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Legge AA, Middleton JL, Fiander M, Cracknell J, Osborn DA, Gordon A. Shorter versus longer duration antibiotic regimens for treatment of culture-positive neonatal sepsis. Cochrane Database Syst Rev 2024; 7:CD015555. [PMID: 38989924 PMCID: PMC11238623 DOI: 10.1002/14651858.cd015555] [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] [Indexed: 07/12/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the safety and effectiveness of shorter versus longer duration antibiotic regimens for the treatment of culture-positive neonatal sepsis with or without meningitis.
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Affiliation(s)
- Alexandra A Legge
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | | | - David A Osborn
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Adrienne Gordon
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Institute of Women, Children and Families, Sydney Local Health District, Sydney, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, Australia
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Toan ND, Darton TC, Huong NHT, Nhat LTH, Nguyen TNT, Tuyen HT, Thinh LQ, Mau NK, Tam PTT, Phuong CN, Nhan LNT, Minh NNQ, Xuan NM, Thuong TC, Hung NT, Boinett C, Reece S, Karkey A, Day JN, Baker S. Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000875. [PMID: 36962870 PMCID: PMC10021837 DOI: 10.1371/journal.pgph.0000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 07/13/2022] [Indexed: 06/18/2023]
Abstract
Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.
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Affiliation(s)
- Nguyen Duc Toan
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Thomas C. Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Nguyen Hoang Thien Huong
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | - Le Thanh Hoang Nhat
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - To Nguyen Thi Nguyen
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ha Thanh Tuyen
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Le Quoc Thinh
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Nguyen Kien Mau
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Pham Thi Thanh Tam
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Cam Ngoc Phuong
- Hanh Phuc International Hospital, Binh Duong Province, Vietnam
| | - Le Nguyen Thanh Nhan
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Ngo Minh Xuan
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Tang Chi Thuong
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Department of Health, Ho Chi Minh City, Vietnam
| | - Nguyen Thanh Hung
- Clinical Departments, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Department of Paediatrics, Vietnam National University School of Medicine, Ho Chi Minh City, Vietnam
| | | | - Stephen Reece
- Kymab, Babraham Research Campus, Cambridge, United Kingdom
| | - Abhilasha Karkey
- Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Jeremy N. Day
- Hospital for Tropical Diseases, Wellcome Trust Africa and Asia Programmes, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Stephen Baker
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Goh GL, Lim CSE, Sultana R, De La Puerta R, Rajadurai VS, Yeo KT. Risk Factors for Mortality From Late-Onset Sepsis Among Preterm Very-Low-Birthweight Infants: A Single-Center Cohort Study From Singapore. Front Pediatr 2022; 9:801955. [PMID: 35174116 PMCID: PMC8841856 DOI: 10.3389/fped.2021.801955] [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: 10/26/2021] [Accepted: 12/22/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the risk factors for mortality associated with late onset sepsis (LOS) among preterm very-low-birthweight (VLBW) infants. STUDY DESIGN We performed a retrospective cohort study of infants born <32 weeks gestation and <1,500 gm admitted to a Singaporean tertiary-level neonatal intensive care unit. We determined the clinical, microbial, and laboratory risk factors associated with mortality due to culture-positive LOS in this cohort. RESULTS A total of 1,740 infants were admitted, of which 169 (9.7%) developed LOS and 27 (16%) died. Compared to survivors, those who died had lower birth gestational age (median 24 vs. 25 weeks, p = 0.02) and earlier LOS occurrence (median 10 vs. 17 days, p = 0.007). There was no difference in the incidence of meningitis (11.1 vs. 16.9%, p = 0.3), NEC (18.5 vs. 14.8%, p = 0.6), or intestinal surgery (18.5 vs. 23.3%, p = 0.6) among infants who died compared to survivors. Gram-negative bacteria accounted for 21/27 (77.8%) LOS-associated deaths and almost all (13/14, 93%) fulminant episodes. The presence of multiorgan failure, as evidenced by the need for mechanical ventilation (100 vs. 79.0%, p = 0.008), elevated lactate (12.4 vs. 2.1 mmol/L, p < 0.001), and inotropic support (92.6 vs. 37.5%, p < 0.001), was significantly associated with mortality. Infants who died had significantly lower white blood cell (WBC) counts (median 4.2 × 109/L vs. 9.9 × 109/L, p = 0.001), lower platelet count (median 40 × 109/L vs. 62 × 109/L, p = 0.01), and higher immature to total neutrophil (I: T) ratio (0.2 vs. 0.1, p = 0.002). Inotrope requirement [AOR 22.4 (95%CI 2.9, 103.7)], WBC <4 × 109/L [AOR 4.7 (1.7, 13.2)], and I: T ratio >0.3 [AOR 3.6 (1.3, 9.7)] were independently associated with LOS mortality. CONCLUSIONS In a setting with predominantly Gram-negative bacterial infections, the need for inotropic support, leukopenia, and elevated I: T ratio were significantly associated with LOS mortality among preterm VLBW infants.
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Affiliation(s)
- Guan Lin Goh
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Charis Shu En Lim
- KK Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Rowena De La Puerta
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Victor Samuel Rajadurai
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Kee Thai Yeo
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
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Abstract
BACKGROUND Breakdown of the developmentally immature epidermal barrier may permit entry for micro-organisms leading to invasive infection in preterm infants. Topical emollients may improve skin integrity and barrier function and thereby prevent invasive infection, a major cause of mortality and morbidity in preterm infants. OBJECTIVES To assess the effect of topical application of emollients (ointments, creams, or oils) on the risk of invasive infection and mortality in preterm infants. SEARCH METHODS We searched CENTRAL via Cochrane Register of Studies (CRS) Web and MEDLINE via Ovid (updated 08 January 2021) and the reference lists of retrieved articles. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that assessed the effect of prophylactic application of topical emollient on the risk of invasive infection, mortality, other morbidity, and growth and development in preterm infants. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on mortality and invasive infection. MAIN RESULTS We included 22 trials with a total of 5578 infant participants. The main potential sources of bias were lack of clarity on the methods used to generate random sequences and conceal allocation in half of the trials, and lack of masking of parents, caregivers, clinicians, and investigators in all of the trials. Eight trials (2086 infants) examined the effect of topical ointments or creams. Most participants were very preterm infants cared for in healthcare facilities in high-income countries. Meta-analyses suggested that topical ointments or creams may have little or no effect on invasive infection (RR 1.13, 95% confidence interval (CI) 0.97 to 1.31; low certainty evidence) or mortality (RR 0.94, 95% CI 0.82 to 1.08; low certainty evidence). Fifteen trials (3492 infants) assessed the effect of topical plant or vegetable oils. Most of these trials were undertaken in low- or middle-income countries and were based in healthcare facilities. One large (2249 infants) community-based trial occurred in a rural field practice in India. Meta-analyses suggested that topical oils may reduce invasive infection (RR 0.71, 95% CI 0.52 to 0.96; I² = 52%; low certainty evidence) but have little or no effect on mortality (RR 0.94, 95% CI 0.82 to 1.08, I² = 3%; low certainty evidence). One trial (316 infants) that compared petroleum-based ointment versus sunflower seed oil in very preterm infants in Bangladesh showed little or no effect on invasive infection (RR 0.91, 95% CI 0.57 to 1.46; low certainty evidence), but suggested that ointment may lower mortality slightly (RR 0.82, 95% CI 0.68 to 0.98; RD -0.12, 95% CI -0.23 to -0.01; number needed to treat for an additional beneficial outcome 8, 95% CI 4 to 100; low certainty evidence). One trial (64 infants) that assessed the effect of coconut oil versus mineral oil in preterm infants with birth weight 1500 g to 2000 g in India reported no episodes of invasive infection or death in either group (very low certainty evidence). AUTHORS' CONCLUSIONS The level of certainty about the effects of emollient therapy on invasive infection or death in preterm infants is low. Since these interventions are mostly inexpensive, readily accessible, and generally acceptable, further good-quality randomised controlled trials in healthcare facilities, and in community settings in low- or middle-income countries, may be justified.
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Affiliation(s)
- Jemma Cleminson
- Centre for Reviews and Dissemination, University of York, York, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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Abdellatif M, Al-Khabori M, Rahman AU, Khan AA, Al-Farsi A, Ali K. Outcome of Late-onset Neonatal Sepsis at a Tertiary Hospital in Oman. Oman Med J 2019; 34:302-307. [PMID: 31360318 PMCID: PMC6642716 DOI: 10.5001/omj.2019.60] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives We sought to determine the prevalence, pattern of causative organisms, and mortality of newborns with culture-proven late-onset sepsis (LOS) and to determine and compare the risk factors linked to late-onset gram-positive and late-onset gram-negative sepsis in Sultan Qaboos University Hospital (SQUH). Methods We conducted a cross-sectional retrospective study of data obtained between 1 January 2007 and 31 December 2014 (eight years) from infants in the neonatal intensive care unit (NICU) at SQUH. Infants born in SQUH (inborn) and other institutions (outborn) with positive blood cultures were included in the study. Results The total number of live births and admissions during the study period were 26 289 and 3559, respectively. The total number of infants identified with LOS were 125 of whom 69 (55.2%) were gram-positive, 52 (41.6%) were gram-negative, and four (3.2%) were due to Candida species (spp.). The majority of infants (n = 113, 90.4%) were inborn; 69 (55.2%) were males and 56 (44.8%) were females. The prevalence of LOS among inborn admissions was 4.3 per 1000 live births. Most infections occurred in very low birth weight infants (n = 81, 64.8%). Eleven (8.8%) infants died due to gram-negative sepsis. Klebsiella pneumoniae followed by Pseudomonas aeruginosa were the leading cause of death. Maternal intrapartum antibiotics were the only independent risk factor correlating with gram-negative organisms in multivariate analysis (p = 0.003). Conclusions LOS poses a burden in the NICU, which could be due to the increasing survival of premature babies. The main contributing organisms to LOS are gram-positive bacteria. Klebsiella spp. is a major cause of mortality in LOS. The use of intrapartum antibiotic prophylaxis in mothers might explain the positive correlation of maternal antibiotics as a risk factor with gram-negative infections.
