1
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Strunk T, Molloy EJ, Mishra A, Bhutta ZA. Neonatal bacterial sepsis. Lancet 2024; 404:277-293. [PMID: 38944044 DOI: 10.1016/s0140-6736(24)00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 07/01/2024]
Abstract
Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.
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Affiliation(s)
- Tobias Strunk
- Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, Perth, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, University of Dublin and Trinity Research in Childhood Centre, Dublin, Ireland; Children's Health Hospital at Tallaght, Tallaght University Hospital, Dublin, Ireland; Trinity Translational Medicine Institute, St James Hospital, Dublin, Ireland; Neonatology, Children's Health Hospital at Crumlin, Dublin, Ireland; Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Archita Mishra
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute for Global Health and Development, The Aga Khan University South-Central Asia, Karachi, Pakistan
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2
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Obayashi M, Iwata S, Okuda T, Mori I, Nakane S, Togawa Y, Sugimoto M, Togawa T, Muramatsu K, Saitoh S, Sugiura T, Iwata O. Antenatal Growth, Gestational Age, Birth, Enteral Feeding, and Blood Citrulline Levels in Very Low Birth Weight Infants. Nutrients 2024; 16:476. [PMID: 38398801 PMCID: PMC10893150 DOI: 10.3390/nu16040476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/25/2024] Open
Abstract
Early enteral nutrition using reliable biomarkers of intestinal function must be established to improve neurodevelopmental outcomes in very low birth weight infants (VLBWIs). Serum citrulline levels reflect the intestinal function in adults. To elucidate the relationship among antenatal growth, postnatal enteral nutrition, and blood citrulline levels, a retrospective single-center observational study was conducted on 248 VLBWIs born between April 2014 and March 2021. A mixed effect model and post hoc simple slope analysis were used to estimate the correlations between clinical variables and citrulline levels at Early (day 5.1) and Late (day 24.3) postnatal ages. Greater gestational age, birth weight, and amount of enteral nutrition at the time of blood sampling were associated with lower citrulline levels at the Early postnatal age and higher citrulline levels at the Late postnatal age. Provided that Early citrulline levels predominantly reflect the consequence of antenatal citrulline metabolism, it is suggested that fetal growth and maturation are likely to promote citrulline catabolism in utero and its synthesis after birth. With additional insights into the temporal transition point wherein the maturation-dependent balance of citrulline metabolism shifts from catabolism-dominant to synthesis-dominant, citrulline emerges as a potential biomarker for assessing intestinal function and gastrointestinal disorders.
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Affiliation(s)
- Midori Obayashi
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Sachiko Iwata
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan; (S.I.); (S.S.)
| | - Tomoya Okuda
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Ichita Mori
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Shigeharu Nakane
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Yasuko Togawa
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Mari Sugimoto
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Takao Togawa
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan; (S.I.); (S.S.)
| | - Kanji Muramatsu
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Shinji Saitoh
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan; (S.I.); (S.S.)
| | - Takahiro Sugiura
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
| | - Osuke Iwata
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan (T.O.); (I.M.); (S.N.); (M.S.)
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan; (S.I.); (S.S.)
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3
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O'Reilly D, Murphy CA, Moore CM, Ní Áinle F, Gormley IC, Morrell CN, Curley A, Mc Callion N, Maguire P. Markers of platelet activation foR identification of late onset sEpsis in infaNTs: PARENT study protocol. Pediatr Res 2024; 95:852-856. [PMID: 37758864 DOI: 10.1038/s41390-023-02812-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Newborns are at high risk of sepsis. At present there is no definitive "rule in" blood test for sepsis at the point of clinical concern. A positive blood culture remains the gold standard test for neonatal sepsis, however laboratory markers that correlate prospectively with culture positive sepsis could aid clinicians in making decisions regarding administration of empiric antibiotic therapies. METHODS This multi-site, prospective observational study will take place in two neonatal intensive care units (National Maternity Hospital and Rotunda Hospital, Dublin). Neonates born at less than 34 weeks will be enroled and informed consent obtained prior to late onset sepsis work up. If at any point subsequently during their neonatal intensive care stay they develop signs and symptoms of possible sepsis requiring blood culture, an additional sodium citrate sample will be obtained. Infants will be categorised into three groups as follows: (i) culture positive sepsis, (ii) culture negative sepsis where an infant receives 5 days of antibiotics (iii) non sepsis. Our primary outcome is to establish if differential platelet/endothelial activation can prospectively identify neonatal culture positive late onset sepsis. TRIAL REGISTRATION NUMBER NCT05530330 IMPACT: Preterm infants are a high risk group for the development of sepsis which is a major cause of mortality in this population. Platelets have been associated with host response to invasive bacterial infections both in animal models and translational work. A positive blood culture is the gold standard test for neonatal sepsis but can be unreliable due to limited blood sampling in the very low birth weight population. This study hopes to establish if platelet/endothelial associated plasma proteins can prospectively identify late onset neonatal sepsis.
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Affiliation(s)
- Daniel O'Reilly
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, 4, Ireland.
- Department of Neonatology, Rotunda Hospital, Dublin, 1, Ireland.
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland.
| | - Claire Anne Murphy
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland
| | - Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland
- School of Medicine, University College Dublin, Dublin, 4, Ireland
| | - Fionnuala Ní Áinle
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, 4, Ireland
- Department of Haematology, Rotunda Hospital, Dublin, 1, Ireland
- Department of Haematology, Mater Hospital, Dublin, 7, Ireland
| | | | | | - Anna Curley
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland
| | - Naomi Mc Callion
- Department of Neonatology, Rotunda Hospital, Dublin, 1, Ireland
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, 2, Ireland
| | - Patricia Maguire
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, 4, Ireland
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4
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Das A, Ariyakumar G, Gupta N, Kamdar S, Barugahare A, Deveson-Lucas D, Gee S, Costeloe K, Davey MS, Fleming P, Gibbons DL. Identifying immune signatures of sepsis to increase diagnostic accuracy in very preterm babies. Nat Commun 2024; 15:388. [PMID: 38195661 PMCID: PMC10776581 DOI: 10.1038/s41467-023-44387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 12/12/2023] [Indexed: 01/11/2024] Open
Abstract
Bacterial infections are a major cause of mortality in preterm babies, yet our understanding of early-life disease-associated immune dysregulation remains limited. Here, we combine multi-parameter flow cytometry, single-cell RNA sequencing and plasma analysis to longitudinally profile blood from very preterm babies (<32 weeks gestation) across episodes of invasive bacterial infection (sepsis). We identify a dynamically changing blood immune signature of sepsis, including lymphopenia, reduced dendritic cell frequencies and myeloid cell HLA-DR expression, which characterizes sepsis even when the common clinical marker of inflammation, C-reactive protein, is not elevated. Furthermore, single-cell RNA sequencing identifies upregulation of amphiregulin in leukocyte populations during sepsis, which we validate as a plasma analyte that correlates with clinical signs of disease, even when C-reactive protein is normal. This study provides insights into immune pathways associated with early-life sepsis and identifies immune analytes as potential diagnostic adjuncts to standard tests to guide targeted antibiotic prescribing.
