Risk factors for nosocomial infections in selected neonatal intensive care units in Colombia, South America

Exposure to prescribed medication in early life and impacts on gut microbiota and disease development

The gut microbiota during early life plays a crucial role in infant development. This microbial-host interaction is also essential for metabolism, immunity, and overall human health in later life. Early-life pharmaceutical exposure, mainly referring to exposure during pregnancy, childbirth, and infancy, may change the structure and function of gut microbiota and affect later human health. In this Review, we describe how healthy gut microbiota is established in early life. We summarise the commonly prescribed medications during early life, including antibiotics, acid suppressant medications and other medications such as antidepressants, analgesics and steroid hormones, and discuss how these medication-induced changes in gut microbiota are involved in the pathological process of diseases, including infections, inflammatory bowel disease, metabolic diseases, allergic diseases and neurodevelopmental disorders. Finally, we review some critical methods such as dietary therapy, probiotics, prebiotics, faecal microbiota transplantation, genetically engineered phages, and vagus nerve stimulation in early life, aiming to provide a new strategy for the prevention of adverse health outcomes caused by prescribed medications exposure in early life.

Epidemiology of neonatal infections in hospitals of Nepal: evidence from a large- scale study

Background

Every year, neonatal infections account for approximately 750,000 neonatal deaths globally. It is the third major cause of neonatal death, globally and in Nepal. There is a paucity of data on clinical aetiology and outcomes of neonatal infection in Nepal. This paper aims to assess the incidence and risk factors of neonatal infection in babies born in public hospitals of Nepal.

Methods

This is a prospective cohort study conducted for a period of 14 months, nested within a large-scale cluster randomized control trial which evaluated the Helping Babies Breathe Quality Improvement package in 12 public hospitals in Nepal. All the mothers who consented to participate within the study and delivered in these hospitals were included in the analysis. All neonates admitted into the sick newborn care unit weighing > 1500 g or/and 32 weeks or more gestation with clinical signs of infection or positive septic screening were taken as cases and those that did not have an infection were the comparison group. Bivariate and multi-variate analysis of socio-demographic, maternal, obstetric and neonatal characteristics of case and comparison group were conducted to assess risk factors associated with neonatal infection.

Results

The overall incidence of neonatal infection was 7.3 per 1000 live births. Babies who were born to first time mothers were at 64% higher risk of having infection (aOR-1.64, 95% CI, 1.30–2.06, p-value< 0.001). Babies born to mothers who had no antenatal check-up had more than three-fold risk of infection (aOR-3.45, 95% CI, 1.82–6.56, p-value< 0.001). Babies born through caesarean section had more than two-fold risk (aOR-2.06, 95% CI, 1.48–2.87, p-value< 0.001) and babies with birth asphyxia had more than three-fold risk for infection (aOR-3.51, 95% CI, 1.71–7.20, p-value = 0.001).

Conclusion

Antepartum factors, such as antenatal care attendance, and intrapartum factors such as mode of delivery and birth asphyxia, were risk factors for neonatal infections. These findings highlight the importance of ANC visits and the need for proper care during resuscitation in babies with birth asphyxia.

Association between histamine-2 receptor antagonists and adverse outcomes in neonates: A systematic review and meta-analysis

Background

The use of histamine-2 receptor antagonists (H₂RA) in neonates is still debated because of possible risk of infection, necrotizing enterocolitis (NEC) and increased mortality.

Aim

To review whether the use of H₂RA in neonates admitted to neonatal intensive care units (NICU) is associated with infection, NEC or mortality.