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Affiliation(s)
| | | | - Assad Ur Rahman
- Pediatrics Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ashfaq Ahmad Khan
- Pediatrics Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ahmed Al-Farsi
- Pediatrics Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalid Ali
- Pediatrics Department, Sultan Qaboos University Hospital, Muscat, Oman
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Griffiths J, Jenkins P, Vargova M, Bowler U, Juszczak E, King A, Linsell L, Murray D, Partlett C, Patel M, Berrington J, Embleton N, Dorling J, Heath PT, McGuire W, Oddie S. Enteral lactoferrin to prevent infection for very preterm infants: the ELFIN RCT. Health Technol Assess 2019; 22:1-60. [PMID: 30574860 DOI: 10.3310/hta22740] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Infections acquired in hospital are an important cause of morbidity and mortality in very preterm infants. Several small trials have suggested that supplementing the enteral diet of very preterm infants with lactoferrin, an antimicrobial protein processed from cow's milk, prevents infections and associated complications. OBJECTIVE To determine whether or not enteral supplementation with bovine lactoferrin (The Tatua Cooperative Dairy Company Ltd, Morrinsville, New Zealand) reduces the risk of late-onset infection (acquired > 72 hours after birth) and other morbidity and mortality in very preterm infants. DESIGN Randomised, placebo-controlled, parallel-group trial. Randomisation was via a web-based portal and used an algorithm that minimised for recruitment site, weeks of gestation, sex and single versus multiple births. SETTING UK neonatal units between May 2014 and September 2017. PARTICIPANTS Infants born at < 32 weeks' gestation and aged < 72 hours at trial enrolment. INTERVENTIONS Eligible infants were allocated individually (1 : 1 ratio) to receive enteral bovine lactoferrin (150 mg/kg/day; maximum 300 mg/day) or sucrose (British Sugar, Peterborough, UK) placebo (same dose) once daily from trial entry until a postmenstrual age of 34 weeks. Parents, caregivers and outcome assessors were unaware of group assignment. OUTCOMES Primary outcome - microbiologically confirmed or clinically suspected late-onset infection. Secondary outcomes - microbiologically confirmed infection; all-cause mortality; severe necrotising enterocolitis (NEC); retinopathy of prematurity (ROP); bronchopulmonary dysplasia (BPD); a composite of infection, NEC, ROP, BPD and mortality; days of receipt of antimicrobials until 34 weeks' postmenstrual age; length of stay in hospital; and length of stay in intensive care, high-dependency and special-care settings. RESULTS Of 2203 enrolled infants, primary outcome data were available for 2182 infants (99%). In the intervention group, 316 out of 1093 (28.9%) infants acquired a late-onset infection versus 334 out of 1089 (30.7%) infants in the control group [adjusted risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.04]. There were no significant differences in any secondary outcomes: microbiologically confirmed infection (RR 1.05, 99% CI 0.87 to 1.26), mortality (RR 1.05, 99% CI 0.66 to 1.68), NEC (RR 1.13, 99% CI 0.68 to 1.89), ROP (RR 0.89, 99% CI 0.62 to 1.28), BPD (RR 1.01, 99% CI 0.90 to 1.13), or a composite of infection, NEC, ROP, BPD and mortality (RR 1.01, 99% CI 0.94 to 1.08). There were no differences in the number of days of receipt of antimicrobials, length of stay in hospital, or length of stay in intensive care, high-dependency or special-care settings. There were 16 reports of serious adverse events for infants in the lactoferrin group and 10 for infants in the sucrose group. CONCLUSIONS Enteral supplementation with bovine lactoferrin does not reduce the incidence of infection, mortality or other morbidity in very preterm infants. FUTURE WORK Increase the precision of the estimates of effect on rarer secondary outcomes by combining the data in a meta-analysis with data from other trials. A mechanistic study is being conducted in a subgroup of trial participants to explore whether or not lactoferrin supplementation affects the intestinal microbiome and metabolite profile of very preterm infants. TRIAL REGISTRATION Current Controlled Trials ISRCTN88261002. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 74. See the NIHR Journals Library website for further project information. This trial was also sponsored by the University of Oxford, Oxford, UK. The funder provided advice and support and monitored study progress but did not have a role in study design or data collection, analysis and interpretation.
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Affiliation(s)
- James Griffiths
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Paula Jenkins
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Monika Vargova
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Andrew King
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - David Murray
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | | | - Janet Berrington
- Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Nicholas Embleton
- Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Paul T Heath
- St George's, University of London and St George's University Hospitals NHS Trust, London, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sam Oddie
- Bradford Institute for Health Research, Bradford, UK
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Dong Y, Glaser K, Speer CP. Late-onset sepsis caused by Gram-negative bacteria in very low birth weight infants: a systematic review. Expert Rev Anti Infect Ther 2019; 17:177-188. [PMID: 30640556 DOI: 10.1080/14787210.2019.1568871] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Very low birth weight (VLBW) infants are highly susceptible to late-onset sepsis (LOS). Compared to Gram-positive bacteria, Gram-negative bacteria are less common to cause LOS, but are associated with a more severe clinical manifestation, higher mortality, and increased risk of neonatal morbidity. So far, the clinical picture of late-onset Gram-negative sepsis (LOGNS) in VLBW infants has not been elucidated. An up-to-date and thorough understanding of the clinical picture of LOGNS in VLBW infants is important to optimize current anti-sepsis protocols. Areas covered: Literature published in the last three decades was searched for data on the epidemiology, pathogen profile, risk factors, clinical manifestations, laboratory parameters, mortality, and short-term and long-term morbidity of LOGNS in VLBW infants. Expert opinion: Gram-negative bacteria are major contributors of neonatal morbidity and mortality in VLBW infants with LOS, potentially posing a significant disease burden. Unravelling the pathogen-specific clinical picture of LOGNS and the underlying mechanisms is of particular interest. VLBW infants may differ from more mature neonates in terms of disease burden and clinical course of LOGNS. Epidemiologic studies aided by advanced molecular techniques may help to develop anti-sepsis protocols specialized for VLBW infants, with strategies targeting Gram-negative bacteria.
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Affiliation(s)
- Ying Dong
- a University Children's Hospital , University of Wuerzburg , Wuerzburg , Germany.,b Department of Neonatology , Children's Hospital of Fudan University , Shanghai , China
| | - Kirsten Glaser
- a University Children's Hospital , University of Wuerzburg , Wuerzburg , Germany
| | - Christian P Speer
- a University Children's Hospital , University of Wuerzburg , Wuerzburg , Germany
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Brown JVE, Meader N, Cleminson J, McGuire W. C-reactive protein for diagnosing late-onset infection in newborn infants. Cochrane Database Syst Rev 2019; 1:CD012126. [PMID: 30640979 PMCID: PMC6373636 DOI: 10.1002/14651858.cd012126.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Late-onset infection is the most common serious complication associated with hospital care for newborn infants. Because confirming the diagnosis by microbiological culture typically takes 24 to 48 hours, the serum level of the inflammatory marker C-reactive protein (CRP) measured as part of the initial investigation is used as an adjunctive rapid test to guide management in infants with suspected late-onset infection. OBJECTIVES To determine the diagnostic accuracy of serum CRP measurement in detecting late-onset infection in newborn infants. SEARCH METHODS We searched electronic databases (MEDLINE, Embase, and Science Citation Index to September 2017), conference proceedings, previous reviews, and the reference lists of retrieved articles. SELECTION CRITERIA We included cohort and cross-sectional studies evaluating the diagnostic accuracy of serum CRP levels for the detection of late-onset infection (occurring more than 72 hours after birth) in newborn infants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility for inclusion, evaluated the methodological quality of included studies, and extracted data to estimate diagnostic accuracy using hierarchical summary receiver operating characteristic (SROC) models. We assessed heterogeneity by examining variability of study estimates and overlap of the 95% confidence interval (CI) in forest plots of sensitivity and specificity. MAIN RESULTS The search identified 20 studies (1615 infants). Most were small, single-centre, prospective cohort studies conducted in neonatal units in high- or middle-income countries since the late 1990s. Risk of bias in the included studies was generally low with independent assessment of index and reference tests. Most studies used a prespecified serum CRP threshold level as the definition of a 'positive' index test (typical cut-off level between 5 mg/L and 10 mg/L) and the culture of a pathogenic micro-organism from blood as the reference standard.At median specificity (0.74), sensitivity was 0.62 (95% CI 0.50 to 0.73). Heterogeneity was evident in the forest plots but it was not possible to conduct subgroup or meta-regression analyses by gestational ages, types of infection, or types of infecting micro-organism. Covariates for whether studies used a predefined threshold or not, and whether studies used a standard threshold of between 5 mg/L and 10 mg/L, were not statistically significant. AUTHORS' CONCLUSIONS The serum CRP level at initial evaluation of an infant with suspected late-onset infection is unlikely to be considered sufficiently accurate to aid early diagnosis or select infants to undergo further investigation or treatment with antimicrobial therapy or other interventions.
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Affiliation(s)
| | - Nicholas Meader
- University of YorkCentre for Reviews and DisseminationYorkUK
| | - Jemma Cleminson
- University of YorkCentre for Reviews and DisseminationYorkUK
| | - William McGuire
- University of YorkCentre for Reviews and DisseminationYorkUK
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Abstract
BACKGROUND The main aim is to determine the incidence and associated factors of late onset sepsis (LOS) in very low birth weight infants (500-1500 g), from the NEOCOSUR Network during years 2001-2013. Secondary objectives are to describe the microbiology of the first and second episode of LOS and to study the association between catheter dwell time and LOS. METHODS Demographic information and outcome data are prospectively and routinely collected across the network using predefined diagnostic criteria and online data entry. LOS was confirmed by isolation of the organism in blood or through cerebrospinal fluid in cultures. The participating countries were Argentina, Brazil, Chile, Paraguay, Peru and Uruguay. RESULTS Overall incidence was 22.2% (3066/13,821). Infants who developed LOS were smaller by weight and gestational age; also, they feature less prenatal care and prenatal steroids, and longer hospital stays. A greater number of infants in the LOS group had 1 minute Apgar Scores ≤3. Multivariate logistic regression analysis showed a positive association between LOS and necrotizing enterocolitis, mechanical ventilation requirements, patent ductus arteriosus, oxygen dependency at 36 weeks and death. The majority of first LOS episode was caused by coagulase-negative staphylococci (44.3%). An increased risk of LOS was observed in relation to catheter dwell time (6% per day of stay of central lines). CONCLUSIONS The incidence of LOS was associated with mechanical ventilation, patent ductus arteriosus, necrotizing enterocolitis and death. LOS was an important cause of morbidity and mortality in very low birth weight infants in our network, and coagulase-negative staphylococci was the most frequent causative microorganism.