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Affiliation(s)
- A Das
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, UK.
- Division of Infection and Immunity, University College London, London, WC1E 6BT, UK.
| | - G Ariyakumar
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, UK
| | - N Gupta
- Department of Neonatology, Evelina London Neonatal Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - S Kamdar
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, UK
| | - A Barugahare
- Bioinformatics Platform and Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - D Deveson-Lucas
- Bioinformatics Platform and Department of Microbiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - S Gee
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, UK
| | - K Costeloe
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - M S Davey
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - P Fleming
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Neonatology, Homerton Healthcare NHS Foundation Trust, London, UK
| | - D L Gibbons
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, Guy's Hospital, London, UK.
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5
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Iijima S. Clinical Dilemma Involving Treatments for Very Low-Birth-Weight Infants and the Potential Risk of Necrotizing Enterocolitis: A Narrative Literature Review. J Clin Med 2023; 13:62. [PMID: 38202069 PMCID: PMC10780023 DOI: 10.3390/jcm13010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Necrotizing enterocolitis (NEC) is a critical gastrointestinal emergency with substantial morbidity and mortality risks, especially for very low-birth-weight (VLBW) infants, and unclear multifactorial pathophysiology. Whether common treatments for VLBW infants increase the NEC risk remains controversial. Indomethacin (utilized for patent ductus arteriosus) offers benefits but is concerning because of its vasoconstrictive impact on NEC susceptibility. Similarly, corticosteroids used to treat bronchopulmonary dysplasia may increase vulnerability to NEC by compromising immunity and altering the mesenteric blood flow. Histamine-2 receptor blockers (used to treat gastric bleeding) may inadvertently promote NEC by affecting bacterial colonization and translocation. Doxapram (used to treat apnea) poses a risk of gastrointestinal disturbance via gastric acid hypersecretion and circulatory changes. Glycerin enemas aid meconium evacuation but disrupt microbial equilibrium and trigger stress-related effects associated with the NEC risk. Prolonged antibiotic use may unintentionally increase the NEC risk. Blood transfusions for anemia can promote NEC via interactions between the immune response and ischemia-reperfusion injury. Probiotics for NEC prevention are associated with concerns regarding sepsis and bacteremia. Amid conflicting evidence, this review unveils NEC risk factors related to treatments for VLBW infants, offers a comprehensive overview of the current research, and guides personalized management strategies, thereby elucidating this clinical dilemma.
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Affiliation(s)
- Shigeo Iijima
- Department of Regional Neonatal-Perinatal Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
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6
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Su Y, Xu L, Hu J, Musha J, Lin S. Meta-Analysis of Enhanced Recovery After Surgery Protocols for the Perioperative Management of Pediatric Colorectal Surgery. J Pediatr Surg 2023; 58:1686-1693. [PMID: 36610934 DOI: 10.1016/j.jpedsurg.2022.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This meta-analysis aimed to investigate the effects and safety of enhanced recovery after surgery (ERAS) for the management of pediatric colorectal surgery. METHODS We retrieved relevant studies from PubMed, EMBASE, the Cochrane Library, and China National Knowledgement Infrastructure (CNKI) from its inception until 20 May 2022. Meta-analysis was performed using RevMan 5.4, and power analysis was calculated using G∗Power 3.1. RESULTS Ten studies involving 1298 patients were included for meta-analysis. Meta-analysis suggested that ERAS protocol significantly lessened intraoperative fluids (mean difference [MD], -3.11; 95% confidence interval, -4.99 to -1.22) and postoperative opioid usage (MD, -0.58; 95% CI, -1.08 to -0.26), shortened time to bowel return (MD, -12.02; 95% CI, -20.03 to -4.02), first enteral nutrition (MD, -20.88; 95% CI, -28.34 to -13.42) and oral intake (MD, -1.40; 95% CI, -1.96 to -0.84), lowered readmission rate in 30 days (relative risk [RR], 0.61, 95% CI, 0.41 to 0.90), shortened length of hospital stay (MD, -1.50; 95% CI, -1.25 to -1.09), and reduced in-hospital costs (MD, -0.26; 95% CI, -0.34 to -0.18); however, there was a comparable rate of postoperative complications between the two groups. Sensitivity analysis significantly changed the result of the readmission rate in 30 days. The statistical power of all outcomes ranged from 26.84% to 99.44%. CONCLUSIONS Our findings demonstrate the beneficial role of the ERAS protocol in accelerating rehabilitation, shortening the length of hospital stay, and decreasing in-hospital costs among pediatric patients undergoing colorectal surgery. LEVELS OF EVIDENCE LEVEL V.
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Affiliation(s)
- Yingchun Su
- Urology, Surgical Oncology, and Neurosurgery Department, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China.
| | - Lu Xu
- Operating Room, Urumqi First People's Hospital (Children's Hospital), Urumq, 830000, China
| | - Jinhui Hu
- Intensive Care Unit, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China
| | - Jiayinaxi Musha
- Urology and Surgical Oncology, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China
| | - Song Lin
- Urology and Surgical Oncology, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China
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7
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Scheese DJ, Sodhi CP, Hackam DJ. New insights into the pathogenesis of necrotizing enterocolitis and the dawn of potential therapeutics. Semin Pediatr Surg 2023; 32:151309. [PMID: 37290338 PMCID: PMC10330774 DOI: 10.1016/j.sempedsurg.2023.151309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disorder in premature infants that causes significant morbidity and mortality. Research efforts into the pathogenesis of NEC have discovered a pivotal role for the gram-negative bacterial receptor, Toll-like receptor 4 (TLR4), in its development. TLR4 is activated by dysbiotic microbes within the intestinal lumen, which leads to an exaggerated inflammatory response within the developing intestine, resulting in mucosal injury. More recently, studies have identified that the impaired intestinal motility that occurs early in NEC has a causative role in disease development, as strategies to enhance intestinal motility can reverse NEC in preclinical models. There has also been broad appreciation that NEC also contributes to significant neuroinflammation, which we have linked to the effects of gut-derived pro-inflammatory molecules and immune cells which activate microglia in the developing brain, resulting in white matter injury. These findings suggest that the management of the intestinal inflammation may secondarily be neuroprotective. Importantly, despite the significant burden of NEC on premature infants, these and other studies have provided a strong rationale for the development of small molecules with the capability of reducing NEC severity in pre-clinical models, thus guiding the development of specific anti-NEC therapies. This review summarizes the roles of TLR4 signaling in the premature gut in the pathogenesis of NEC, and provides insights into optimal clinical management strategies based upon findings from laboratory studies.