Materials and method

We performed a systematic search in PubMed, Web of Science and SCOPUS databases using the terms “histamine-2 receptor antagonists”, “infection”, “necrotizing enterocolitis”, “mortality”, “neonates” and related terms to identify studies published up to April 30, 2017. We included studies conducted in hospitalized neonates and exposed to H₂RA. The primary outcomes were infection, NEC and mortality. We included reports of infections with clinical signs and positive culture, and NEC according to Bell stages (stage ≥II) based on standardised clinical and radiologic criteria. Among 1,144 studies identified, 10 fulfilled the selection criteria. Information extracted included study design, sample size and number of participants, along with the outcomes of interest. We conducted a meta-analysis of adjusted data and pooled estimates of infection, NEC and mortality are reported as odds ratios (OR) and 95% confidence intervals (95%CI).

Results

Ten studies were analysed. There were substantial associations between H₂RA and infection (pooled OR: 2.09; 95%CI: 1.35–3.24; P = 0.001) and NEC (pooled OR: 2.81, 95%CI: 1.19–6.64; P = 0.02) but not with the mortality risk (pooled OR: 1.76; 95%CI: 0.50–6.16; P: 0.38).

Conclusion

Current evidence suggests that H₂RA is associated with an increased risk of infection and NEC, but not with mortality in neonates admitted to NICU. The use of H₂RA in neonates must be stringently considered when necessary.

Molecular epidemiology of carbapenem resistant gram-negative bacilli from infected pediatric population in tertiary - care hospitals in Medellín, Colombia: an increasing problem

BACKGROUND

Gram-negative bacilli are a cause of serious infections in the pediatric population. Carbapenem are the treatment of choice for infections caused by multidrug-resistant Gram-negative bacilli, but the emergence of carbapenem resistance has substantially reduced access to effective antimicrobial regimens. Children are a population vulnerable to bacterial infections and the emergence of resistance can worsen prognosis. The aim of this study is to describe the clinical and molecular characteristics of infections caused by carbapenem-resistant Gram-negative bacilli in pediatric patients from five tertiary-care hospitals in Medellín, Colombia.

METHODS

A cross-sectional study was conducted in five tertiary-care hospitals from June 2012 to June 2014. All pediatric patients infected by carbapenem-resistant Gram-negative bacilli were included. Clinical information for each patient was obtained from medical records. Molecular analyses included PCR for detection of bla VIM, bla IMP bla NDM, bla OXA-48 and bla KPC genes and PFGE and MLST for molecular typing.

RESULTS

A total of 59 patients were enrolled, most of them less than 1 year old (40.7 % n = 24), with a previous history of antibiotic use (94.9 %; n = 56) and healthcare-associated infections - predominately urinary tract infections (31.0 %; n = 18). Klebsiella pneumoniae was the most frequent bacteria (47.4 %), followed by Enterobacter cloacae (40.7 %) and Pseudomonas aeruginosa (11.9 %). For K. pneumoniae, KPC was the predominant resistance mechanism (85.7 %; n = 24) and ST14 was the most common clone (39.3 % n = 11), which included strains closely related by PFGE. In contrast, E. cloacae and P. aeruginosa were prevailing non-carbapenemase-producing isolates (only KPC and VIM were detected in 1 and 3 isolates, respectively) and high genetic diversity according to PFGE and MLST was found in the majority of the cases.

CONCLUSIONS

In recent years, increasing carbapenem-resistant bacilli in children has become in a matter of great concern. It is important to conduct systemic surveillance and take measures to prevent dissemination of multidrug-resistant bacteria.

Risk Factors for Health Care-Associated Bloodstream Infections in a Neonatal Intensive Care Unit

Background

Healthcare-associated bloodstream infections (HCA-BSI) are a major cause of morbidity and mortality in neonatal intensive care units (NICUs).

Objectives

We aimed to determine the causative organisms and risk factors of HCA-BSIs in NICUs.

Methods

This study was performed between January 2011 and December 2014 in the neonatal intensive care unit of Dicle university, Turkey. The study consisted of 126 patients (infected group) with positive blood culture and 126 randomly selected patients (uninfected control group) with negative blood culture after four days of hospitalization.