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Gordon A, Greenhalgh M, McGuire W. Early planned removal versus expectant management of peripherally inserted central catheters to prevent infection in newborn infants. Cochrane Database Syst Rev 2018; 6:CD012141. [PMID: 29940073 PMCID: PMC6513452 DOI: 10.1002/14651858.cd012141.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Duration of use may be a modifiable risk factor for central venous catheter-associated bloodstream infection in newborn infants. Early planned removal of peripherally inserted central catheters (PICCs) is recommended as a strategy to reduce the incidence of infection and its associated morbidity and mortality. OBJECTIVES To determine the effectiveness of early planned removal of PICCs (up to two weeks after insertion) compared to an expectant approach or a longer fixed duration in preventing bloodstream infection and other complications in newborn infants. SEARCH METHODS We searched of the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), Ovid MEDLINE, Embase, Maternity & Infant Care Database, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (until April 2018), and conference proceedings and previous reviews. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that assessed the effect of early planned removal of umbilical venous catheters (up to two weeks after insertion) compared to an expectant management approach or a longer fixed duration in preventing bloodstream infection and other complications in newborn infants. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility independently. We planned to analyse any treatment effects in the individual trials and report the risk ratio and risk difference for dichotomous data and mean difference for continuous data, with respective 95% confidence intervals. We planned to use a fixed-effect model in meta-analyses and explore potential causes of heterogeneity in sensitivity analyses. We planned to assess the quality of evidence for the main comparison at the outcome level using "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) methods. MAIN RESULTS We did not identify any eligible randomised controlled trials. AUTHORS' CONCLUSIONS There are no trial data to guide practice regarding early planned removal versus expectant management of PICCs in newborn infants. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical dilemma.
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Affiliation(s)
- Adrienne Gordon
- Royal Prince Alfred HospitalNeonatologyMissenden RoadCamperdownSydneyNSWAustralia2050
| | - Mark Greenhalgh
- RPA Women and Babies, Royal Prince Alfred HospitalRPA Newborn CareSydneyNSWAustralia2050
| | - William McGuire
- Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Kent A, Kortsalioudaki C, Monahan IM, Bielicki J, Planche TD, Heath PT, Sharland M. Neonatal gram-negative infections, antibiotic susceptibility and clinical outcome: an observational study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F507-F512. [PMID: 26951742 DOI: 10.1136/archdischild-2015-309554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Neonatal gram-negative (GN) infections are associated with high mortality and morbidity. Early appropriate antibiotic treatment is vital and gentamicin is the most frequently used antibiotic on neonatal units (NNUs). Antimicrobial breakpoints are predominantly based on adult data and the relationship between minimum inhibitory concentrations (MICs) and outcome in neonates is unclear. We aimed to determine the MIC of GN pathogens causing neonatal infections and relate this to clinical outcomes. METHODS MICs for eight antibiotics plus extended spectrum β-lactamase (ESBL) production were determined for invasive GN bacterial isolates from eight UK NNUs. European Committee on Antimicrobial Susceptibility Testing breakpoints were applied. MIC was correlated with clinical outcome using multivariable regression analysis. RESULTS 118 isolates from 116 patients were analysed. The median birth gestation and postnatal age was 27 weeks (IQR 24.6-32.3) and 20 days (IQR 5-44), respectively. Pathogens included Escherichia coli (51%), Klebsiella spp (23%) and Enterobacter spp (22%). 10-day attributable mortality was 18.1% (21 patients) with the highest mortality from Pseudomonas aeruginosa infections. ESBL producers accounted for 13.8% of the isolates. In regression analysis, increasing gentamicin MIC was associated with increased mortality in gentamicin treated patients across the full MIC range (OR per loge increase in MIC: 2.29; 95% CI 1.23 to 4.26, p=0.009), including susceptible isolates only (MIC ≤4) (OR 3.05; 95% CI 1.10 to 8.46, p=0.032). CONCLUSIONS Neonatal mortality from GN infections remains high and is associated with increasing gentamicin MIC, even for isolates deemed susceptible. A better understanding of population-specific MICs and aminoglycoside dosing is required to guide empiric antibiotic treatment.
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Affiliation(s)
- Alison Kent
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
| | | | - Irene M Monahan
- Institute of Infection and Immunity, St George's, University of London, London, UK
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
| | - Timothy D Planche
- Institute of Infection and Immunity, St George's, University of London, London, UK.,Department of Medical Microbiology, St George's Healthcare NHS Trust, London, UK
| | - Paul T Heath
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
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12
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Gordon A, Greenhalgh M, McGuire W. Early planned removal versus expectant management of peripherally inserted central catheters to prevent infection in newborn infants. Hippokratia 2016. [DOI: 10.1002/14651858.cd012141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Adrienne Gordon
- Royal Prince Alfred Hospital; Neonatology; Missenden Road Camperdown Sydney NSW Australia 2050
| | - Mark Greenhalgh
- RPA Women and Babies, Royal Prince Alfred Hospital; RPA Newborn Care; Sydney NSW Australia 2050
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of York; York Y010 5DD UK
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Vasudevan C, Oddie SJ, McGuire W. Early removal versus expectant management of central venous catheters in neonates with bloodstream infection. Cochrane Database Syst Rev 2016; 4:CD008436. [PMID: 27095103 PMCID: PMC7173748 DOI: 10.1002/14651858.cd008436.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uncertainty exists regarding the management of newborn infants with a bloodstream infection and a central venous catheter in place. The central venous catheter may act as a nidus for infecting organisms and observational studies have suggested that early removal of the catheter is associated with a lower incidence of persistent or complicated infection. However, since central venous catheters provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management also need to be considered. OBJECTIVES To determine the effect of early removal versus expectant management of central venous catheters on morbidity and mortality in newborn infants with bloodstream infections. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE (1966 to October 2015), EMBASE (1980 to October 2015), CINAHL (1982 to October 2015), conference proceedings and previous reviews. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of central venous catheters in neonates with bloodstream infections. DATA COLLECTION AND ANALYSIS We used the standard methods of the Cochrane Neonatal Review Group. MAIN RESULTS We did not identify any eligible randomised controlled trials. AUTHORS' CONCLUSIONS There are no trial data to guide practice regarding early removal versus expectant management of central venous catheters in newborn infants with bloodstream infections. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.
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Affiliation(s)
| | - Sam J Oddie
- Bradford Royal InfirmaryDuckworth LaneBradfordUKBD9 6RJ
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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14
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Reichert F, Piening B, Geffers C, Gastmeier P, Bührer C, Schwab F. Pathogen-Specific Clustering of Nosocomial Blood Stream Infections in Very Preterm Infants. Pediatrics 2016; 137:peds.2015-2860. [PMID: 26956103 DOI: 10.1542/peds.2015-2860] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nosocomial infections in NICUs tend to cluster, sometimes as devastating outbreaks, but pathogen-specific transmission probabilities are unknown. We aimed to quantify the pathogen-specific risk of a blood stream infection (BSI) in preterm infants after an index case with that pathogen in the same department. METHODS Data of 44 818 infants below 1500 g birth weight of the German NICU surveillance system (2000-2011) were used to calculate the probability of a BSI in the presence or absence of another infant in the same unit with a same-pathogen BSI. RESULTS The relative risk was similar for the more common pathogens, Enterococcus spp (4.3; 95% confidence interval: 2.7-6.9; n = 243), Enterobacter spp (7.9, 5.4-11.4; n = 246), Escherichia coli (7.9; 5.1-12.1; n = 210), Candida albicans (8.7; 5.0-15.4; n = 138), Staphylococcus aureus (9.5; 7.6-12.1; n = 407) and Klebsiella spp (13.1; 9.0-19.1; n = 190) but markedly elevated for Serratia spp (77.5; 41.1-146.1; n = 58) and Pseudomonas aeruginosa (64.5; 25.7-162.1; n = 38). Rates of BSI per 100 exposed infants ranged between 2.21 (Enterococcus) and 8.15 (Serratia). The same pattern emerged after adjustments were made for patients' characteristics or when the analysis was restricted to positive blood cultures during the preceding 30 days. CONCLUSIONS Although BSIs with P aeruginosa or Serratia spp in preterm infants are rare, they are associated with a markedly elevated risk of secondary same-pathogen BSI and should prompt intensified active surveillance and infection control measures.