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Affiliation(s)
- Daniel J Scheese
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Chhinder P Sodhi
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - David J Hackam
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA.
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8
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Pace E, Yanowitz TD, Waltz P, Morowitz MJ. Antibiotic therapy and necrotizing enterocolitis. Semin Pediatr Surg 2023; 32:151308. [PMID: 37295297 DOI: 10.1016/j.sempedsurg.2023.151308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Antibiotic therapy remains a cornerstone of treatment of both medical and surgical presentations of necrotizing enterocolitis (NEC). However, guidelines regarding the administration of antibiotics for the treatment of NEC are lacking and practices vary amongst clinicians. Although the pathogenesis of NEC is unknown, there is consensus that the infant gastrointestinal microbiome contributes to the disease. The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC. Yet others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC by inducing a state of dysbiosis. This narrative review summarizes what is known about antibiotics and their association with the infant microbiome and NEC, current antibiotic prescribing practices for infants with medical and surgical NEC, as well as potential strategies to further optimize the use of antibiotics in this population of infants.
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Affiliation(s)
- Elizabeth Pace
- University of Pittsburgh Department of Surgery, United States
| | - Toby D Yanowitz
- University of Pittsburgh Department of Pediatrics, Division of Neonatology, United States
| | - Paul Waltz
- University of Pittsburgh Department of Surgery, Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, United States
| | - Michael J Morowitz
- University of Pittsburgh Department of Surgery, Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, United States.
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9
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Cuna A, Nsumu M, Menden HL, Chavez-Bueno S, Sampath V. The Detrimental Effects of Peripartum Antibiotics on Gut Proliferation and Formula Feeding Injury in Neonatal Mice Are Alleviated with Lactobacillus rhamnosus GG. Microorganisms 2023; 11:1482. [PMID: 37374984 DOI: 10.3390/microorganisms11061482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Peripartum antibiotics can negatively impact the developing gut microbiome and are associated with necrotizing enterocolitis (NEC). The mechanisms by which peripartum antibiotics increase the risk of NEC and strategies that can help mitigate this risk remain poorly understood. In this study, we determined mechanisms by which peripartum antibiotics increase neonatal gut injury and evaluated whether probiotics protect against gut injury potentiated by peripartum antibiotics. To accomplish this objective, we administered broad-spectrum antibiotics or sterile water to pregnant C57BL6 mice and induced neonatal gut injury to their pups with formula feeding. We found that pups exposed to antibiotics had reduced villus height, crypt depth, and intestinal olfactomedin 4 and proliferating cell nuclear antigen compared to the controls, indicating that peripartum antibiotics impaired intestinal proliferation. When formula feeding was used to induce NEC-like injury, more severe intestinal injury and apoptosis were observed in the pups exposed to antibiotics compared to the controls. Supplementation with the probiotic Lactobacillus rhamnosus GG (LGG) reduced the severity of formula-induced gut injury potentiated by antibiotics. Increased intestinal proliferating cell nuclear antigen and activation of the Gpr81-Wnt pathway were noted in the pups supplemented with LGG, suggesting partial restoration of intestinal proliferation by probiotics. We conclude that peripartum antibiotics potentiate neonatal gut injury by inhibiting intestinal proliferation. LGG supplementation decreases gut injury by activating the Gpr81-Wnt pathway and restoring intestinal proliferation impaired by peripartum antibiotics. Our results suggest that postnatal probiotics may be effective in mitigating the increased risk of NEC associated with peripartum antibiotic exposure in preterm infants.
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Affiliation(s)
- Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marianne Nsumu
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Heather L Menden
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Susana Chavez-Bueno
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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10
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Gamberini C, Donders S, Al-Nasiry S, Kamenshchikova A, Ambrosino E. Antibiotic Use in Pregnancy: A Global Survey on Antibiotic Prescription Practices in Antenatal Care. Antibiotics (Basel) 2023; 12:antibiotics12050831. [PMID: 37237734 DOI: 10.3390/antibiotics12050831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Antibiotic prescription and use practices in the antenatal care setting varies across countries and populations and has the potential to significantly contribute to the global spread of antibiotic resistance. This study aims to explore how healthcare practitioners make decisions about antibiotic prescriptions for pregnant women and what factors play a role in this process. A cross-sectional exploratory survey consisting of 23 questions, including 4 free-text and 19 multiple-choice questions, was distributed online. Quantitative data were collected through multiple-choice questions and was used to identify the most common infections diagnosed and the type of antibiotics prescribed. Qualitative data were gathered through free-text answers to identify gaps, challenges, and suggestions, and the data were analyzed using thematic analysis. A total of 137 complete surveys mostly from gynecologists/obstetricians from 22 different countries were included in the analysis. Overall, national and international clinical guidelines and hospital guidelines/protocols were the most frequently used sources of information. This study highlights the crucial role of laboratory results and guidelines at different levels and emphasizes region-specific challenges and recommendations. These findings underscore the pressing need for tailored interventions to support antibiotic prescribers in their decision-making practice and to address emerging resistance.
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Affiliation(s)
- Carlotta Gamberini
- Institute for Public Health Genomics (IPHG), Department of Genetics and Cell Biology, Research School GROW for Oncology and Reproduction, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Sabine Donders
- Institute for Public Health Genomics (IPHG), Department of Genetics and Cell Biology, Research School GROW for Oncology and Reproduction, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, Research School GROW for Oncology and Reproduction, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands
| | - Alena Kamenshchikova
- Department of Health, Ethics and Society, School of Public Health and Primary Care, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Elena Ambrosino
- Institute for Public Health Genomics (IPHG), Department of Genetics and Cell Biology, Research School GROW for Oncology and Reproduction, Faculty of Health, Medicine & Life Sciences, Maastricht University, 6229 ER Maastricht, The Netherlands
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Bautista GM, Cera AJ, Chaaban H, McElroy SJ. State-of-the-art review and update of in vivo models of necrotizing enterocolitis. Front Pediatr 2023; 11:1161342. [PMID: 37082706 PMCID: PMC10112335 DOI: 10.3389/fped.2023.1161342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/22/2023] Open
Abstract
NEC remains one of the most common causes of mortality and morbidity in preterm infants. Animal models of necrotizing enterocolitis (NEC) have been crucial in improving our understanding of this devastating disease and identifying biochemical pathways with therapeutic potential. The pathogenesis of NEC remains incompletely understood, with no specific entity that unifies all infants that develop NEC. Therefore, investigators rely on animal models to manipulate variables and provide a means to test interventions, making them valuable tools to enhance our understanding and prevent and treat NEC. The advancements in molecular analytic tools, genetic manipulation, and imaging modalities and the emergence of scientific collaborations have given rise to unique perspectives and disease correlates, creating novel pathways of investigation. A critical review and understanding of the current phenotypic considerations of the highly relevant animal models of NEC are crucial to developing novel therapeutic and preventative strategies for NEC.
