What is the rationale for the use of granulocyte and granulocyte-macrophage colony-stimulating factors in the neonatal intensive care unit?

Early-Onset Neutropenia in Small-for-Gestational-Age Infants

BACKGROUND

Early neutropenia is more common in small for gestational age (SGA) neonates (birth weight <10th percentile) than in appropriately grown neonates. However, several aspects of this variety of neutropenia are unknown, including the duration, kinetic mechanism, and outcomes.

METHODS

Using 10 years of multihospital records, we studied SGA neonates who, during the first week after birth, had neutrophil counts <1000/μL.

RESULTS

This degree of neutropenia was more common in SGA neonates (6%, 207/3650) than in non-SGA matched controls (1%, 46/3650; P < .001). Neutrophil counts stayed below the lower reference interval for 7 days. Ratios of immature to total neutrophils were within the reference interval, suggesting reduced neutrophil production, not accelerated neutrophil use or destruction. Increased nucleated red cells at birth correlated with decreased neutrophils (P < .001). Neutropenia was not independently associated with maternal hypertensive disorders, over and above the effect of SGA. Of 201 neutropenic SGA neonates, 129 (64%) also had thrombocytopenia. Sixteen percent of neutropenic neonates were treated with recombinant granulocyte colony-stimulating factor (rG-CSF) or intravenous immunoglobulin (IVIG), with no reduction in late-onset sepsis or necrotizing enterocolitis (NEC). Regression analysis showed that neutropenia (but not thrombocytopenia in the absence of neutropenia) was independently associated with increased odds of developing necrotizing enterocolitis (odds ratio 4.01, 90% confidence interval 2.08 to 7.35, P < .001).

CONCLUSIONS

Neutropenia of SGA is a condition of 1-week duration. It is more closely associated with SGA than maternal hypertension (likely owing to neutrophil hypoproduction associated with intrauterine hypoxia), often accompanied by thrombocytopenia, not obviously improved by rG-CSF or IVIG, and associated with an increased risk for NEC.

A randomized case-controlled study of recombinant human granulocyte colony stimulating factor for the treatment of sepsis in preterm neutropenic infants

BACKGROUND

To investigate the efficacy and safety of recombinant human granulocyte colony-stimulating factor, recombinant human granulocyte-macrophage colony-stimulating factor (rhG-CSF) to treat sepsis in neutropenic preterm infants.

METHODS

Fifty-six neutropenic preterm infants with suspected or culture-proven sepsis hospitalized in Zeynep Kamil Maternity and Children's Educational and Training Hospital, Kozyatağı/Istanbul, Turkey between January 2008 and January 2010 were enrolled. Patients were randomized either to receive rhG-CSF plus empirical antibiotics (Group I) or empirical antibiotics alone (Group II). Clinical features were recorded. Daily complete blood count was performed until neutropenia subsided. Data were analyzed using SPSS version 11.5.

RESULTS

Thirty-three infants received rhG-CSF plus antibiotic treatment and 23 infants received antibiotic treatment. No drug-related adverse event was recorded. Absolute neutrophil count values were significantly higher on the 2(nd) study day and 3(rd) study day in Group I. Short-term mortality did not differ between the groups.

CONCLUSION

Treatment with rhG-CSF resulted in a more rapid recovery of ANC in neutropenic preterm infants. However, no reduction in short-term mortality was documented.

Lactate dehydrogenase and severity of pain in children with sickle cell disease

OBJECTIVES

This prospective study was carried out to assess lactate dehydrogenase (LDH) as a biochemical marker during acute painful episode and steady state in children with sickle cell disease (SCD).

DESIGN AND METHODS

A prospective descriptive study has been carried out on children and adolescents with SCD and pain during a vaso-occlusive episode. A total of 76 patients aged 1-18 years were included. Assessment of pain was done using the suitable pain assessment tool (visual analogue scales, Oucher scale) for school and preschool children. Complete blood count, liver function tests, LDH and C-reactive protein assay were performed on all patients during acute painful episode and steady state.