Results

We found that the most common causative agents isolated from nosocomial infections (NIs) were 20.7% Staphylococcus epidermidis, 26.7% Klebsiella spp., and 13.3% Acinetobacter spp. Incidences of low gestational age, low birth weight, vaginal birth type, and long length of hospitalization were higher in the infected neonates than in the uninfected neonates. In the univariate analysis, surgical operation, ventriculoperitoneal shunt, use of umbilical catheter, nasogastric or orogastric tube, urinary catheter, mechanical ventilation, surfactant treatment, erythrocyte transfusion, plasma transfusion, thrombocyte transfusion, total parenteral nutrition infusion, intracranial hemorrhage, length of hospital stay, fifth-minute Apgar score, and total parenteral nutrition time were significantly associated with NIs. In the multiple logistic regression analysis, fifth-minute Apgar, use of erythrocyte transfusion and surgical operation were found as the independent risk factors for HCA-BSI.

Conclusions

This study determined the causative organisms and risk factors of HCA-BSIs in NICUs.

Neonatal Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Treatment at United States Children's Hospitals

OBJECTIVE

To determine treatment frequency and duration of histamine-2 receptor antagonist (H2RA)/proton pump inhibitor (PPI) use among infants hospitalized within US children's hospital neonatal intensive care units and evaluate diagnoses/demographic factors associated with use.

STUDY DESIGN

We retrospectively analyzed a cohort of neonatal intensive care unit infants admitted to 43 US children's hospitals within the Pediatric Health Information System database between January 2006 and March 2013 to determine H2RA/PPI treatment frequency, timing/duration of treatment, factors associated with use, percent of infants remaining on treatment at discharge, and interhospital prescribing variation. We used a modified Poisson regression to calculate the adjusted probability of infants ever receiving H2RAs/PPIs in relation to diagnosis, gestation, and sex.

RESULTS

Of the 122 002 infants evaluated, 23.8% (n = 28 989) ever received an H2RA or PPI; 19.0% received H2RAs (n = 23 187), and 10.5% (n = 12 823) received PPIs. Extremely preterm infants and term infants were the most likely to receive H2RA and PPI treatment. Infants with gastroesophageal reflux disease (relative risk [RR] = 3.13) and congenital heart disease (RR = 2.41) had the highest H2RA/PPI treatment probabilities followed by those with an ear, nose, and throat diagnosis (RR = 2.34; P < .05). The majority of treated infants remained treated at discharge.

CONCLUSIONS

Despite limited evidence and increasing safety concerns, H2RAs/PPIs are frequently prescribed to extremely preterm neonates and those with congenital anomalies and continued through discharge. Our findings support the need for innovative studies to examine the comparative effectiveness and safety of H2RA/PPIs vs no treatment in these high-risk neonatal populations.

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

BACKGROUND

The use of unnecessary tests and treatments contributes to health care waste. The "Choosing Wisely" campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine.

METHODS

A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments.

RESULTS

A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants.

CONCLUSIONS

The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.

[Epidemiology of nosocomial bacterial infection in a neonatal intensive care unit in Morocco]

In neonatal intensive care units, the incidence of nosocomial infection is high. This study aimed to determine the epidemiology of a nosocomial bacterial infection in the neonatal intensive care unit of Mohamed VI university hospital. A total of 702 newborns were included in this study. Of the 702 neonates studied, 91 had developed a nosocomial infection. The incidence rate was 13% and incidence density was 21.2 per 1000 patient-days. The types of infection were: bloodstream infections (89%), pneumonia (6.6%), meningitis (3.3%), and urinary tract infections (1.1%). Nosocomial infection was particularly frequent in cases of low birth weight, prematurity, young age at admission, umbilical venous catheter, and mechanical ventilation. Multiresistant bacteria included enterobacteria producing betalactamase (76.9%), especially enterobacteria that were dominated by Klebsiella pneumoniae (39.7%). The mortality rate was 52.7% in nosocomial infections, 19 (20.87%) of whom had septic shock. The results of this study show that nosocomial infection is an intrahospital health problem that could be remedied by a prevention strategy.