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Affiliation(s)
- Geoanna M. Bautista
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
| | - Anjali J. Cera
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
| | - Hala Chaaban
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma, OK, United States
| | - Steven J. McElroy
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
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12
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Cuna A, Morowitz MJ, Sampath V. Early antibiotics and risk for necrotizing enterocolitis in premature infants: A narrative review. Front Pediatr 2023; 11:1112812. [PMID: 36865691 PMCID: PMC9971631 DOI: 10.3389/fped.2023.1112812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023] Open
Abstract
While prompt initiation of antibiotics at birth due to concerns for early onset sepsis is common, it often leads to many preterm infants being exposed to treatment despite negative blood cultures. Such exposure to early antibiotics can impact the developing gut microbiome putting infants at increased risk of several diseases. Necrotizing enterocolitis (NEC), a devastating inflammatory bowel disease that affects preterm infants, is among the most widely studied neonatal disease that has been linked to early antibiotics. While some studies have demonstrated an increased risk of NEC, other studies have demonstrated seemingly contrary findings of decreased NEC with early antibiotics. Studies using animal models have also yielded differing findings of benefit vs. harm of early antibiotic exposure on subsequent NEC susceptibility. We thus sought to conduct this narrative review to help clarify the relationship between early antibiotics exposure and future risk of NEC in preterm infants. Our objectives are to: (1) summarize findings from human and animal studies that investigated the relationship between early antibiotics and NEC, (2) highlight important limitations of these studies, (3) explore potential mechanisms that can explain why early antibiotics may increase or decrease NEC risk, and (4) identify future directions for research.
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Affiliation(s)
- Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MOUnited States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MOUnited States
| | - Michael J. Morowitz
- Division of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PAUnited States
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MOUnited States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MOUnited States
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13
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Vatne A, Hapnes N, Stensvold HJ, Dalen I, Guthe HJ, Støen R, Brigtsen AK, Rønnestad AE, Klingenberg C. Early Empirical Antibiotics and Adverse Clinical Outcomes in Infants Born Very Preterm: A Population-Based Cohort. J Pediatr 2023; 253:107-114.e5. [PMID: 36179887 DOI: 10.1016/j.jpeds.2022.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the association between empirical antibiotic therapy in the first postnatal week in uninfected infants born very preterm and the risk of adverse outcomes until discharge. STUDY DESIGN Population-based, nationwide registry study in Norway including all live-born infants with a gestational age <32 weeks surviving first postnatal week without sepsis, intestinal perforation, or necrotizing enterocolitis (NEC) between 2009 and 2018. Primary outcomes were severe NEC, death after the first postnatal week, and/or a composite outcome of severe morbidity (severe NEC, severe bronchopulmonary dysplasia [BPD], severe retinopathy of prematurity, late-onset sepsis, or cystic periventricular leukomalacia). The association between empirical antibiotics and adverse outcomes was assessed using multivariable logistic regression models, adjusting for known confounders. RESULTS Of 5296 live-born infants born very preterm, 4932 (93%) were included. Antibiotics were started in first postnatal week in 3790 of 4932 (77%) infants and were associated with higher aOR of death (aOR 9.33; 95% CI: 1.10-79.5, P = .041), severe morbidity (aOR 1.88; 95% CI: 1.16-3.05, P = .01), and severe BPD (aOR 2.17; 95% CI: 1.18-3.98; P = .012), compared with those not exposed. Antibiotics ≥ 5 days were associated with higher odds of severe NEC (aOR 2.27; 95% CI: 1.02-5.06; P = .045). Each additional day of antibiotics was associated with 14% higher aOR of death or severe morbidity and severe BPD. CONCLUSIONS Early and prolonged antibiotic exposure within the first postnatal week was associated with severe NEC, severe BPD, and death after the first postnatal week.
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Affiliation(s)
- Anlaug Vatne
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nina Hapnes
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Ingvild Dalen
- Department of Research, Section of Biostatistics, Stavanger University Hospital, Stavanger, Norway
| | - Hans Jørgen Guthe
- Department of Paediatrics and Adolescents Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ragnhild Støen
- Paediatric Department, St. Olav's University Hospital, Trondheim, Norway
| | - Anne Karin Brigtsen
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Arild E Rønnestad
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Medical faculty, Institute for clinical medicine, University of Oslo, Oslo, Norway
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway; Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway.
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14
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Pugh CP, Baber M, White G. Necrotizing enterocolitis following treatment of congenital syphilis with penicillin in a term newborn. SAGE Open Med Case Rep 2023; 11:2050313X231172672. [PMID: 37205159 PMCID: PMC10186574 DOI: 10.1177/2050313x231172672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
Necrotizing enterocolitis is a disease process of intestinal disruption which has been associated with gastrointestinal microbial alterations after antibiotic exposure. Treatment guidelines and antibiotic exposure for congenital syphilis have historically been based on limited evidence. This case presents a term infant who developed necrotizing enterocolitis after treatment for congenital syphilis.
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Affiliation(s)
- Charles Preston Pugh
- Charles Preston Pugh, Department of Pediatrics,
University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 512-5B, Little
Rock, AR 72205, USA.