RESULTS

LDH has been found to increase significantly during acute painful episode compared with steady state (p < 0.01). There is also a significant positive correlation between LDH level and severity of pain (p < 0.05). In addition, C-reactive protein level was found to be significantly elevated during acute painful episode (p < 0.01) and its level correlates significantly with severity of pain (p = 0.01).

CONCLUSION

From this study it can be concluded that LDH is a significant biochemical marker for the severity of pain during a vaso-occlusive episode in SCD.

Outbreak of Acinetobacter infection in extremely low birth weight neonates

OBJECTIVE

We describe the first outbreak of multiple drug-resistant Acinetobacter baumannii (MDR-Ab) in a neonatal intensive care unit in the United States.

DESIGN/METHODS

MDR-Ab was identified in the blood of a 24-week gestation, 7-day-old extremely low birth weight neonate. Multiple samplings of surveillance surface cultures were performed on exposed and nonexposed neonates. Enhanced infection control measures were implemented. Pulsed-field gel electrophoresis was performed to determine the genetic relatedness of the MDR-Ab isolates. Medical records were reviewed for all exposed patients.

RESULTS

MDR-Ab was recovered from 6 additional neonates. Of these 7 MDR-Ab (index + 6) neonates, 4 died, 3 of whom had positive blood cultures. All affected neonates were born between 23 to 26 weeks gestational age, and were <7 days postnatal age and <750 g (430-720) at the time of exposure. All were housed within the same room as the index case. None of the other 5 exposed neonates older than postnatal day 7 or weighing >750 g at birth were affected. No additional cases occurred outside the original room. Pulsed-field gel electrophoresis was consistent with a clonal origin, identical to MDR-Ab recovered from the referring hospital.

CONCLUSIONS

This MDR-Ab outbreak was rapidly controlled with enhanced infection control measures and was novel in that it affected only <750 g neonates, at < or =26 weeks gestational age, and < or =7 days postnatal age at the time of exposure, suggesting that invasive Ab has a special affinity for damaged or nonkeratinized immature skin in developmentally immature immunologic hosts.

Blood lysophosphatidylcholine (LPC) levels and characteristic molecular species in neonates: prolonged low blood LPC levels in very low birth weight infants

Lysophosphatidylcholine (LPC) has various stimulatory effects on many types of immune cells. The purpose of our study was to characterize blood LPC levels and to determine the composition of LPC molecular species (LPCs) in the neonatal period. Thirty-six neonates were enrolled in this study and then grouped according to birth-weight as follows: non-very low birth weight (NVLBW); >or=1,500 g (n=17), and very low birth weight (VLBW); <1,500 g (n=19). Sixteen healthy normal adults were used as controls. Levels of total blood LPC and LPCs (16:0-, 18:0-, 18:1-, 18:2-, and 20:4-LPC species) were measured using HPLC coupled with tandem mass spectrometry. Total blood LPC levels at birth in neonates in both groups (NVLBW and VLBW) were significantly lower than those of adult levels. In NVLBW infants, LPC levels reached adult levels at postnatal day 3 compared with VLBW infants, who attained adult levels after postnatal day 57 (around full-term). The composition of the LPCs was different not only between neonates and adults, but between NVLBW and VLBW infants. These findings may be associated with the difference of immunity among adults, NVLBW, and VLBW infants.

Reducing the global burden of sepsis in infants and children: a clinical practice research agenda

OBJECTIVE

Sepsis remains a predominant cause of mortality and morbidity in children in the developing and industrialized world. This review discusses a clinical practice research agenda to reduce this global burden.

DESIGN

Summary of the literature with analysis by experts.