Nosocomial infections in pediatric population and antibiotic resistance of the causative organisms in north of iran

Background:

Treatment of the nosocomial infections is complicated especially in children due to an increase in the antibiotic-resistant bacteria.

Objectives:

The aim of this study was to survey the nosocomial infections in children and determine the antibiotic susceptibility of their causative organisms in teaching hospitals in the north of Iran.

Patients and Methods:

The investigation was designed as a retrospective cross-sectional study. The study population consisted of patients under 12 years old, which were hospitalized in three teaching hospitals in the north of Iran and had symptoms of nosocomial infections in 2012. The required data of patients were extracted and entered in the information forms. The collected data were analyzed using SPSS (ver. 16). Descriptive statistics and Fisher’s exact tests (Monte Carlo) were used.

Results:

Out of the total number of 34556 hospitalized patients in three teaching hospitals, 61 (0.17%) patients were children under 12 years old age with nosocomial infection from which 50.81% were girls and 49.18% were boys. Most of these patients (55.73%) were admitted to the burn unit. The most common type of nosocomial infection (49.18%) was wound infection. Pseudomonas spp. (36.84%) and Acinetobacter spp. (28.02%) were the most common bacteria isolated from the clinical specimens. All the Acinetobacter spp. were multidrug-resistant. All the gram negative and gram positive bacterial species in our study showed high resistance to antibiotics.

Conclusions:

The rate of nosocomial infections was low in our study because the detection of nosocomial infection was based on the clinical grounds in most cases and laboratory reports might contain false-negative results. These results provide useful information for future large scale surveillance in the context of prevention programs.

Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease?

BACKGROUND

It has become common practice to empirically treat infants and children who have suspected gastroesophageal reflux disease by using acid-suppressive medications. However, evidence to support the effectiveness of these medications in the pediatric population is limited. With multiple studies in adult patients indicating increased risk of infection, we reviewed the literature to determine the association between acid-suppressive medications and serious adverse effects in infants and children.

METHODS

We conducted a PubMed search on the adverse effects of H2 antagonists and proton pump inhibitors in pediatric patients. The studies selected were original research and systematic reviews with control groups and study objectives evaluating the relationship between acid-suppressive medications and serious adverse effects (namely, infections).

RESULTS

Fourteen studies met our inclusion criteria. The majority of studies found a significant association between acid-suppressive medications and the risk of necrotizing enterocolitis, sepsis/bacteremia, pneumonia, and gastrointestinal infections in infants and children.

CONCLUSIONS

Given the questionable efficacy of H2 antagonists and proton pump inhibitors and the growing evidence of increased risk of serious infections, acid-suppressive medications should be used cautiously in infants and children suspected of having gastroesophageal reflux disease.

Adesão à técnica de lavagem de mãos em Unidade de Terapia Intensiva Neonatal

OBJETIVO:Avaliar o cumprimento da técnica de lavagem das mãos empregadas em uma unidade de terapia intensiva neonatal (UTIN) pelos profissionais de saúde e visitantes. MÉTODOS: Estudo prospectivo e observacional em uma UTIN universitária em Santos (SP). Observações foram feitas nos períodos da manhã e da tarde por um período de sete meses. Os dados foram coletados por dois estudantes de medicina em planilha específica. As pessoas observadas não sabiam da natureza do trabalho. Para comparar os resultados obsevados entre categorias profissionais e entre períodos de observação, utilizou-se o teste do qui-quadrado ou exato de Fisher, com duas abordagens: a) análise por intenção de tratar (considerando o número total de indivíduos e assumindo que aqueles que não lavaram as mãos adotaram o procedimento incorreto) e b) análise por protocolo (apenas aqueles que lavaram as mãos foram considerados). Rejeitou-se a hipótese de nulidade se p<0,05. RESULTADOS:Foram realizadas 43 observações com duração de cerca de 30 minutos cada uma, sendo 20 minutos durante a manhã e 23 à tarde. Entre as pessoas analisadas, seis (14%) eram médicos, 26 (60%) da equipe de enfermagem, três (7%) técnicos de laboratório e raio X e oito (19%) acompanhantes de pacientes. Dentre os observados, 24 (56%) lavaram as mãos antes de entrar na unidade, sendo a lavagem observada com maior frequência no período da manhã (75%) do que à tarde (39%). A técnica correta não foi observada em nenhuma das vezes. CONCLUSÕES:A técnica de lavagem das mãos raramente é adequada e, por isso, programas educacionais para aumentar a adesão dos profissionais de saúde são importantes.