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15
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Standardising the elusive diagnosis of NEC in the premature infant - A practical score. Early Hum Dev 2022; 175:105692. [PMID: 36343515 DOI: 10.1016/j.earlhumdev.2022.105692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The perceived risk of necrotising enterocolitis (NEC) can result in overtreatment of the otherwise adapting preterm neonate. We aim to develop an assessment tool to aid the decision making in the management of preterm neonates at risk of NEC. METHOD An evidence-based assessment tool was designed bringing together clinical, laboratory and radiological signs commonly associated with NEC. A numerical score was awarded for each sign, with those more specific to NEC being graded higher. A multi-centre validation was conducted of the proposed assessment tool over three tertiary neonatal units. RESULTS A total of 125 patients were included, 53 (42.4 %) with a final diagnosis of NEC and 72 (57.6 %) with an alternative diagnosis. The NEC group had a significantly higher total score compared to the non-NEC group; 15(2-28) vs. 4(1-9) (p ≤ 0.0001). In ROC analysis, using a cut-off of eight, the assessment tool gave a sensitivity of 92.3 % and a specificity of 90.4 % for identifying NEC compared to an alternative diagnosis. CONCLUSION This comprehensive scoring system encourages a full assessment of the infant before deciding on withholding feeds, starting antibiotics, and transferring to a surgical centre. It is a safe objective measure to support a diagnosis of NEC in the presence of certain clinical signs.
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16
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Abstract
Neonatal infections remain an important cause of neonatal morbidity and mortality worldwide. Neonatal sepsis is a systemic infection that can be classified as early-onset or late-onset pending the timing of presentation. The pathophysiology and causative pathogens of neonatal sepsis vary, with early-onset sepsis being associated with a vertically transmitted infection from mother to neonate versus late onset sepsis being commonly associated with nosocomial infections. The signs and symptoms of neonatal sepsis mimic those associated with prematurity, making timely diagnosis difficult for treating clinicians. The management of neonatal sepsis is centered around obtaining adequate culture data and initiation of broad-spectrum parenteral antibiotics. Controversies surrounding the management of neonatal sepsis include the administration of empiric antibiotics, given recent clinical studies associating early antibiotic use with clinical sequelae such as late-onset sepsis, necrotizing enterocolitis, and death in the preterm, low-birthweight infant population.
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Affiliation(s)
- Elizabeth Pace
- University of Pittsburgh, Department of Surgery, Pittsburgh, PA, United States.
| | - Toby Yanowitz
- University of Pittsburgh, Department of Neonatology, Pittsburgh, PA, United States
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17
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Morowitz MJ, Katheria AC, Polin RA, Pace E, Huang DT, Chang CCH, Yabes JG. The NICU Antibiotics and Outcomes (NANO) trial: a randomized multicenter clinical trial assessing empiric antibiotics and clinical outcomes in newborn preterm infants. Trials 2022; 23:428. [PMID: 35606829 PMCID: PMC9125935 DOI: 10.1186/s13063-022-06352-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Early-onset sepsis is an important cause of neonatal morbidity and mortality in the preterm population. Infants perceived to be at increased risk for early-onset sepsis are often treated empirically with broad-spectrum antibiotics while awaiting confirmatory blood cultures, despite an overall incidence of early-onset sepsis of 2–3% among extremely-low-birthweight (ELBW) infants. Recent observational studies associate perinatal antibiotic use with an increased incidence of necrotizing enterocolitis, late-onset sepsis, and mortality among ELBW infants. Given currently available data and variability in clinical practice, we designed a prospective multi-institutional randomized controlled trial to determine the safety of early antibiotic use in ELBW infants. Methods The NICU Antibiotics and Outcomes (NANO) trial is a multicenter, double-blinded, randomized controlled trial. A sample of 802 ELBW preterm infants will undergo web-based stratified block randomization to receive empiric antibiotics (EA; ampicillin and gentamicin) or placebo during routine evaluation for early-onset sepsis. Participating sites will use preexisting institutional protocols for antibiotic dosage and duration. Infants born at participating sites with a gestational age of 29 weeks or less are eligible for enrollment. Exclusion criteria include maternal intrauterine infection, hemodynamic or respiratory instability, delivery by caesarean section for maternal indications without labor or prolonged rupture of membranes, and prior administration of antibiotics. The primary outcome is the composite incidence of necrotizing enterocolitis, late-onset sepsis, or death during participants’ index hospitalization. Maternal and infant samples will be collected longitudinally and assessed for differences in microbiome composition and diversity. Discussion The NANO trial is designed to compare the rate of adverse outcomes of EA use at birth versus placebo in ELBW preterm infants. If EA at birth worsens clinical outcomes, then the results of the trial may help providers decrease antibiotic utilization in the NICU and subsequently decrease the incidence of complications associated with early antibiotic use in ELBW infants. If we instead find that EA improve outcomes, then the trial will validate a longstanding clinical practice that has not previously been supported by high-quality data. Future studies will assess long-term clinical and microbial outcomes in infants who received empiric antibiotics following delivery. Trial registration Trial registration data: June 25, 2019 NCT03997266. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06352-3.
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Affiliation(s)
- Michael J Morowitz
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Rangos Research Center 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Anup C Katheria
- Division of Pediatrics, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, 92123, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University, New York, NY, 10032, USA
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - David T Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Chung-Chou H Chang
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Johathan G Yabes
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, USA
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18
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Early Antibiotic Exposure Alters Intestinal Development and Increases Susceptibility to Necrotizing Enterocolitis: A Mechanistic Study. Microorganisms 2022; 10:microorganisms10030519. [PMID: 35336095 PMCID: PMC8951210 DOI: 10.3390/microorganisms10030519] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/24/2022] Open
Abstract
Increasing evidence suggests that prolonged antibiotic therapy in preterm infants is associated with increased mortality and morbidities, such as necrotizing enterocolitis (NEC), a devastating gastrointestinal pathology characterized by intestinal inflammation and necrosis. While a clinical correlation exists between antibiotic use and the development of NEC, the potential causality of antibiotics in NEC development has not yet been demonstrated. Here, we tested the effects of systemic standard-of-care antibiotic therapy for ten days on intestinal development in neonatal mice. Systemic antibiotic treatment impaired the intestinal development by reducing intestinal cell proliferation, villi height, crypt depth, and goblet and Paneth cell numbers. Oral bacterial challenge in pups who received antibiotics resulted in NEC-like intestinal injury in more than half the pups, likely due to a reduction in mucous-producing cells affecting microbial–epithelial interactions. These data support a novel mechanism that could explain why preterm infants exposed to prolonged antibiotics after birth have a higher incidence of NEC and other gastrointestinal disorders.