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Affiliation(s)
| | - Brar Piening
- Institute for Hygiene and Environmental Medicine, Charité University Medical Center, Berlin, Germany
| | - Christine Geffers
- Institute for Hygiene and Environmental Medicine, Charité University Medical Center, Berlin, Germany
| | - Petra Gastmeier
- Institute for Hygiene and Environmental Medicine, Charité University Medical Center, Berlin, Germany
| | | | - Frank Schwab
- Institute for Hygiene and Environmental Medicine, Charité University Medical Center, Berlin, Germany
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15
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Brown JVE, Meader N, Cleminson J, McGuire W. C-reactive protein for diagnosing late-onset infection in newborn infants. Hippokratia 2016. [DOI: 10.1002/14651858.cd012126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Nicholas Meader
- University of York; Centre for Reviews and Dissemination; York UK
| | - Jemma Cleminson
- University of York; Centre for Reviews and Dissemination; York UK
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of York; York Y010 5DD UK
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16
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Tsai MH, Wu IH, Lee CW, Chu SM, Lien R, Huang HR, Chiang MC, Fu RH, Hsu JF, Huang YC. Neonatal gram-negative bacillary late-onset sepsis: A case-control-control study on a prospectively collected database of 5,233 admissions. Am J Infect Control 2016; 44:146-53. [PMID: 26559734 DOI: 10.1016/j.ajic.2015.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/08/2015] [Accepted: 09/08/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gram-negative bacillary (GNB) bloodstream infections account for 20%-30% of neonatal late-onset sepsis (LOS). We aimed to identify the incidence, clinical characteristics, and risk factors for adverse outcomes in neonates with GNB LOS. METHODS All patients with GNB LOS admitted to the neonatal intensive care units (NICUs) of a university-affiliated teaching hospital in Taiwan from January 1, 2004-December 31, 2011, were enrolled. A case-control-control study was performed to evaluate risk factors for acquisition of neonatal GNB LOS. RESULTS Of the 5,010 neonates, 290 (5.8%) had a total of 346 episodes of GNB LOS (36.7% of total LOS), with an incidence rate of 13.6 per 10,000 neonate hospital days. The overall mortality rate was 17.6% (51/290), and the sepsis attributable mortality rate was 9.8% (34/346 episodes). After multivariate logistic regression analysis, neonates with prolonged use of total parenteral nutrition (adjusted odds ratio [OR] = 1.53; 95% confidence interval [CI], 1.02-2.29; P = .041) were independently associated with acquisition of GNB LOS. The independent predictors of in-hospital mortality were Pseudomonas aeruginosa etiology (OR = 11.45; 95% CI, 2.83-46.24) and underlying secondary pulmonary hypertension (OR = 18.02; 95% CI, 3.28-98.89), renal disease (OR = 17.16; 95% CI, 2.96-99.38), and neuromuscular comorbidities (OR = 2.72; 95% CI, 1.06-7.00). CONCLUSION Given the higher illness severity and sepsis-attributable mortality rate of neonatal GNB LOS in the NICU, strategies to reduce the incidence need to be addressed urgently.
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Abstract
BACKGROUND Breakdown of the developmentally immature epidermal barrier may permit entry for micro-organisms leading to invasive infection in preterm infants. Topical emollients may improve skin integrity and barrier function and thereby prevent invasive infection, a major cause of mortality and morbidity in preterm infants. OBJECTIVES To assess the effect of topical application of emollients (ointments, creams, or oils) on the incidence of invasive infection, other morbidity, and mortality in preterm infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), MEDLINE via PubMed (1966 to August 2015), EMBASE (1980 to August 2015), and CINAHL (1982 to August 2015). We also searched clinical trials databases, conference proceedings, previous reviews and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that assessed the effect of prophylactic application of topical emollient (ointments, creams, or oils) on the incidence of invasive infection, mortality, other morbidity, and growth and development in preterm infants. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference for continuous data, with respective 95% confidence intervals. We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in subgroup analyses. MAIN RESULTS We identified 18 eligible primary publications (21 trial reports). A total of 3089 infants participated in the trials. The risk of bias varied with lack of clarity on methods to conceal allocation in half of the trials and lack of blinding of caregivers or investigators in all of the trials being the main potential sources of bias.Eight trials (2086 infants) examined the effect of topical ointments or creams. Most participants were very preterm infants cared for in health-care facilities in high-income countries. Meta-analyses did not show evidence of a difference in the incidence of invasive infection (typical risk ratio (RR) 1.13, 95% confidence interval (CI) 0.97 to 1.31; low quality evidence) or mortality (typical RR 0.87, 95% CI 0.75 to 1.03; low quality evidence).Eleven trials (1184 infants) assessed the effect of plant or vegetable oils. Nine of these trials were undertaken in low- or middle-income countries and all were based in health-care facilities rather than home or community settings. Meta-analyses did not show evidence of a difference in the incidence of invasive infection (typical RR 0.71, 95% CI 0.51 to 1.01; low quality evidence) or mortality (typical RR 0.94, 95% CI 0.81 to 1.08; moderate quality evidence). Infants massaged with vegetable oil had a higher rate of weight gain (about 2.55 g/kg/day; 95% CI 1.76 to 3.34), linear growth (about 1.22 mm/week; 95% CI 1.01 to 1.44), and head growth (about 0.45 mm/week; 95% CI 0.19 to 0.70). These meta-analyses contained substantial heterogeneity. AUTHORS' CONCLUSIONS The available data do not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high-, middle- or low-income settings. Some evidence of an effect of topical vegetable oils on neonatal growth exists but this should be interpreted with caution because lack of blinding may have introduced caregiver or assessment biases. Since these interventions are low cost, readily accessible, and generally acceptable, further randomised controlled trials, particularly in both community- and health care facility-based settings in low-income countries, may be justified.
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Affiliation(s)
- Jemma Cleminson
- University of YorkAcademic Clinical Fellow in Child Health NIHR Centre for Reviews & DisseminationYorkUK
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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18
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Balain M, Oddie SJ, McGuire W. Antimicrobial-impregnated central venous catheters for prevention of catheter-related bloodstream infection in newborn infants. Cochrane Database Syst Rev 2015; 2015:CD011078. [PMID: 26409791 PMCID: PMC9240922 DOI: 10.1002/14651858.cd011078.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Central venous catheter-related bloodstream infection is an important cause of mortality and morbidity in newborn infants cared for in neonatal units. Potential strategies to prevent these infections include the use of central venous catheters impregnated with antimicrobial agents. OBJECTIVES To determine the effect of antimicrobial-impregnated central venous catheters in preventing catheter-related bloodstream infection in newborn infants. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 8), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), conference proceedings and previous reviews. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing central venous catheters impregnated or coated with any antibiotic or antiseptic versus central venous catheters without antibiotic or antiseptic coating or impregnation in newborn infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Group, with independent evaluation of risk of bias and data extraction by two review authors. MAIN RESULTS We found only one small trial (N = 98). This trial found that silver zeolite-impregnated umbilical venous catheters reduced the incidence of bloodstream infection in very preterm infants (risk ratio 0.11, 95% confidence interval 0.01 to 0.87; risk difference -0.17, 95% CI -0.30 to -0.04; number needed to treat for benefit 6, 95% CI 3 to 25]. AUTHORS' CONCLUSIONS Although the data from one small trial indicates that antimicrobial-impregnated central venous catheters might prevent catheter-related bloodstream infection in newborn infants, the available evidence is insufficient to guide clinical practice. A large, simple and pragmatic randomised controlled trial is needed to resolve on-going uncertainty.
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Affiliation(s)
| | - Sam J Oddie
- Bradford Royal InfirmaryDuckworth LaneBradfordUKBD9 6RJ
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Whole Genome Sequencing in Real-Time Investigation and Management of a Pseudomonas aeruginosa Outbreak on a Neonatal Intensive Care Unit. Infect Control Hosp Epidemiol 2015; 36:1058-64. [PMID: 26050101 DOI: 10.1017/ice.2015.133] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To use whole genome sequencing to describe the likely origin of an outbreak of Pseudomonas aeruginosa in a neonatal unit. DESIGN Outbreak investigation. SETTING The neonatal intensive care unit service of a major obstetric tertiary referral center. PATIENTS Infants admitted to the neonatal unit who developed P. aeruginosa colonization or infection. METHODS We undertook whole genome sequencing of P. aeruginosa strains isolated from colonized infants and from the neonatal unit environment. RESULTS Eighteen infants were colonized with P. aeruginosa. Isolates from 12 infants and 7 environmental samples were sequenced. All but one of the clinical isolates clustered in ST253 and no differences were detected between unmapped reads. The environmental isolates revealed a variety of sequence types, indicating a large diverse bioburden within the unit, which was subsequently confirmed via enterobacterial repetitive intergenic consensus-polymerase chain reaction typing of post-outbreak isolates. One environmental isolate, obtained from a sink in the unit, clustered within ST253 and differed from the outbreak strain by 9 single-nucleotide polymorphisms only. This information allowed us to focus infection control activities on this sink. CONCLUSIONS Whole genome sequencing can provide detailed information in a clinically relevant time frame to aid management of outbreaks in critical patient management areas. The superior discriminatory power of this method makes it a powerful tool in infection control.
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Hsu JF, Chu SM, Huang YC, Lien R, Huang HR, Lee CW, Chiang MC, Fu RH, Tsai MH. Predictors of clinical and microbiological treatment failure in neonatal bloodstream infections. Clin Microbiol Infect 2015; 21:482.e9-17. [DOI: 10.1016/j.cmi.2015.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 10/24/2022]
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Incidence, clinical characteristics and attributable mortality of persistent bloodstream infection in the neonatal intensive care unit. PLoS One 2015; 10:e0124567. [PMID: 25875677 PMCID: PMC4398497 DOI: 10.1371/journal.pone.0124567] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 03/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An atypical pattern of neonatal sepsis, characterized by persistent positive blood culture despite effective antimicrobial therapy, has been correlated with adverse outcomes. However, previous studies focused only on coagulate-negative staphylococcus infection. METHODS All episodes of persistent bloodstream infection (BSI), defined as 3 or more consecutive positive blood cultures with the same bacterial species, at least two of them 48 hours apart, during a single sepsis episode, were enrolled over an 8-year period in a tertiary level neonatal intensive care unit. These cases were compared with all non-persistent BSI during the same period. RESULTS We identified 81 episodes of persistent BSI (8.5% of all neonatal late-onset sepsis) in 74 infants, caused by gram-positive pathogens (n=38, 46.9%), gram-negative pathogens (n=21, 25.9%), fungus (n=20, 24.7%) and polymicrobial bacteremia (n=2, 2.5%). Persistent BSI does not differ from non-persistent BSI in most clinical characteristics and patient demographics, but tends to have a prolonged septic course, longer duration of feeding intolerance and more frequent requirement of blood transfusions. No difference was observed for death attributable to infection (9.8% vs. 6.5%), but neonates with persistent BSI had significantly higher rates of infectious complications (29.6% vs. 9.2%, P < 0.001), death from all causes (21.6% vs. 11.7%, P = 0.025), and duration of hospitalization among survivors [median (interquartile range): 80.0 (52.5-117.5) vs. 64.0 (40.0-96.0) days, P = 0.005] than those without persistent BSI. CONCLUSIONS Although persistent BSI does not contribute directly to increased mortality, the associated morbidities, infectious complications and prolonged septic courses highlight the importance of aggressive treatment to optimize outcomes.
