Staphylococcus aureus infections in Australasian neonatal nurseries

Methicillin resistant staphylococcus aureus infection in neonates- a major concern and a call for action

Background

Methicillin-Resistant Staphylococcus aureus (MRSA) is both a human commensal and a pathogen that causes neonatal infection which is associated with significant morbidity and mortality. Its genetic flexibility and versatility have equipped it with the ability to develop resistance to numerous antibiotics. Outbreaks of infections in neonatal intensive care units as well as community infections have been reported mostly in developed countries. However, there is a paucity of data on neonatal MRSA infection in developing countries. The study aims to highlight cases of MRSA infection, describe the clinical presentation, and outline the antibiotic susceptibility pattern among term neonates in our facility.

Methodology

It was a prospective cross-sectional hospital-based study carried out from October 2018 to July 2019. A total of 248 term neonates with suspected sepsis were enrolled in the study and had their blood samples taken for investigations including blood culture. Bacterial identification and antibiotic susceptibility patterns were carried out using MicrobactTM24E (Oxiod UK) and Staph ID and modified Kirby-Bauer disk diffusion technique respectively.

Results

Out of the 248 subjects enrolled in the study, 34.2% had proven sepsis, with Staphylococcus species accounting for 56.4% of these cases. Among those with staphylococcal sepsis, 56.3% were found to have MRSA infection. Notably, the majority (94.4%) of cases originated from outside the hospital, presenting as neonatal sepsis with non-specific clinical features. Sensitivity testing revealed that ciprofloxacin and chloramphenicol were the most effective antibiotics against the identified pathogens.

Conclusion

The presence of MRSA infections in neonates poses a critical public health threat. This trend underscores the emergence of antimicrobial resistance, potentially compromising treatment efficacy and jeopardizing neonatal well-being. Urgent and decisive measures are necessary to curb this trajectory.

Variable preterm oral microbiome stabilizes and reflects a full-term infant profile within three months

BACKGROUND

Preterm infants suffer higher morbidity and mortality rates compared to full-term infants, but little is known about how changes to oral and respiratory tract microbiota may impact disease development.

METHODS

Here, very preterm neonates (n = 50) were selected to study oral and respiratory microbiota development during the first few months post-birth, where 26 individuals were diagnosed with BPD and/or sepsis. These infants were compared to 14 healthy full-term infants and 16 adults. Microbiota diversity, composition, and species abundances were calculated from 16S ribosomal RNA gene sequences in buccal swabs and tracheal aspirates at two time points (within a week and 1-3 months post-birth).

RESULTS

Collection time point was the biggest factor to significantly influence the preterm oral microbial diversity and composition. In addition, BPD and sepsis were linked to distinct preterm oral microbiota diversity and composition, and opportunistic pathogens previously associated with these diseases were identified in the initial sample for both healthy preterm neonates and those with the disease. Compared to the full-term infant and adult dataset, preterm infant diversity and composition was initially significantly different, but resembled full-term infant diversity and composition over time.

CONCLUSION

Overall, consequences of microbiota development need further examination in preterm infant infections and later development.

IMPACT

Non-gut microbiota research on preterm infants is limited. At one week post-birth, preterm infants harbor distinct oral microbiota that are not shared with full-term children or adults, eventually becoming similar to full-term infants at 36 weeks postmenstrual age. DNA from potential opportunistic pathogens was observed in the mouth and lungs of preterm infants within a week of birth, and microbes associated with BPD were identified in the lungs. Oral microbiota in preterm infants over the first 2-3 months is unique and may be connected to short- and long-term health outcomes in these children.

Neonatal Staphylococcus Aureus Sepsis: a 20-year Western Australian experience

OBJECTIVES

The purpose of this study was to characterise neonatal Staphylococcus aureus (SA) sepsis in Western Australia (WA) between 2001 and 2020 at the sole tertiary neonatal intensive care unit (NICU), examine risk factors for sepsis in the cohort, and compare short- and long-term outcomes to control infants without any sepsis.