RESULTS

Many interventions have been proven effective in decreasing sepsis. Heterologous immunization with attenuated Bacillus Camille Guerin vaccine reduces all-cause mortality, and specific immunizations further reduce morbidity and mortality from many specific microbes. Antepartum antibiotics reduce the prevalence of cerebral palsy and mortality in infants. Administration of antibiotics to neonates with signs of sepsis reduces all-cause mortality five-fold and can also reduce mortality in the big four killers of children: severe pneumonia, diarrhea, malaria, or measles. Immunonutrition with zinc and vitamin A can further reduce morbidity in diarrhea and pneumonia and reduce mortality in measles. First-hour rapid intravenous fluid resuscitation achieves 100% survival in dengue shock, and time-sensitive fluid resuscitation and inotropic support reduces mortality ten-fold in meningococcal septic shock. Multiple organ failure occurs when late or inadequate resuscitation results in systemic thrombosis or when infection is not eradicated because of immunosuppression or inadequate source control.

CONCLUSIONS

The global burden of sepsis can be reduced by 1) prevention with improved heterologous or specific vaccines and vitamin or mineral supplement programs; 2) early recognition and treatment with appropriate antibiotics, intravenous fluid resuscitation, and inotropic support in organized healthcare-delivery systems; and 3) development of new diagnostics and therapeutics that reduce systemic thrombosis, improve immune function, and kill resistant organisms.

Pediatric considerations

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for other supportive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN AND METHODS

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. Pediatric representatives attended the various section meetings and workshops to contrast adult and pediatric management. These are published here as pediatric considerations.

CONCLUSION

Pediatric considerations included a more likely need for intubation due to low functional residual capacity, more difficult intravenous access, fluid resuscitation based on weight with 40-60 mL kg or higher needed, decreased cardiac output and increased systemic vascular resistance as the most common hemodynamic profile, greater use of physical examination therapeutic endpoints, the unsettled issue of high-dose steroids for therapy of septic shock, and greater risk of hypoglycemia with aggressive glucose control.

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

We used a modified Delphi methodology for grading recommendations, built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.

RESULTS

Key recommendations, listed by category and not by hierarchy, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition; appropriate diagnostic studies to ascertain causative organisms before starting antibiotics; early administration of broad-spectrum antibiotic therapy; reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate; a usual 7-10 days of antibiotic therapy guided by clinical response; source control with attention to the method that balances risks and benefits; equivalence of crystalloid and colloid resuscitation; aggressive fluid challenge to restore mean circulating filling pressure; vasopressor preference for norepinephrine and dopamine; cautious use of vasopressin pending further studies; avoiding low-dose dopamine administration for renal protection; consideration of dobutamine inotropic therapy in some clinical situations; avoidance of supranormal oxygen delivery as a goal of therapy; stress-dose steroid therapy for septic shock; use of recombinant activated protein C in patients with severe sepsis and high risk for death; with resolution of tissue hypoperfusion and in the absence of coronary artery disease or acute hemorrhage, targeting a hemoglobin of 7-9 g/dL; appropriate use of fresh frozen plasma and platelets; a low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome; application of a minimal amount of positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome; a semirecumbent bed position unless contraindicated; protocols for weaning and sedation/analgesia, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening; avoidance of neuromuscular blockers, if at all possible; maintenance of blood glucose <150 mg/dL after initial stabilization; equivalence of continuous veno-veno hemofiltration and intermittent hemodialysis; lack of utility of bicarbonate use for pH > or =7.15; use of deep vein thrombosis/stress ulcer prophylaxis; and consideration of limitation of support where appropriate. Pediatric considerations included a more likely need for intubation due to low functional residual capacity; more difficult intravenous access; fluid resuscitation based on weight with 40-60 mL/kg or higher needed; decreased cardiac output and increased systemic vascular resistance as the most common hemodynamic profile; greater use of physical examination therapeutic end points; unsettled issue of high-dose steroids for therapy of septic shock; and greater risk of hypoglycemia with aggressive glucose control.

CONCLUSION

Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that are hoped to translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually and even more rapidly as some important new knowledge becomes as available.

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

OBJECTIVE

To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A-E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.

PARTICIPANTS

Participants included 44 critical care and infectious disease experts representing 11 international organizations.

RESULTS

A total of 46 recommendations plus pediatric management considerations.

CONCLUSIONS

Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.