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22
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Pammi M, Weisman LE. Late-onset sepsis in preterm infants: update on strategies for therapy and prevention. Expert Rev Anti Infect Ther 2015; 13:487-504. [DOI: 10.1586/14787210.2015.1008450] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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de Souza Rugolo LMS, Bentlin MR, Mussi-Pinhata M, de Almeida MFB, Lopes JMDA, Marba STM, Fiori HH, Procianoy RS, Leone CR. Late-onset sepsis in very low birth weight infants: a Brazilian Neonatal Research Network Study. J Trop Pediatr 2014; 60:415-21. [PMID: 25063461 DOI: 10.1093/tropej/fmu038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Late-onset sepsis (LOS) is an important cause of morbidity and mortality in very low birth weight (VLBW) infants. AIM To determine the incidence, risk factors and etiology of LOS. METHODS LOS was investigated in a multicenter prospective cohort of infants at eight public university neonatal intensive care units (NICUs). Inclusion criteria included inborn, 23-33 weeks of gestational age, 400-1499 g birth weight, who survived >3 days. RESULTS Of 1507 infants, 357 (24%) had proven LOS and 345 (23%) had clinical LOS. Infants with LOS were more likely to die. The majority of infections (76%) were caused by Gram-positive organisms. Independent risk factors for proven LOS were use of central venous catheter and mechanical ventilation, age at the first feeding and number of days on parenteral nutrition and on mechanical ventilation. CONCLUSION LOS incidence and mortality are high in Brazilian VLBW infants. Most risk factors are associated with routine practices at NICU.
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Affiliation(s)
| | - Maria Regina Bentlin
- Department of Pediatrics, Botucatu School of Medicine, Sao Paulo State University-UNESP, Botucatu, SP, Brazil
| | | | | | | | | | - Humberto Holmer Fiori
- Department of Pediatrics, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Bakhuizen SE, de Haan TR, Teune MJ, van Wassenaer-Leemhuis AG, van der Heyden JL, van der Ham DP, Mol BWJ. Meta-analysis shows that infants who have suffered neonatal sepsis face an increased risk of mortality and severe complications. Acta Paediatr 2014; 103:1211-8. [PMID: 25073543 DOI: 10.1111/apa.12764] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/06/2014] [Accepted: 07/28/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Infants suffering from neonatal sepsis face an increased risk of early death and long-term neurodevelopmental delay. This paper analyses and summarises the existing data on short-term and long-term outcomes of neonatal sepsis, based on 12 studies published between January 2000 and 1 April 2012 and covering 3669 neonates with sepsis. CONCLUSION Infants who have suffered neonatal sepsis face an increased risk of mortality and severe complications such as brain damage and, or, neurodevelopmental delay.
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Affiliation(s)
- Sabine E. Bakhuizen
- Department of Obstetrics & Gynaecology; Academic Medical Centre; Amsterdam The Netherlands
| | - Timo R. de Haan
- Department of Neonatology; Emma Children's Hospital; Academic Medical Centre; Amsterdam The Netherlands
| | - Margreet J. Teune
- Department of Obstetrics & Gynaecology; Academic Medical Centre; Amsterdam The Netherlands
| | | | | | - David P. van der Ham
- Department of Obstetrics & Gynaecology; Martini Hospital Groningen; Groningen The Netherlands
| | - Ben Willem J. Mol
- School of Paediatrics and Reproductive Health; The Robinson Institute; University of Adelaide; Adelaide SA Australia
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Characterizing the burden of invasive Pseudomonas infection on neonatal units in the UK between 2005 and 2011. J Hosp Infect 2014; 88:109-12. [PMID: 25146224 DOI: 10.1016/j.jhin.2014.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 07/08/2014] [Indexed: 11/21/2022]
Abstract
Concern about Pseudomonas infection in neonatal units has focused on outbreaks. This study analysed cases of invasive Pseudomonas infection in 18 UK neonatal units participating in the NeonIN Neonatal Infection Surveillance Network from January 2005 to December 2011. Forty-two cases were reported. The majority (35/42, 93%) of cases were late-onset (median 14 days, range 2-262 days), the highest incidence was seen in extremely-low-birthweight infants and all cases were sporadic. One-third of cases were known to be colonized prior to invasive disease. Attributable mortality was 18%. Opportunities for preventing invasive disease due to this important pathogen should be prioritized.
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Tsai MH, Chu SM, Hsu JF, Lien R, Huang HR, Chiang MC, Fu RH, Lee CW, Huang YC. Risk factors and outcomes for multidrug-resistant Gram-negative bacteremia in the NICU. Pediatrics 2014; 133:e322-9. [PMID: 24420803 DOI: 10.1542/peds.2013-1248] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the risk factors antibiotic therapy and outcomes of multidrug-resistant (MDR) Gram-negative bacilli (GNB) bacteremia in NICU patients. METHODS Episodes of MDR GNB bacteremia were compared with a non-MDR GNB bacteremia group in an 8-year cohort study. RESULTS Of 1106 bacteremias, 393 (35.5%) were caused by GNB. Seventy (18.6%) were caused by an MDR strain. The most frequent mechanism of resistance was extended-spectrum β-lactamase production (67.1%), mainly by Klebsiella pneumoniae (59.6%). Previous antibiotic exposure to third-generation cephalosporin (odds ratio [OR]: 5.97; 95% confidence interval [CI]: 2.37-15.08; P < .001) and carbapenem (OR: 3.60; 95% CI: 1.26-10.29; P = .017) and underlying renal disease (OR: 7.08; 95% CI: 1.74-28.83; P = .006) were identified as independent risk factors for MDR GNB acquisition. Patients with MDR GNB bacteremia more likely received inadequate initial antibiotic therapy (72.9% vs 7.8%; P < .001) had higher rates of infectious complication (21.4% vs 10.5%; P = .011) and overall case fatality +rate (28.6% vs 10.5%; P < .001). Independent risk factors for overall mortality were presence of infectious complications after bacteremia (OR: 3.16; 95% CI: 1.41-7.08; P = .005) and underlying secondary pulmonary hypertension with or without cor pulmonale (OR: 6.19; 95% CI: 1.88-20.31; P = .003). CONCLUSIONS MDR GNB accounted for 18.6% of all neonatal GNB bacteremia in the NICU, especially in those with previous broad-spectrum antibiotic therapy and underlying renal disease. The most frequent mechanism of resistance was extended-spectrum β-lactamase (ESBL) production. Neonates with MDR GNB were more likely to develop infectious complications, which were independently associated with a higher overall case-fatality rate.
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Affiliation(s)
- Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan
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Tsai MH, Chu SM, Hsu JF, Lien R, Huang HR, Chiang MC, Fu RH, Lee CW, Huang YC. Polymicrobial bloodstream infection in neonates: microbiology, clinical characteristics, and risk factors. PLoS One 2014; 9:e83082. [PMID: 24454692 PMCID: PMC3891628 DOI: 10.1371/journal.pone.0083082] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 11/07/2013] [Indexed: 11/21/2022] Open
Abstract
Background Polymicrobial bloodstream infections (PBSIs) have been associated with complex underlying medical conditions and a high incidence of specific microorganisms in several settings, but the relevant data are scarce in neonates. Methods Positive blood cultures from January 2004 to December 2011 in the neonatal intensive care unit (NICU) of Chang Gung Memorial Hospital (CGMH) were reviewed. Each neonate with PBSI (case episode) was matched to two episodes of monomicrobial BSI (control episode) by birth weight, gestational age and gender. Records were reviewed to compare their underlying medical conditions, organisms isolated, adequacy of therapy, clinical characteristics and outcomes. Results Forty-five episodes of PBSI (4.4% of all neonatal BSIs) were identified in 43 neonates. Gram-negative organisms constituted 59.8% of all PBSI pathogens, and 33 (73.3%) of PBSIs were caused by at least one Gram-negative organism. PBSIs were significantly more likely to be the recurrent episode and have endotracheal tube in place. No significant difference was found between PBSIs and controls in terms of demographics and most chronic conditions. PBSIs were significantly associated with a higher severity of illness, a longer duration of septic symptoms, and a higher rate of modification of antimicrobial regimens than monomicrobial BSIs. However, the sepsis-attributable mortality rates were comparable between these two groups. Conclusions In the NICU, PBSIs were more often caused by Gram-negative bacilli, and often occurred in neonates without any chronic conditions. The clinical significance of PBSIs included a more severe illness, longer duration of septic symptoms and a higher rate of modification of antimicrobial regimens.
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Affiliation(s)
- Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Reyin Lien
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chiang-Wen Lee
- Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Yhu-Chering Huang
- Division of Pediatric Infectious Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail:
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Incidence, clinical characteristics and risk factors for adverse outcome in neonates with late-onset sepsis. Pediatr Infect Dis J 2014; 33:e7-e13. [PMID: 23899966 DOI: 10.1097/inf.0b013e3182a72ee0] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Late-onset sepsis (LOS) is a common complication in the neonatal intensive care unit. We aimed to describe the epidemiology, clinical characteristics and risk factors for adverse outcome in neonates with LOS. METHODS We conducted a cohort study of all neonates with LOS at the neonatal intensive care unit of a Tertiary Taiwan Medical Center from January 2004 through December 2011 and used multivariate logistic regression to identify risk factors for final adverse outcome. RESULTS Among 5010 neonates over 253,644 neonate-days, 713 (14.2%) experienced a total of 942 episodes of LOS (incidence rate, 3.71 episodes per 1000 neonate-days). Although the rates of LOS were inversely proportional to birth weight and gestational age, the incidence rates were comparable among extremely preterm, late preterm and full term neonates. Fungemia was found to have significantly higher rate of infectious complication (30.8%), persistent bloodstream infection (19.2%) and sepsis attributable mortality (23.1%). The overall mortality rate was 12.6% (90/713), and sepsis attributable mortality rate was 7.2% (68/942 episodes). Independent predictors of in-hospital mortality were Pseudomonas LOS (adjusted odds ratio [OR], 14.31; 95% confidence interval [CI]: 3.87-53.0), fungemia (OR, 5.69; 95% CI: 2.48-13.01), presence of congenital anomalies (OR, 4.12; 95% CI: 1.60-10.60), neuromuscular comorbidities (OR, 3.34; 95% CI: 1.66-6.73) and secondary pulmonary hypertension with/without cor pulmonale (OR, 23.48; 95% CI: 5.96-92.49). CONCLUSIONS LOS predisposes hospitalized neonates to increased risk of mortality or morbidity, especially caused by Pseudomonas aeruginosa or Candida spp. More aggressive treatment strategy is worth consideration in neonates with presumed LOS, particularly those with certain underlying chronic conditions.