METHODS

Retrospective cohort study at the Neonatal Directorate at King Edward Memorial Hospital (KEMH) and Perth Children's Hospital, using electronic databases and patient medical records.

RESULTS

The overall incidence of SA sepsis was 0.10 per 1000 live births (62/614207). From 2001 to 2010 the incidence was 0.13/1000 live births, reducing to 0.07/1000 live births from 2011 to 2020. SA was most frequently isolated from endotracheal aspirates, and infants with SA sepsis had longer median duration of ventilatory support than those without any sepsis (31 days vs 18 days respectively, p < 0.001). In our cohort, SA sepsis was associated with worse neurodevelopmental outcomes compared to infants without any sepsis.

CONCLUSIONS

The incidence of neonatal SA sepsis has reduced over the last 20 years, suggesting potential effectiveness of the preventative interventions implemented. Endotracheal tube (ETT) colonisation and prolonged ventilation may be under-recognised as potential sources of SA infection. Our study suggests SA sepsis may negatively impact neurodevelopmental outcomes.

Topical emollient for preventing infection in preterm infants

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.

Cervical adenitis caused by Staphylococcus aureus in a newborn

Cervical acute lymphadenitis is rarely described in neonates. We present the case of a 12-day-old preterm, fed by nasogastric tube, who presented a tender erythematous submandibular swelling. Laboratory data showed neutrophilia and an elevation of C reactive protein and procalcitonin. Ultrasound findings suggested cellulitis and adenitis with abscess. The culture of the drainage material identified methicillin-sensitive Staphylococcus aureus With the administration of the right antibiotic treatment, a good clinical outcome was observed.

Challenges in developing a consensus definition of neonatal sepsis

Sepsis remains a leading cause of morbidity and mortality in the neonatal population, and at present, there is no unified definition of neonatal sepsis. Existing consensus sepsis definitions within paediatrics are not suited for use in the NICU and do not address sepsis in the premature population. Many neonatal research and surveillance networks have criteria for the definition of sepsis within their publications though these vary greatly and there is typically a heavy emphasis on microbiological culture. The concept of organ dysfunction as a diagnostic criterion for sepsis is rarely considered in neonatal literature, and it remains unclear how to most accurately screen neonates for organ dysfunction. Accurately defining and screening for sepsis is important for clinical management, health service design and future research. The progress made by the Sepsis-3 group provides a roadmap of how definitions and screening criteria may be developed. Similar initiatives in neonatology are likely to be more challenging and would need to account for the unique presentation of sepsis in term and premature neonates. The outputs of similar consensus work within neonatology should be twofold: a validated definition of neonatal sepsis and screening criteria to identify at-risk patients earlier in their clinical course. IMPACT: There is currently no consensus definition of neonatal sepsis and the definitions that are currently in use are varied.A consensus definition of neonatal sepsis would benefit clinicians, patients and researchers.Recent progress in adults with publication of Sepsis-3 provides guidance on how a consensus definition and screening criteria for sepsis could be produced in neonatology.We discuss common themes and potential shortcomings in sepsis definitions within neonatology.We highlight the need for a consensus definition of neonatal sepsis and the challenges that this task poses.

Enteral lactoferrin to prevent infection for very preterm infants: the ELFIN RCT

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.

Staphylococcus aureus Bacteremia in Children: Antibiotic Resistance and Mortality

BACKGROUND

Staphylococcus aureus (SA) is a major cause of bacteremia in children. Methicillin-resistant SA (MRSA) is considered a public health threat; however, the differences in the prognosis of children with methicillin-susceptible SA (MSSA) versus MRSA bacteremia are not well defined.

METHODS

Data from all SA bacteremia events in children (0-16 years) from 2002 to 2016 in a single Israeli tertiary center were collected. Positive cultures within 48 hours of hospitalization were considered community associated (CA). Those obtained afterward or from children hospitalized within the previous year were considered health-care associated (HA).

