Neonatal citrobacter sepsis: clinical and epidemiological aspects

A pilot randomized controlled trial comparing noradrenaline and adrenaline as a first-line vasopressor for fluid-refractory septic shock in neonates

Background and study design

Limited data exists on noradrenaline therapy in neonatal septic shock. We compared the efficacy of noradrenaline with adrenaline in neonatal septic shock. This single center, open label, pilot randomized controlled trial included neonates with clinical evidence of sepsis and shock.

Study outcomes

Primary outcomes were: 1) resolution of shock one hour after treatment, and 2) mortality during hospital stay. Secondary outcomes included: need for additional vasopressors; hemodynamic stability without further administration of vasopressors for ≥2 h; changes in blood pressure and heart rate after 1 h of vasopressor treatment; and morbidities during the hospital stay.

Results

Of 65 eligible neonates, 42 were randomized (21 each in adrenaline and noradrenaline treatment arms) between August 2020 and January 2022, at level III neonatal intensive care unit (NICU) of Bharati Vidyapeeth Deemed University Medical College and Hospital (BVDUMCH). The mean (SD) gestational age and mean (SD) birth weight were 36.1(4.2) weeks and 1.8 (0.2) kilograms birth weight for noradrenaline and 36.9 (4.1) weeks and 1.7 (0.7) kilograms for adrenaline. Shock resolved within 1 h of vasopressor therapy in 76.2% neonates in the noradrenaline arm and 61.9% in adrenaline arm (p value-0.53). Mortality during hospital stay was 28.6% (6/21) in noradrenaline group and 33.3% (7/21) in adrenaline group (p value- 0.58). Additional vasopressors were required in 23.8% neonates of the noradrenaline group compared to 38.1% neonates in adrenaline arm (p value-0.53). Median (SD) duration of intensive care stay was 6 (SD) days in the noradrenaline group and 10 (SD) days in the adrenaline group (p value-0.045).

Conclusion

Among neonates with septic shock, the efficacy of noradrenaline was comparable to adrenaline in resolving septic shock after one hour of infusion and on the mortality during hospital stay.

Clinical Trial Registration

https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDI2NTc=&Enc=&userName=noradrenaline, Clinical Trials Registry - India with identifier CTRI/2020/08/027185 (17/08/2020).

Citrobacter infections in a tertiary care hospital in Northern India

OBJECTIVES

This prospective study was carried out to look for the frequency of isolation of Citrobacter species from clinical specimens and study their antimicrobial susceptibility pattern.

METHODS

Patients from whom Citrobacter species were isolated during routine diagnostic testing from January to December 2004 were included in the study. Isolates were identified by standard biochemical tests. Antimicrobial susceptibility testing was performed by disk diffusion method as per National Committee of Clinical Laboratory Standards (NCCLS) guidelines.

RESULTS

Citrobacter species were isolated from a total of 205 patients. Infection was nosocomially acquired in 94.6% patients. One hundred eighty one (88.3%) patients had significant underlying illnesses. Culture yielded Citrobacter koseri in 185 (90.2%) and Citrobacter freundii in 20 (9.8%) patients. The distribution of isolates was as follows: urine (46.2%), respiratory tract (16.3%), blood (15.8%), pus (12.1%) and sterile body fluids (9.3%). Drug resistance was observed to be more in C. koseri as compared to C. freundii.

CONCLUSIONS

Citrobacter infections are often nosocomially acquired, seen in patients with significant underlying diseases and isolates are commonly drug-resistant. Adoption of hospital infection control practices and a good antibiotic policy may prevent their spread.

Enterobacter sepsis in the newborn--a growing problem in Karachi

Enterobacter sepsis is commonly recognized as a hospital-acquired infection in childhood. In a five year prospective surveillance of neonatal sepsis at the Aga Khan University Hospital in Karachi, we identified Enterobacter sepsis in 28/292 (10%) cases, with an incidence of 0.7 per thousand births among inborn infants. There was no significant difference in predisposing factors and clinical features between Enterobacter and other infections. Approximately half (47%) of Enterobacter infections presented within 72 h of birth and the associated mortality was 21%. Increasing resistance to commonly used first- and second-line antibiotics over the last five years was noted. Enterobacter infections are emerging as significant pathogens among cases of neonatal sepsis in Karachi.

Identification of infant food as a vehicle in a nosocomial outbreak of Citrobacter freundii: epidemiological subtyping by allozyme, whole-cell protein and antibiotic resistance

A total of 38 Citrobacter freundii strains was isolated from patients and their environment at a neonatal intensive care unit of a large hospital where colonization and clinical diseases due to the agent had been observed. Epidemiological investigations were carried out by subtyping, for which a combination of allozyme, whole-cell protein and resistance pattern analysis was used. Infant formula was identified as a vehicle of nosocomial spread. This shows that the role of foods in the transmission of hospital infections should not be underestimated. The combination of methods applied, in particular a limited enzyme set, is recommended also for epidemiological investigations of food-borne infections and establishment of their causes.