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de Haan TR, Beckers L, de Jonge RCJ, Spanjaard L, van Toledo L, Pajkrt D, van Wassenaer-Leemhuis AG, van der Lee JH. Neonatal gram negative and Candida sepsis survival and neurodevelopmental outcome at the corrected age of 24 months. PLoS One 2013; 8:e59214. [PMID: 23527140 PMCID: PMC3601057 DOI: 10.1371/journal.pone.0059214] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 02/07/2013] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To evaluate the long term neurodevelopmental outcome of premature infants exposed to either gram- negative sepsis (GNS) or neonatal Candida sepsis (NCS), and to compare their outcome with premature infants without sepsis. METHODS Historical cohort study in a population of infants born at <30 weeks gestation and admitted to the Neonatal Intensive Care Unit (NICU) of the Academic Medical Center in Amsterdam during the period 1997-2007. Outcome of infants exposed to GNS or NCS and 120 randomly chosen uncomplicated controls (UC) from the same NICU were compared. Clinical data during hospitalization and neurodevelopmental outcome data (clinical neurological status; Bayley-test results and vision/hearing test results) at the corrected age of 24 months were collected. An association model with sepsis as the central determinant of either good or adverse outcome (death or severe developmental delay) was made, corrected for confounders using multiple logistic regression analysis. RESULTS Of 1362 patients, 55 suffered from GNS and 29 suffered from NCS; cumulative incidence 4.2% and 2.2%, respectively. During the follow-up period the mortality rate was 34% for both GNS and NCS and 5% for UC. The adjusted Odds Ratio (OR) [95% CI] for adverse outcome in the GNS group compared to the NCS group was 1.4 [0.4-4.9]. The adjusted ORs [95% CI] for adverse outcome in the GNS and NCS groups compared to the UC group were 4.8 [1.5-15.9] and 3.2 [0.7-14.7], respectively. CONCLUSIONS We found no statistically significant difference in outcome at the corrected age of 24 months between neonatal GNS and NCS cases. Suffering from either gram-negative or Candida sepsis increased the odds for adverse outcome compared with an uncomplicated neonatal period.
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Affiliation(s)
- Timo R de Haan
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center Amsterdam, The Netherlands.
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Chiang PJ, Hsu JF, Tsai MH, Lien R, Chiang MC, Huang HR, Chiang CC, Liang HF, Chu SM. The impact of patent ductus arteriosus in neonates with late onset sepsis: a retrospective matched-case control study. Pediatr Neonatol 2012; 53:309-14. [PMID: 23084724 DOI: 10.1016/j.pedneo.2012.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 01/31/2012] [Accepted: 05/21/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Late-onset sepsis (LOS) in neonates with patent ductus arteriosus (PDA) may predispose them to more complicated hospital courses. The objective of this study was to determine the incidence, the distribution of pathogens, and the clinical features of LOS in neonates with PDA and analyze their outcomes. METHODS The medical records were reviewed retrospectively of infants with PDA and LOS who were hospitalized in NICUs of Chang Gung Children's Hospital between January 2003 and December 2009. The clinical features of these infants were compared with a group of gestational age and birth body weight-matched neonates with LOS during the same period. RESULTS During this period, 224 neonates were found to have at least one event of blood-culture proven LOS and 79 (35.3%) were documented to have PDA. Although most LOS episodes (85/104, 81.7%) in neonates with PDA occurred after closure of PDA, neonates with PDA had a significantly higher rate of bronchopulmonary dysplasia (81.0% vs. 61.0%, p = 0.002) and a relatively higher rate of recurrent sepsis (25.3% vs. 15.2%, p = 0.079) than those without PDA. Longer durations of ventilator support and hospital stay were also noted in neonates with PDA as compared to those without (p = 0.001 and 0.005, respectively). CONCLUSION In neonates with LOS, the presence of PDA, even though it is aggressively treated with indomethacin or surgical intervention, may still contribute to the complexity of hospitalization. Close monitoring and aggressive treatments are warranted in these neonates with PDA.
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Affiliation(s)
- Pei-Jung Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi, Taiwan
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Hammoud MS, Al-Taiar A, Thalib L, Al-Sweih N, Pathan S, Isaacs D. Incidence, aetiology and resistance of late-onset neonatal sepsis: a five-year prospective study. J Paediatr Child Health 2012; 48:604-9. [PMID: 22404730 DOI: 10.1111/j.1440-1754.2012.02432.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Investigate the incidence, etiological pattern and the antimicrobial resistance of late-onset neonatal infections over a period of 5 years. METHODS Longitudinal audit of neonatal sepsis from January 2005 to December 2009, in the main maternity hospital in Kuwait. Late-onset neonatal infection was defined as the culture of a single potentially pathogenic organism from blood or cerebrospinal fluid from an infant older than 6 days in association with clinical or laboratory findings consistent with infection. RESULTS The overall incidence was 16.9 (95% confidence interval: 15.8-18.0) episodes per 1000 live births. The commonest pathogen was coagulase-negative Staphylococcus, 339 (35.7%), while Klebsiella was the most common gram-negative infection, 178 (18.8%). Escherichia coli, Enterococcus and Enterobacter spp were each responsible for 6% of all infections. Candida caused 104 (11.0%) infections. The general pattern of infection remained unchanged over the study period. Case fatality was 11.7% (95% confidence interval: 9.7-13.9%) and was high for Pseudomonas (18.4%) and Candida (22.1%) infections. Approximately 24 and 20% of Klebsiella infections were resistant to cefotaxime and gentamicin, respectively, while 28 and 24% of Escherichia coli infections were resistant to cefotaxime and gentamicin, respectively. CONCLUSION The incidence of late-onset infection in Kuwait is high, resembling that in resource-poor countries. The high incidence coupled with low case fatality provides an example for settings where tertiary care is introduced without strict measures against nosocomial infections. Prevention against nosocomial infections in neonatal units has the potential to further reduce neonatal mortality in these settings.
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Affiliation(s)
- Majeda S Hammoud
- Department of Pediatrics Community Medicine, Kuwait University, Kuwait, Kuwait.
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Aneja RK, Varughese-Aneja R, Vetterly CG, Carcillo JA. Antibiotic therapy in neonatal and pediatric septic shock. Curr Infect Dis Rep 2011; 13:433-41. [PMID: 21732046 DOI: 10.1007/s11908-011-0197-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Severe sepsis accounts for nearly 4,500 deaths (mortality rate 10%), and is responsible for nearly $2 billion annual healthcare expenditure in the United States. Early and speedy treatment of critically ill septic patients can halt or reduce the likelihood of physiologic progression to multi-system organ failure. A cornerstone of this therapeutic strategy is antibiotic administration. In this review, we discuss the empirical treatment strategies for the treatment of early and late neonatal sepsis, along with pediatric sepsis. Furthermore, we discuss the rationale that underlies the adoption of such treatment strategies. The present article also discusses the emergence of multi-drug organisms as the causative agents for sepsis, i.e. methicillin-resistant Staphylococcus aureus (MRSA), resistant enterococci and Klebsiella pneumoniae carbapenemases (KPC).
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Affiliation(s)
- Rajesh K Aneja
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 15224, USA,
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Vasudevan C, McGuire W. Early removal versus expectant management of central venous catheters in neonates with bloodstream infection. Cochrane Database Syst Rev 2011:CD008436. [PMID: 21833966 DOI: 10.1002/14651858.cd008436.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Uncertainty exists regarding the management of central venous catheters (CVCs) in neonates with bloodstream infections. Early CVC removal may reduce the risk of persistent or complicated infection and its associated morbidity and mortality. However, since CVCs provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management need to be considered. OBJECTIVES To determine the effect of early removal versus expectant management of CVCs on morbidity and mortality in neonates with bloodstream infections.. SEARCH STRATEGY We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials ((CENTRAL), The Cochrane Library, 2011, Issue 1), MEDLINE (1966 to January 2011), EMBASE (1980 to January 2011), CINAHL (1982 to January 2011), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of CVCs in neonates with bloodstream infections. DATA COLLECTION AND ANALYSIS We used the standard methods of the Cochrane Neonatal Review Group. MAIN RESULTS We did not identify any eligible randomised controlled trials. AUTHORS' CONCLUSIONS There are no trial data to guide practice regarding early removal versus expectant management of CVCs in neonates with bloodstream infections. While observational data generally indicate that early removal is associated with a lower incidence of persistent or complicated infection, caution should be exercised in applying these findings to practice because of inherent biases in the study design. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.
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Yapicioglu H, Ozcan K, Sertdemir Y, Mutlu B, Satar M, Narli N, Tasova Y. Healthcare-associated infections in a neonatal intensive care unit in Turkey in 2008: incidence and risk factors, a prospective study. J Trop Pediatr 2011; 57:157-64. [PMID: 20601690 DOI: 10.1093/tropej/fmq060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this study, we have prospectively recorded healthcare-associated infections (HAIs) in NICU and found incidence density as 18 infections per 1000 patient days. Of the infections, 51.3% was bacteriemia (BSI), and 45.1% was ventilator-associated pneumonia (VAP). Gram-negative microorganisms were predominant in VAP and Staphylococcus epidermidis was the leading microorganism (53.0% of BSIs) in BSIs. Multivariate logistic regression analysis showed the importance of hood O(2) use in days (RR: 1.3) and total parenteral nutrition use in days (RR: 1.09) for BSIs. Umbilical arterial catheterization in days (RR: 1.94), ventilator use in days (RR: 1.05), chest tube (RR: 12.55), orogastric feeding (RR: 3.32) and total parenteral nutrition in days (RR: 1.05) were found to be significantly associated with VAP. In conclusion, incidence density in our unit is high and Gram-negative rods are predominant similar to developing countries. These results strongly suggest improving measures of prevention and control of HAIs in the unit.