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19
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Ahearn-Ford S, Berrington JE, Stewart CJ. Development of the gut microbiome in early life. Exp Physiol 2022; 107:415-421. [PMID: 35041771 PMCID: PMC9305283 DOI: 10.1113/ep089919] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/07/2022] [Indexed: 11/28/2022]
Abstract
New Findings What is the topic of this review? The importance of the early life gut microbiome, with a focus on preterm infants and microbially related diseases. Current techniques to study the preterm gut microbiome are appraised, and the potential of recent methodological advancements is discussed. What advances does it highlight? Recent findings in the field achieved by the application of advanced technologies, the applicability of intestinally derived organoid models to study host–microbiome interactions in the preterm gut, and recent developments in enhancing the physiological relevance of such models. Preterm intestinally derived organoids may provide novel insights into the mechanisms underlying preterm disease, as well as diagnosis and treatment opportunities. These models have huge translational potential, offering a step towards precision medicine.
Abstract Accumulating evidence affirms the importance of the gut microbiome in both health and disease. In early life, there exists a critical period in which the composition of gut microbes is particularly malleable and subject to a wide range of influencing factors. Disturbances to microbial communities during this time may be beneficial or detrimental to short and long‐term health outcomes. For infants born prematurely, naïve immune systems, immature gastrointestinal tracts and additional clinical needs put this population at high risk of abnormal microbial colonisation, resulting in increased susceptibility to diseases including necrotising enterocolitis (NEC) and late‐onset sepsis (LOS). Traditional cell culture methods, gnotobiotic animals, molecular sequencing techniques (16S rRNA gene sequencing and metagenomics) and advanced ‘omics’ technologies (transcriptomics, proteomics and metabolomics) have been fundamental in exploring the associations between diet, gut microbes, microbial functions and disease. Despite significant investment and ongoing research efforts, prevention and treatment strategies in NEC and LOS remain limited. Recent endeavours have focused on searching for new, more physiologically relevant models to simulate the preterm intestine. Preterm intestinally derived organoids represent a promising in vitro approach in the study of host–microbiome interactions in the preterm infant gut, offering new and exciting possibilities in this field.
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Affiliation(s)
- Sinead Ahearn-Ford
- Clinical and Translational Research Institute, Newcastle University, Newcastle, NE2 4HH, UK
| | - Janet E Berrington
- Clinical and Translational Research Institute, Newcastle University, Newcastle, NE2 4HH, UK.,Newcastle Neonatal Service, Newcastle Hospitals NHS Trust, Newcastle, NE1 4LP, UK
| | - Christopher J Stewart
- Clinical and Translational Research Institute, Newcastle University, Newcastle, NE2 4HH, UK
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20
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Zhu K, Gao H, Yuan L, Wang L, Deng F. Prolonged antibiotic therapy increased necrotizing enterocolitis in very low birth weight infants without culture-proven sepsis. Front Pediatr 2022; 10:949830. [PMID: 36147802 PMCID: PMC9485444 DOI: 10.3389/fped.2022.949830] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/08/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES We aimed to identify the factors associated with necrotizing enterocolitis (NEC) and to assess the associations of the initial empirical antibiotic therapy (IEAT) duration and antibiotic therapy duration/hospital stay ratio (A/H ratio) before NEC with subsequent NEC in very low birth weight (VLBW) infants with gestational age less than 32 weeks without proven sepsis. METHODS A retrospective study was conducted at the NICU of the First Affiliated Hospital of Medical University of Anhui province from June 2015 to May 2022, and 567 VLBW infants with gestational age less than 32 weeks were included in the study. We divided the VLBW infants into those with and without NEC according to modified Bell's criteria. We then used descriptive statistics to identify the factors associated with NEC and multivariate analyses to evaluate the associations of IEAT duration and A/H ratio with the occurrence of NEC. RESULTS Of the 567 VLBW neonates admitted to our center, 547 survived and reached the normal discharge criteria. Fifty-one infants (8.99%) were diagnosed as showing NEC. Infants with NEC had a longer total parenteral nutrition time, total enteral nutrition time, and IEAT duration, as well as a higher A/H ratio than those without NEC. In multivariate analyses adjusted for the other factors, IEAT duration was associated with an increased odds of NEC [odds ratio (OR) = 1.267; 95% confidence interval (CI), 1.128-1.423], and the A/H ratio was also associated with increased odds of NEC (OR = 8.718; 95% CI, 2.450-31.030). For the A/H ratio, the area under the curve (AUC) was 0.767 and the ideal cutoff was 0.357, and the sensitivity and specificity were 0.843 and 0.645, respectively. CONCLUSION Prolonged antibiotic therapy may increase the risk of NEC in VLBW infants with a gestational age of fewer than 32 weeks and should be used with caution.
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Affiliation(s)
- Keran Zhu
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hui Gao
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Liping Yuan
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lili Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Fang Deng
- Anhui Provincial Children's Hospital, Hefei, China
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21
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Association between duration of early empiric antibiotics and necrotizing enterocolitis and late-onset sepsis in preterm infants: a multicenter cohort study. Eur J Pediatr 2022; 181:3715-3724. [PMID: 35927379 PMCID: PMC9508214 DOI: 10.1007/s00431-022-04579-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/14/2022] [Accepted: 07/23/2022] [Indexed: 11/23/2022]
Abstract
UNLABELLED The threshold to initiate empiric antibiotics for suspicion of early-onset sepsis (EOS) is low in preterm infants. Antibiotics' effects on short-term outcomes have recently been debated. We aimed at exploring the extent of early empiric antibiotic exposure (EEAE) in preterm infants and the association between the duration of EEAE with necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) within different EEAE groups. EEAE practice for suspicion of EOS was evaluated in all included infants (gestational age < 30 weeks) born in 9 centers in the Netherlands and Belgium between Oct. 2014 and Jan. 2019. EEAE association with NEC and LOS development was analyzed by multivariate regression. After excluding 56 EOS cases, 1259 infants were included. A total of 1122 infants (89.1%) were exposed to empirical antibiotics for the suspicion of EOS of whom 802 (63.7%) had short (≤ 72 h) and 320 (25.4%) prolonged EEAE (> 72 h). Infants with EEAE ≤ 72 h had a lower incidence of NEC compared to both infants without EEAE (adjusted odds ratio (aOR) 0.39; 95% confidence interval (CI) [0.19-0.80]; p = 0.01) and with prolonged EEAE (> 72 h) (aOR [95%CI]: 0.58 [0.35-0.96]; p = 0.03). With every additional day of EEAE, LOS incidence decreased (aOR [95%CI]: 0.90 [0.85-0.97]; p = 0.003). CONCLUSION Almost 90% of preterm infants who have negative blood culture results in the first 72 h of life are exposed to EEAE under suspicion of EOS. One-fourth has prolonged EEAE. Duration of EEAE was differently associated with NEC and LOS incidence. The effects of antibiotics, and potentially induced microbial dysbiosis related to development of NEC and LOS, should further be explored. WHAT IS KNOWN • Preterm infants often receive antibiotics empirically directly after birth for suspicion of early-onset sepsis. • The effects of the duration of early empirical antibiotic exposure on the risk for necrotizing enterocolitis and late-onset sepsis are debated. WHAT IS NEW • Almost 90% of preterm infants with a gestational age below 30 weeks are exposed to antibiotics empirically after birth despite negative culture results. In a quarter of these culture-negative infants, empirical antibiotics are prolonged. • A short course of empirical antibiotics (≤72h) is associated with decreased odds for necrotizing enterocolitis compared to both prolonged (>72h) or no empirical antibiotics after birth. Furthermore, every additional day of empirical antibiotic exposure is associated with decreased risk for late-onset sepsis in the first month of life.
