood cultures at least 48 hours apart with clinical symptoms) or (a serious suspicion of) an intravascular thrombus. Duration of bacteremia prior to rifampin therapy (8.0 ± 3.6 days) was positively correlated (p < 0.001) to the total duration of bacteremia (10.3 ± 3.7 days). After starting rifampin therapy C-reactive protein (CRP) levels of all neonates declined and blood cultures became sterile after 2.3 ± 1.6 days. Vancomycin levels were not consistently measured in all neonates, resulting in late detection of subtherapeutic trough levels.

CONCLUSION

Rifampin may be effective in the treatment of persistent CoNS infections in neonates. Outcome may be improved by adequate monitoring of vancomycin trough levels.

Late-onset group B streptococcal meningitis in a neonate with early antibiotic prophylaxis

An otherwise healthy female baby who had received early postnatal antibiotic prophylaxis because of maternal vaginal group B streptococcal (GBS) colonization died of late-onset GBS meningitis. GBS was isolated from blood and cerebrospinal fluid. Genotyping using pulsed-field gel electrophoresis confirmed that the GBS isolates from the patient were identical to those from her mother's vagina. Susceptibility tests demonstrated no antibiotic resistance. This report provides additional microbiologic evidence indicating that early postnatal antibiotic prophylaxis is not effective in preventing late-onset GBS infections in neonates born to mothers with GBS colonization.

Repeated prevalence surveys of healthcare-associated infections in Finnish neonatal intensive care units

More than one-fifth of patients in neonatal intensive care units (NICUs) have been reported to suffer from healthcare-associated infections (HAIs). The aim of this study was to assess prevalence, onset and types of HAI in Finnish NICU patients. We conducted six monthly point-prevalence surveys in all Finnish NICUs (N=24) between November 2008 and May 2009. For all patients present on the day of survey, the underlying conditions and invasive devices or treatments used on the day of survey and during the preceding six days were recorded on standardised forms. All HAIs active or under treatment on the day of survey were included. HAIs were categorised into early-onset (onset within the first 72 h of life) and late-onset (onset after the first 72 h of life) infections. During the six surveys, 1281 forms were obtained. Among them, 164 HAIs in 163 patients were identified (overall prevalence, 13%); 63 (38%) of the HAIs were late-onset infections (prevalence, 6.5%). Main types of HAI were clinical sepsis, laboratory-confirmed bloodstream infection, conjunctivitis, and pneumonia. Of all HAIs, 24% were microbiologically confirmed. Patients with birth weight <1500 g suffered from late-onset HAIs more commonly than those with birth weight > or =1500 g (10% vs 4%, P<0.01). Also hospitalisation of > or =7 days was associated with increased prevalence of HAI (8% vs 3%, P=0.01). The study was useful in terms of increasing awareness of HAI in the participating NICUs. These results can be used to strengthen incidence surveillance of HAIs in the Finnish NICUs in the future.