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Affiliation(s)
- Hacer Yapicioglu
- Cukurova University Medical Faculty, Department of Pediatrics, Division of Neonatology, Adana, Turkey.
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Deshpande G, Rao S, Patole S, Bulsara M. Updated meta-analysis of probiotics for preventing necrotizing enterocolitis in preterm neonates. Pediatrics 2010; 125:921-30. [PMID: 20403939 DOI: 10.1542/peds.2009-1301] [Citation(s) in RCA: 328] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Systematic reviews of randomized, controlled trials (RCTs) indicate lower mortality and necrotizing enterocolitis (NEC) and shorter time to full feeds after probiotic supplementation in preterm (<34 weeks' gestation) very low birth weight (VLBW; birth weight <1500 g) neonates. The objective of this study was to update our 2007 systematic review of RCTs of probiotic supplementation for preventing NEC in preterm VLBW neonates. METHODS We searched in March 2009 the Cochrane Central register; Medline, Embase, and Cinahl databases; and proceedings of the Pediatric Academic Society meetings and gastroenterology conferences. Cochrane Neonatal Review Group search strategy was followed. Selection criteria were RCTs of any enteral probiotic supplementation that started within first 10 days and continued for > or =7 days in preterm VLBW neonates and reported on stage 2 NEC or higher (Modified Bell Staging). RESULTS A total of 11 (N = 2176), including 4 new (n = 783), trials were eligible for inclusion in the meta-analysis by using a fixed-effects model. The risk for NEC and death was significantly lower. Risk for sepsis did not differ significantly. No significant adverse effects were reported. Trial sequential analysis) showed 30% reduction in the incidence of NEC (alpha = .05 and .01; power: 80%). CONCLUSIONS The results confirm the significant benefits of probiotic supplements in reducing death and disease in preterm neonates. The dramatic effect sizes, tight confidence intervals, extremely low P values, and overall evidence indicate that additional placebo-controlled trials are unnecessary if a suitable probiotic product is available.
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Affiliation(s)
- Girish Deshpande
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
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Sepsis-Related Mortality of Very Low Birth Weight Brazilian Infants: The Role of Pseudomonas aeruginosa. Int J Pediatr 2010; 2009:427682. [PMID: 20182631 PMCID: PMC2825662 DOI: 10.1155/2009/427682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Revised: 09/29/2009] [Accepted: 12/23/2009] [Indexed: 11/17/2022] Open
Abstract
The aim of this study is to identify risk factors for sepsis-related mortality in low birth weight (<1500 g) infants. We performed retrospective cohort study to investigate risk factors for sepsis-related mortality in all neonates birth weight <1500 g admitted to Level III neonatal intensive care unit, Brazil, April 2001/September 2004. Of the 203 cases, 71 (35%) had sepsis. Of those, gram-positive was identified in 52/87 blood cultures (59.8%), the most common Coagulase-negative Staphylococcus (31/87; 35.5%). Gram-negative was present in 29 of the 87 positive blood cultures (33.3%), with Pseudomonas aeruginosa (8/87; 9.1%), the most frequent agent. Overall 21 of 71 infants with sepsis (29.6%) died. Risk factors for sepsis-related mortality were gestational age </=28 weeks, birth weight </=1000 g (9.6 times more often than birth weight >1000 g), five-minute Apgar </=7, gram-negative sepsis, mechanical ventilation (6.7 times higher than no use), and intravascular catheter. Sepsis-related mortality was due, mainly, to Pseudomonas aeruginosa; birth weight </=1000 g and mechanical ventilation were strong sepsis-related mortality predictors.
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Hussein MH, Daoud GA, Kakita H, Kato S, Goto T, Kamei M, Goto K, Ozaki Y, Ito T, Fukuda S, Kato I, Suzuki S, Hashimoto T, Togari H. Effect of polymyxin B-immobilized fiber hemoperfusion on respiratory impairment, hepatocellular dysfunction, and leucopenia in a neonatal sepsis model. Pediatr Surg Int 2010; 26:187-93. [PMID: 19802625 DOI: 10.1007/s00383-009-2476-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Sepsis and septic shock remain a major source of morbidity and mortality in neonates despite advances in antimicrobials and aggressive supportive care. Our aim was to study the effects of polymyxin-B direct hemoperfusion (PMX-DHP) therapy on sepsis-induced respiratory impairment, liver dysfunction and leucopenia in a neonatal cecal ligation and perforation (CLP) model. METHODS Fourteen anesthetized and mechanically ventilated 3-day-old piglets underwent CLP and an arteriovenous extracorporeal circuit from 3 h until 6 h post-CLP, with a PMX column in the PMX-DHP treated group (7 piglets). Changes in oxygen saturation, PCO(2), base excess, white blood cell (WBC) count, platelet count, hematocrit (Hct%), serum glutamate pyruvate transaminase (SGPT), and serum glutamic oxaloacetic transaminase were measured before CLP and at 1, 3 and 6 h after. RESULTS At 6 h, the PMX-DHP group showed lower Hct%, and SGPT in comparison to the control group, but higher oxygen saturation and WBC count. No effects on the platelet count were found. The survival times of the PMX-DHP group were longer than in control. CONCLUSION PMX-DHP therapy limited the respiratory impairment, liver dysfunction and leucopenia in a neonatal septic model, which resulted in an improvement of survival time.
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Affiliation(s)
- Mohamed Hamed Hussein
- Department of Pediatrics Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
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Abstract
BACKGROUND Preterm birth is increasing worldwide, and late preterm births, which comprise more than 70% of all preterm births, account for much of the increase. Early and late onset sepsis results in significant mortality in extremely preterm infants, but little is known about sepsis outcomes in late preterm infants. METHODS This is an observational cohort study of infants <121 days of age (119,130 infants less than or equal to 3 days of life and 106,142 infants between 4 and 120 days of life) with estimated gestational age at birth between 34 and 36 weeks, admitted to 248 neonatal intensive care units in the United States between 1996 and 2007. RESULTS During the study period, the cumulative incidence of early and late onset sepsis was 4.42 and 6.30 episodes per 1000 admissions, respectively. Gram-positive organisms caused the majority of early and late onset sepsis episodes. Infants with early onset sepsis caused by Gram-negative rods and infants with late onset sepsis were more likely to die than their peers with sterile blood cultures (odds ratio [OR]: 4.39, 95% CI: 1.71-11.23, P = 0.002; and OR: 3.37, 95% CI: 2.35-4.84, P < 0.001, respectively). CONCLUSION Late preterm infants demonstrate specific infection rates, pathogen distribution, and mortality associated with early and late onset sepsis. The results of this study are generalizable to late preterm infants admitted to the special care nursery or neonatal intensive care unit.
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Crivaro V, Di Popolo A, Caprio A, Lambiase A, Di Resta M, Borriello T, Scarcella A, Triassi M, Zarrilli R. Pseudomonas aeruginosa in a neonatal intensive care unit: molecular epidemiology and infection control measures. BMC Infect Dis 2009; 9:70. [PMID: 19463153 PMCID: PMC2692859 DOI: 10.1186/1471-2334-9-70] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 05/22/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pseudomonas aeruginosa, a non-fermentative, gram-negative rod, is responsible for a wide variety of clinical syndromes in NICU patients, including sepsis, pneumonia, meningitis, diarrhea, conjunctivitis and skin infections. An increased number of infections and colonisations by P. aeruginosa has been observed in the neonatal intensive care unit (NICU) of our university hospital between 2005 and 2007. METHODS Hand disinfection compliance before and after an educational programme on hand hygiene was evaluated. Identification of microrganisms was performed using conventional methods. Antibiotic susceptibility was evaluated by MIC microdilution. Genotyping was performed by PFGE analysis. RESULTS The molecular epidemiology of Pseudomonas aeruginosa in the NICU of the Federico II University hospital (Naples, Italy) and the infection control measures adopted to stop the spreading of P. aeruginosa in the ward were described. From July 2005 to June 2007, P. aeruginosa was isolated from 135 neonates and caused severe infections in 11 of them. Macrorestriction analysis of clinical isolates from 90 neonates identified 20 distinct genotypes, one major PFGE type (A) being isolated from 48 patients and responsible for 4 infections in 4 of them, four other distinct recurrent genotypes being isolated in 6 to 4 patients. Seven environmental strains were isolated from the hand of a nurse and from three sinks on two occasions, two of these showing PFGE profiles A and G identical to two clinical isolates responsible for infection. The successful control of the outbreak was achieved through implementation of active surveillance of healthcare-associated infections in the ward together with environmental microbiological sampling and an intense educational programme on hand disinfection among the staff members. CONCLUSION P. aeruginosa infections in the NICU were caused by the cross-transmission of an epidemic clone in 4 neonates, and by the selection of sporadic clones in 7 others. An infection control programme that included active surveillance and strict adherence to hand disinfection policies was effective in controlling NICU-acquired infections and colonisations caused by P. aeruginosa.
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Affiliation(s)
- Valeria Crivaro
- Dipartimento di Scienze Mediche Preventive, Sezione di Igiene, Università Federico II, Napoli, Italy.
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Pneumococcal conjugate vaccines probe studies: the solution points to the problem. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2009; 634:69-77. [PMID: 19280850 DOI: 10.1007/978-0-387-79838-7_7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Risk-adjusted surveillance of hospital-acquired infections in neonatal intensive care units: a systematic review. J Hosp Infect 2009; 70:203-11. [PMID: 18723243 DOI: 10.1016/j.jhin.2008.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 06/20/2008] [Indexed: 11/22/2022]
Abstract
Comparisons of bacteraemia incidence between neonatal intensive care units (NICUs) can identify centres with effective infection control, whose practices can be shared with other units. For fair comparisons, infection incidence must be risk-adjusted to control for differences between centres in the vulnerability of babies and the intensity of invasive procedures which can introduce infection. We reviewed risk adjustment methods for between-NICU comparisons of bacteraemia incidence, both in the published literature and in regional and national NICU infection monitoring systems. PubMed and Embase were searched for studies reporting risk-adjusted bacteraemia incidence in more than one NICU. An internet search found NICU infection monitoring systems in Western industrialised countries. In all nine studies that met the inclusion criteria, risk adjustment reduced but did not eliminate variation in bacteraemia incidence between NICUs. In both the studies and the regional monitoring systems, adjustment for baby susceptibility generally involved stratification by factors measured at birth. Adjustment for Length of stay and invasive procedures involved reporting incidence by days with a device, such as central venous catheter days. Methods for NICU infection monitoring lack consistency. Adjustment for factors measured at birth fails to capture changes in susceptibility throughout admission and adjustment for device days does not adequately reflect risk to babies not treated with the device. Further research should address variation in risk for all babies throughout their NICU stay.