Building global health through a center-without-walls: the Vanderbilt Institute for Global Health

The Institute for Global Health at Vanderbilt enables the expansion and coordination of global health research, service, and training, reflecting the university's commitment to improve health services and outcomes in resource-limited settings. Global health encompasses both prevention via public health and treatment via medical care, all nested within a broader community-development context. This has fostered university-wide collaborations to address education, business/economics, engineering, nursing, and language training, among others. The institute is a natural facilitator for team building and has been especially helpful in organizing institutional responses to global health solicitations from the National Institutes of Health (NIH), Centers for Disease Control (CDC), and other funding agencies. This center-without-walls philosophy nurtures noncompetitive partnerships among and within departments and schools. With extramural support from the NIH and from endowment and developmental investments from the school of medicine, the institute funds new pilot projects to nurture global educational and research exchanges related to health and development. Vanderbilt's newest programs are a CDC-supported HIV/AIDS service initiative in Africa and an overseas research training program for health science graduate students and clinical fellows. New opportunities are available for Vanderbilt students, staff, and faculty to work abroad in partnership with international health projects through a number of Tennessee institutions now networked with the institute. A center-without-walls may be a model for institutions contemplating strategic investments to better organize service and teaching opportunities abroad, and to achieve greater successes in leveraging extramural support for overseas and domestic work focused on tropical medicine and global health.

International collaborative research: a Colombian model that promotes infant health and research capacity

Current collaborative efforts in international research with resource-poor nations are frequently paternalistic and deprive these nations of the skills necessary to build independent research capacity. Resource-poor nations have become progressively suspicious of research endeavors originated in industrialized nations that have minimal impact on the health care needs of their populations. The current trend toward globalization requires that certain standards be established to guide these collaborative efforts to create strong partnerships that promote independent evidence-based health research. The objective of this paper is to present a comprehensive approach to health-related international collaborative research with resource-poor nations using as an example a model that has been developed in Colombia, South America.

Cimetidine does not prevent lung injury in newborn premature infants

Animal studies have shown that induction of cytochrome P450 (CYP) in the lung by oxygen exposure may result in the release of free radical oxidants and arachidonic acid metabolites, which can cause lung injury that is reduced by treatment with cimetidine, a CYP inhibitor. To determine whether cimetidine would reduce lung injury in human infants at risk for chronic lung disease, we conducted a randomized clinical trial in which we administered either cimetidine or a placebo for 10 d beginning < 24 h after birth to 84 newborn infants weighing < or = 1250 g who were receiving O2 and mechanical ventilation. Cimetidine had no significant effect on severity of respiratory insufficiency assessed at 10 d postnatal age. F2-isoprostane levels (a marker of oxidant injury) in tracheal aspirates were significantly higher in the cimetidine group at 4 d and at 10 d. There were no significant differences between the groups in tracheal aspirate levels of inflammatory markers (leukotriene B4, IL-8, and nucleated cell count) or arachidonic acid metabolites. We conclude that cimetidine does not reduce lung injury in newborn premature infants receiving O2 and mechanical ventilation. It is possible that cimetidine was not an adequate CYP inhibitor in this context.