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22
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Singh DK, Miller CM, Orgel KA, Dave M, Mackay S, Good M. Necrotizing enterocolitis: Bench to bedside approaches and advancing our understanding of disease pathogenesis. Front Pediatr 2022; 10:1107404. [PMID: 36714655 PMCID: PMC9874231 DOI: 10.3389/fped.2022.1107404] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is a devastating, multifactorial disease mainly affecting the intestine of premature infants. Recent discoveries have significantly enhanced our understanding of risk factors, as well as, cellular and genetic mechanisms of this complex disease. Despite these advancements, no essential, single risk factor, nor the mechanism by which each risk factor affects NEC has been elucidated. Nonetheless, recent research indicates that maternal factors, antibiotic exposure, feeding, hypoxia, and altered gut microbiota pose a threat to the underdeveloped immunity of preterm infants. Here we review predisposing factors, status of unwarranted immune responses, and microbial pathogenesis in NEC based on currently available scientific evidence. We additionally discuss novel techniques and models used to study NEC and how this research translates from the bench to the bedside into potential treatment strategies.
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Affiliation(s)
- Dhirendra K Singh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Claire M Miller
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kelly A Orgel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mili Dave
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
| | - Stephen Mackay
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Misty Good
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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23
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Klerk DH, van Avezaath LK, Loeffen EAH, Hulscher JBF, Kooi EMW. Fetal-neonatal exposure to antibiotics and NEC development: A systematic review and meta-analysis. Front Pediatr 2022; 10:1102884. [PMID: 36727006 PMCID: PMC9885048 DOI: 10.3389/fped.2022.1102884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 12/20/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Fetal and neonatal exposure to antibiotics may contribute to the development of necrotizing enterocolitis (NEC) in preterm infants. This systematic review and meta-analysis investigate whether exposure to third trimester maternal antibiotics (MAB) and/or prolongation of empirical antibiotics (PEAB) are associated with NEC development in preterms. METHOD We included observational and randomized controlled studies, including those on preterm or very low birth weight (VLBW) infants, from MEDLINE and EMBASE, published between 1990 and June 2021. Exposure was defined as third trimester MAB and/or PEAB. The two reviewers independently performed study selection, data extraction, and quality assessment. RESULTS Three cohort studies compared third trimester MAB with no antibiotics. MAB was associated with lower NEC incidence, unadjusted pooled odds ratio (OR) is 0.57 (95% CI: 0.35-0.93). Twelve cohort studies showed that PEAB was associated with an increased risk of NEC. Ten observational cohort studies show an unadjusted OR of 2.72 (1.65-4.47), and two case-control studies show an unadjusted mean difference of 2.31 (0.94-3.68). Moderate to substantial heterogeneity was observed but decreased in studies with low risk of bias and large sample size. CONCLUSION Evidence suggests an association between MAB and decreased risk of NEC and an association between PEAB and increased risk of NEC. Further studies should confirm these associations and explore causality. SYSTEMATIC REVIEW REGISTRATION identifier [CRD42022304937].
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Affiliation(s)
- Daphne H Klerk
- Division of Neonatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Lisanne K van Avezaath
- Division of Neonatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Erik A H Loeffen
- Division of Pediatric Oncology/Hematology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Jan B F Hulscher
- Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Elisabeth M W Kooi
- Division of Neonatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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24
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Bayoumi MAA, Elmalik EE. Gastric pneumatosis in a preterm infant following initial empiric antibiotic therapy. BMJ Case Rep 2021; 14:e246446. [PMID: 34667056 PMCID: PMC8527141 DOI: 10.1136/bcr-2021-246446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mohammad A A Bayoumi
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation, Doha, Qatar
| | - Einas Elzubier Elmalik
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation, Doha, Qatar
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25
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Cuna A, Sampath V, Khashu M. Racial Disparities in Necrotizing Enterocolitis. Front Pediatr 2021; 9:633088. [PMID: 33681105 PMCID: PMC7930220 DOI: 10.3389/fped.2021.633088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a serious disease of the intestinal tract affecting 5-10% of pre-term infants with up to 50% mortality in those that require surgery. There is wide variation in the rates and outcomes of NEC by race and ethnicity, and the reasons for this disparity are poorly understood. In this article, we review the epidemiology and discuss possible explanations for racial and ethnic differences in NEC. Most of the current evidence investigating the role of race in NEC comes from North America and suggests that Hispanic ethnicity and non-Hispanic Black race are associated with higher risk of NEC compared to non-Hispanic White populations. Differences in pre-term births, breastfeeding rates, and various sociodemographic factors does not fully account for the observed disparities in NEC incidence and outcomes. While genetic studies are beginning to identify candidate genes that may increase or decrease risk for NEC among racial populations, current data remain limited by small sample sizes and lack of validation. Complex interactions between social and biological determinants likely underly the differences in NEC outcomes among racial groups. Larger datasets with detailed social, phenotypic, and genotypic information, coupled with advanced bioinformatics techniques are needed to comprehensively understand racial disparities in NEC.
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Affiliation(s)
- Alain Cuna
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, United States.,Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Venkatesh Sampath
- School of Medicine, University of Missouri Kansas City, Kansas City, MO, United States.,Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Minesh Khashu
- Neonatal Service, University Hospitals Dorset, Poole, United Kingdom.,Bournemouth University, Dorset, United Kingdom
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26
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Abstract
Preterm infants are susceptible to infections that can rapidly progress to disastrous outcomes. Antibiotics are lifesaving, but their prolonged and inappropriate use are associated with adverse outcomes. In this review, we discuss the current status of antimicrobial use in the preterm neonatal population, and the challenges in determining the initiation, duration, and choice of antibiotics. Finally, we review the clinical studies on the potential consequences of prolonged antimicrobial exposure in prematurely born infants.