RESULTS

We recorded 427 events, 284 (66%) were HA, 64 (15%) were MRSA and 9 (2%) were CA-MRSA. There was no increase in MRSA during the study period. In-hospital, 30-day and 1-year mortality were 3% (12 cases), 3.5% (16 cases), and 12% (50 cases), respectively. A multivariable analysis controlling for demographics, admitting department and prior morbidity showed an increased 1-year mortality in children with HA bacteremia (hazard ratio [HR] 4.1; 95% confidence interval [CI]: 1.3-12) and prior chronic disease (HR 3.4; 95% CI 1.2 to 9.0). MRSA was not independently associated with increased one-year mortality compared with MSSA: HR (95% CI: 1.4 [0.6-3.1]).

CONCLUSIONS

Short-term pediatric mortality after SA bacteremia is low. HA-SA bacteremia has an increased long-term risk for mortality, particularly in children with chronic diseases. Our data suggest mortality was not increased for MRSA compared with MSSA bacteremia. The very low rate of CA-MRSA bacteremia justifies the current practice not to include glycopeptides in the empiric treatment of CA bacteremia in Israel.

Neonatal Sepsis of Early Onset, and Hospital-Acquired and Community-Acquired Late Onset: A Prospective Population-Based Cohort Study

OBJECTIVE

To assess the epidemiology of blood culture-proven early- (EOS) and late-onset neonatal sepsis (LOS).

STUDY DESIGN

All newborn infants admitted to tertiary care neonatal intensive care units in Switzerland and presenting with blood culture-proven sepsis between September 2011 and December 2015 were included in the study. We defined EOS as infection occurring <3 days after birth, and LOS as infection ≥3 days after birth. Infants with LOS were classified as having community-acquired LOS if onset of infection was ≤48 hours after admission, and hospital-acquired LOS, if onset was >48 hours after admission. Incidence was estimated based on the number of livebirths in Switzerland and adjusted for the proportion of admissions at centers participating in the study.

RESULTS

We identified 444 episodes of blood culture-proven sepsis in 429 infants; 20% of cases were EOS, 62% hospital-acquired LOS, and 18% community-acquired LOS. The estimated national incidence of EOS, hospital-acquired LOS, and community-acquired LOS was 0.28 (95% CI 0.23-0.35), 0.86 (0.76-0.97), and 0.28 (0.23-0.34) per 1000 livebirths. Compared with EOS, hospital-acquired LOS occurred in infants of lower gestational age and was more frequently associated with comorbidities. Community-acquired LOS was more common in term infants and in male infants. Mortality was 18%, 12%, and 0% in EOS, hospital-acquired LOS, and community-acquired LOS, and was higher in preterm infants, in infants with septic shock, and in those requiring mechanical ventilation.

CONCLUSIONS

We report a high burden of sepsis in neonates with considerable mortality and morbidity. EOS, hospital-acquired LOS, and community-acquired LOS affect specific patient subgroups and have distinct clinical presentation, pathogens and outcomes.

Early planned removal versus expectant management of peripherally inserted central catheters to prevent infection in newborn infants

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.

New Threats from an Old Foe: Methicillin-Resistant Staphylococcus aureus Infections in Neonates

Methicillin-resistant Staphylococcus aureus (MRSA) is a ubiquitous human inhabitant and one of the important pathogens of neonatal infections. MRSA is associated with significant mortality and morbidity, especially in very immature preterm neonates. Moreover, MRSA may be implicated in adverse long-term neonatal outcomes, posing a substantial disease burden. Recent advances in molecular microbiology have shed light on the evolution of MRSA population structure and virulence factors, which may contribute to MRSA epidemic waves worldwide. Equipped with remarkable genetic flexibility, MRSA has successfully developed resistance to an extensive range of antibiotics including vancomycin, as well as antiseptics. In the face of these new challenges from MRSA, our armamentarium of anti-infective strategies is very limited and largely dependent on prevention measures. Active surveillance cultures followed by decolonization may be a promising approach to control MRSA infections, with its efficacy and safety in the specific population of neonates yet to be addressed by large multicenter studies.