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Venkatesh MP, Garcia-Prats JA. Management of neonatal sepsis by Gram-negative pathogens. Expert Rev Anti Infect Ther 2009; 6:929-38. [PMID: 19053905 DOI: 10.1586/14787210.6.6.929] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
For the pediatrician and neonatologist who care for term and preterm infants, the challenge remains to keep these infants free of infection after delivery in special-care nurseries and neonatal intensive care units. Studies of complications associated with term infants at risk due to maternal factors, as well as preterm infants after early delivery, have demonstrated that sepsis is a major cause of neonatal mortality and morbidity. Infections due to Gram-negative organisms are increasingly being reported from neonatal units. Moreover, Gram-negative organisms that are multidrug resistant are on the increase and pose a formidable clinical challenge. In this article, we review current epidemiology, risk factors, clinical features, diagnosis, therapy and preventive measures related to Gram-negative infections in neonates.
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Affiliation(s)
- Mohan P Venkatesh
- Baylor College of Medicine & Texas Children's Hospital, 6621 Fannin Street, MC, WT 6-104, Houston, TX 77030, USA.
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Abstract
BACKGROUND Hospitalized neonates are exposed to antibiotic-resistant bacterial pathogens and develop nosocomial infections. Limited data are available regarding the neonatal pharmacokinetics of meropenem, a broad spectrum carbapenem antibiotic. METHODS Neonates <2 months of age received a single dose of meropenem at 10 or 20 mg/kg. Meropenem serum concentrations were measured at specified times during the 24 hours postinfusion. Population pharmacokinetics (PPK) were evaluated using NONMEM. Using Monte Carlo simulation (MCS), the probability of pharmacokinetic-pharmacodynamic target attainment was evaluated by computer modeling from predictions extrapolated from PPK data, using "virtual" dosing regimens of 10, 20, and 40 mg/kg administered every 8 or 12 hours against community- and hospital-acquired pathogens. RESULTS Thirty-seven neonates were enrolled, 22 were born at <36 weeks (range, 23-41 weeks) gestational age. Meropenem clearance was greater in neonates with older chronologic ages and in those born at later gestational ages. Serum creatinine and postconceptional age (PCA) were the best overall predictors of meropenem elimination: CL (L/h/kg) = 0.041 + 0.040/SCr + 0.003 x (PCA-35). MCS demonstrated that in infants during the first 2 weeks of life, a dosage of 20 mg/kg/dose every 8 hours achieved the desired PD target in 95% of preterm neonates and 91% of term neonates against Pseudomonas aeruginosa isolated from patients managed in adult and pediatric intensive care units in the United States. CONCLUSIONS MCS based on PPK determinations demonstrated that a meropenem dose of 20 mg/kg every 8 hours should provide adequate therapy for most nosocomial Gram-negative pathogens.
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Fendler WM, Piotrowski AJ. Procalcitonin in the early diagnosis of nosocomial sepsis in preterm neonates. J Paediatr Child Health 2008; 44:114-8. [PMID: 17927729 DOI: 10.1111/j.1440-1754.2007.01230.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To examine the diagnostic usefulness of procalcitonin (PCT), C-reactive protein and immature to total neutrophil ratio (I : T) in nosocomial sepsis among neonates treated in an intensive care unit. METHODS A retrospective analysis and comparison of diagnostic utility performed in preterm neonates using receiver operating characteristic curves for the diagnosis of culture-proven sepsis. RESULTS A total of 78 clinically suspected sepsis episodes in 73 newborns were analysed. The median values of PCT were: 0.56 ng/mL (interquartile range (IQR) 0.33-1.32) in group with aseptic blood culture (n = 15), 2.69 ng/mL (IQR 1.10-5.29) in Gram-positive (n = 47) and 9.36 ng/mL (IQR 3.11-39.35) in Gram-negative sepsis (n = 16). Only PCT values were significantly different (P < 0.01) among all groups. This was also true when correction for differences in blood withdrawal time was implemented. The positive and negative predictive values of PCT in the diagnosis of sepsis equalled 97.5% and 88.9%, respectively, for a cut-off value of 0.99 ng/mL. PCT was significantly better in diagnosis of sepsis than I : T (P = 0.03). No other significant differences in diagnostic efficacy were noted. The diagnostic efficacy was the highest for measurements made two or more hours since the onset of symptoms. CONCLUSIONS The PCT serum concentration is a valuable tool for early detection of nosocomial sepsis in infants. Highest levels of PCT were observed in Gram-negative infections.
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Affiliation(s)
- Wojciech M Fendler
- Department of Anaesthesia and Intensive Care, Paediatric University Hospital, Medical University in Lodz, Lodz, Poland.
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Abstract
OBJECTIVE Few accurate data are available on the outcome of septic shock in the neonatal period. The objective was to describe outcome and to determine variables associated with death or adverse outcome in neonates with septic shock. DESIGN Retrospective cohort study. SETTING A tertiary neonatal intensive care unit in a university hospital. PATIENTS All patients admitted to the neonatal intensive care unit over a 6-yr period meeting the following criteria: hypotension and/or need for intravenous fluid administration or vasoactive drugs, in the presence of proven or highly probable infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Main outcomes were 28-day mortality and adverse outcome at 18 months of corrected age, defined as death or severe sequelae (cerebral palsy, severe developmental delay, hearing impairment, blindness, or short bowel syndrome). Forty-eight infants were included. Follow-up data at 18 months were obtained for 46 of 48 infants. The 28-day mortality was 40% (19 deaths). Adverse outcome at 18 months of corrected age was observed in 24 of 46 infants (52%; death = 19, severe sequelae = 5). Twenty-eight percent of the infants were alive and had a normal examination at 18 months. Infants with adverse outcome had significantly lower gestational age, birth weight, Apgar score, weight at onset of sepsis, and pH and more often had gram-negative infection, fetal growth restriction, hypoglycemia, and thrombocytopenia. Significant predictors (multivariate analysis) of 28-day mortality and of adverse outcome at 18 months of corrected age were weight (kg) at the onset of sepsis (odds ratio 0.14, 95% confidence interval 0.03-0.55; odds ratio 0.21, 95% confidence interval 0.06-0.74, respectively) and gram-negative infection (odds ratio 10.1, 95% confidence interval 1.5-65.7; odds ratio 45.5, 95% confidence interval 3-637, respectively). CONCLUSIONS Septic shock in the neonatal period has a very poor outcome. Data underscore the extreme vulnerability of very low birth weight infants to septic shock, particularly to gram-negative species.
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[Recommendation for the prevention of nosocomial infections in neonatal intensive care patients with a birth weight less than 1,500 g. Report by the Committee of Hospital Hygiene and Infection Prevention of the Robert Koch Institute]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2008. [PMID: 18041117 PMCID: PMC7080031 DOI: 10.1007/s00103-007-0337-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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[Recommendation for the prevention of nosocomial infections in neonatal intensive care patients with a birth weight less than 1,500 g. Report by the Committee of Hospital Hygiene and Infection Prevention of the Robert Koch Institute]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007; 50:1265-303. [PMID: 18041117 PMCID: PMC7080031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
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Abstract
BACKGROUND Nosocomial sepsis is a frequent and serious complication of premature infants. The increased susceptibility of ELBW infants to infection has been attributed to less effective immune function compared to mature newborns and the invasive nature of necessary supportive care. Breakdown of the barrier function of the skin may be an additional risk factor for nosocomial sepsis. OBJECTIVES To assess the effect of prophylactic application of topical ointment on nosocomial sepsis rates and other complications of prematurity in preterm infants. SEARCH STRATEGY Searches were made of the Cochrane Central Registry of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003), Ovid DC MEDLINE through June 2003, previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, and journal hand searching in the English language. SELECTION CRITERIA Randomized controlled trials which compared the effect of prophylactic application of topical ointment to routine (standard) skin care or as needed topical therapy in preterm infants are included in this review. DATA COLLECTION AND ANALYSIS Data regarding clinical outcomes including infection [including any bacterial infection, bacterial infection with a known pathogen, coagulase negative staphylococcal infection, fungal infection, and any nosocomial infection (bacterial or fungal)], patent ductus arteriosus, oxygen requirement at 28 days, chronic lung disease and mortality were excerpted from the reports of the clinical trials by the reviewers. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Four randomized controlled trials were identified. All four studies reported improved skin condition in infants treated with prophylactic topical ointment (results not reported here). All four studies reported on the incidence of any nosocomial infection, fungal infection and coagulase negative staphylococcal infection. Infants treated with prophylactic topical ointment are at increased risk of coagulase negative staphylococcal infection (typical relative risk 1.31, 95% CI 1.02, 1.70; typical risk difference 0.04, 95% CI 0.00, 0.08); and any nosocomial infection (typical relative risk 1.20, 95% CI 1.00, 1.43; typical risk difference 0.05, 95% CI 0.00, 0.09). A trend toward increased risk of any bacterial infection was found in infants treated with prophylactic topical ointment (typical relative risk 1.19, 95% CI 0.97, 1.46; typical risk difference 0.04, 95% CI -0.01, 0.08). There was no significant difference found in the risk of bacterial infection with a known pathogen, fungal infection, or other complications related to prematurity. REVIEWER'S CONCLUSIONS Prophylactic application of topical ointment increases the risk of coagulase negative staphylococcal infection and any nosocomial infection. A trend toward increased risk of any bacterial infection was noted in infants prophylactically treated. Topical ointment should not be used routinely in preterm infants.
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Affiliation(s)
- J M Conner
- Vermont Oxford Network, 33 Kilburn St., Burlington, Vermont 05401, USA
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