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27
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Cantey JB. Early Antibiotic Therapy and Adverse Outcomes in Preterm Infants: Time for a Trial! J Pediatr 2020; 227:13-14. [PMID: 32693104 DOI: 10.1016/j.jpeds.2020.07.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/15/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, University of Texas Health San Antonio, San Antonio, Texas.
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28
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Murphy C, Nair J, Wrotniak B, Polischuk E, Islam S. Antibiotic Treatments and Patient Outcomes in Necrotizing Enterocolitis. Am J Perinatol 2020; 37:1250-1257. [PMID: 31307104 DOI: 10.1055/s-0039-1693429] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study aimed to examine the impact of different antibiotic treatments on necrotizing enterocolitis (NEC) outcomes. STUDY DESIGN Patient outcomes, including total parenteral nutrition and hospitalization durations, abdominal surgeries, intestinal strictures, and mortality data, were analyzed and compared by various antibiotic groups and treatment durations for 160 NEC patients managed at the Women and Children's Hospital of Buffalo between 2008 and 2016. RESULTS Fourteen different antibiotics were used for NEC, most commonly ampicillin, gentamicin, and metronidazole (AGM). Medical (vs. surgical) NEC patients more likely received AGM (37 vs. 6%, p < 0.001). Surgical (vs. medical) NEC patients more likely received vancomycin (80 vs. 30%, p < 0.001) and antipseudomonal agents (69 vs. 15%, p < 0.001). For medical NEC there were no outcome differences between patients receiving only AGM versus those receiving other treatments; in patients receiving AGM, there were no outcome differences in durations of ≤10 days versus longer courses. CONCLUSION Antibiotic use for NEC varies substantially without definite outcome differences. Particularly with medical NEC, AGM for ≤10 days had comparable outcomes to other treatments. In light of growing concern for short and longer term adverse effects with early-life antibiotic exposure, narrow-spectrum and shorter course NEC treatment may be preferred.
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Affiliation(s)
- Catherine Murphy
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Jayasree Nair
- Division of Neonatology, Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, New York
| | - Brian Wrotniak
- Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, New York
| | - Emily Polischuk
- Department of Pharmacy, John R. Oishei Children's Hospital of Buffalo, Buffalo, New York
| | - Shamim Islam
- Division of Infectious Diseases, Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, New York
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29
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Association of initial empirical antibiotic therapy with increased risk of necrotizing enterocolitis. Eur J Pediatr 2020; 179:1047-1056. [PMID: 32424744 DOI: 10.1007/s00431-020-03679-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
Whether the prophylactic use of antibiotics increase the risk of necrotizing enterocolitis (NEC) remains controversial. This review aims to investigate initial empirical antibiotic therapy (IEAT) and is associated with the risk of NEC. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched through March 1, 2020. All studies on the impacts of antibiotic exposure on NEC development were included. Thirteen studies including 7901 participants were selected. Two reviewers independently examined the extracted data and assessed the quality of the included studies. Random-effects model was used to pool the effect estimates. We found that IEAT (≥ 5 days) was associated with an increased risk of NEC in adjusted (Odds risk [OR] 1.51, 95% confidence interval [CI] 1.22-1.87) and unadjusted (OR 2.35, 95% CI 1.54-3.57) analyses. Sensitivity analysis also supported these findings.Conclusion: The evidence suggests an association between IEAT (≥ 5 days) and the risk of NEC. Further studies are needed to address whether the association with IEAT is causal.What is Known:•Necrotizing enterocolitis (NEC) is acute inflammatory necrosis of the intestinal tractin the newborn infant.•Some observational studies have associated initial empirical antibiotics with an increased risk of subsequent NEC.What is New:•Initial empirical antibiotic therapy (IEAT) (≥ 5 days) appear to increase the risk of NEC.
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30
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Underwood MA, Mukhopadhyay S, Lakshminrusimha S, Bevins CL. Neonatal intestinal dysbiosis. J Perinatol 2020; 40:1597-1608. [PMID: 32968220 PMCID: PMC7509828 DOI: 10.1038/s41372-020-00829-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/17/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
The initial colonization of the neonatal intestinal tract is influenced by delivery mode, feeding, the maternal microbiota, and a host of environmental factors. After birth, the composition of the infant's microbiota undergoes a series of significant changes particularly in the first weeks and months of life ultimately developing into a more stable and diverse adult-like population in childhood. Intestinal dysbiosis is an alteration in the intestinal microbiota associated with disease and appears to be common in neonates. The consequences of intestinal dysbiosis are uncertain, but strong circumstantial evidence and limited confirmations of causality suggest that dysbiosis early in life can influence the health of the infant acutely, as well as contribute to disease susceptibility later in life.
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Affiliation(s)
- Mark A. Underwood
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA USA
| | - Sagori Mukhopadhyay
- grid.25879.310000 0004 1936 8972Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Satyan Lakshminrusimha
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA USA
| | - Charles L. Bevins
- grid.27860.3b0000 0004 1936 9684Department of Medical Microbiology and Immunology, UC Davis School of Medicine, Davis, CA USA
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31
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Fundora JB, Guha P, Shores DR, Pammi M, Maheshwari A. Intestinal dysbiosis and necrotizing enterocolitis: assessment for causality using Bradford Hill criteria. Pediatr Res 2020; 87:235-248. [PMID: 31238334 PMCID: PMC7224339 DOI: 10.1038/s41390-019-0482-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 02/08/2023]
Abstract
In recent years, several studies have shown that premature infants who develop NEC frequently display enteric dysbiosis with increased Gram-negative bacteria for several days to weeks prior to NEC onset. The importance of these findings, for the possibility of a causal role of these bacteria in NEC pathogenesis, and for potential value of gut dysbiosis as a biomarker of NEC, is well-recognized. In this review, we present current evidence supporting the association between NEC in premature infants and enteric dysbiosis, and its evaluation using the Bradford Hill criteria for causality. To provide an objective appraisal, we developed a novel scoring system for causal inference. Despite important methodological and statistical limitations, there is support for the association from several large studies and a meta-analysis. The association draws strength from strong biological plausibility of a role of Gram-negative bacteria in NEC and from evidence for temporality, that dysbiosis may antedate NEC onset. The weakness of the association is in the low level of consistency across studies, and the lack of specificity of effect. There is a need for an improved definition of dysbiosis, either based on a critical threshold of relative abundances or at higher levels of taxonomic resolution.
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Affiliation(s)
- Jennifer B Fundora
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pallabi Guha
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Darla R Shores
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohan Pammi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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