Empiric antibiotic regimens for neonatal sepsis in Australian and New Zealand neonatal intensive care units

AIM

Neonatal sepsis remains an important cause of morbidity and mortality, and requires prompt empiric treatment. However, only a minority of babies who receive antibiotics for suspected sepsis have an infection. Antimicrobial exposure in infancy has important short- and long-term consequences. There is no consensus regarding empirical antimicrobial regimens.

METHODS

The study included a survey of empiric antimicrobial regimens in all tertiary neonatal intensive care units in Australia and New Zealand in 2013-2014.

RESULTS

All 27 units responded. For early-onset sepsis, all units used a combination of gentamicin with either penicillin or ampicillin. For late-onset sepsis, the frequency of units using empiric vancomycin (41%) versus empiric flucloxacillin (48%) was similar. Gestational age or the presence of a central venous catheter had little influence on using vancomycin instead of flucloxacillin. For late-onset sepsis with meningitis there was marked variation in antimicrobial combinations, with 15 different regimens described. A total of 93% used a cefotaxime-based regimen, either as monotherapy (22%) or combined with a second (22%) or third (48%) agent. For suspected necrotising enterocolitis, 89% used an aminoglycoside, metronidazole and a penicillin. Historical outbreaks of multi-resistant organisms exerted long-term influence over regimen choice.

CONCLUSIONS

There was limited use of broad-spectrum agents such as carbapenems or third-generation cephalosporins. In this region with low methicillin-resistant Staphylococcus aureus prevalence, empiric vancomycin use was common, selected for activity against coagulase-negative staphylococci. Empiric vancomycin is rarely necessary because coagulase-negative staphylococci are often contaminants and sepsis is rarely fulminant, occurring almost exclusively in extremely low birthweight infants. Implementation of appropriate, local antimicrobial policies is crucial to minimise antimicrobial exposure in this vulnerable population and halt the development of antimicrobial resistance.

Management of early-onset neonatal sepsis differs in the north and south of Scandinavia

AIM

This study compared the management and outcomes of early-onset neonatal sepsis (EONS) in two tertiary neonatal units in Denmark and Norway.

METHODS

We retrospectively studied all infants diagnosed with EONS between April 2010 and March 2013 and managed at Odense University Hospital, Denmark, and the University Hospital of North Norway, Norway. Clinical and laboratory data were collected from patient records.

RESULTS

We identified 137 EONS cases in Denmark and 101 in Norway. There were 35 culture-confirmed EONS cases: 16% of the Danish cases and 13% of the Norwegian cases. Staphylococcus aureus was the most frequently detected pathogen in 11 cases (31%), followed by Group B streptococci in nine (26%) and Escherichia coli in six (17%). In 85% of the 238 cases, the empiric therapy comprised gentamicin and a beta-lactam, namely ampicillin in Denmark and benzylpenicillin in Norway. Patients with positive blood cultures had higher C-reactive protein levels than patients with negative blood cultures and higher sepsis-attributable mortality. Lumbar punctures were performed more frequently in Denmark.

CONCLUSION

There were marginal differences in the management of EONS between units in Denmark and Norway, mainly in their choice of antibiotics and the use of lumbar punctures. Staphylococcus aureus was the most common pathogen.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

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.

Topical emollient for preventing infection in preterm infants

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.

Burden of Invasive Staphylococcus aureus Infections in Hospitalized Infants

IMPORTANCE

Staphylococcus aureus is a frequent cause of infection in hospitalized infants. These infections are associated with increased mortality and morbidity and longer hospital stays, but data on the burden of S aureus disease in hospitalized infants are limited.

OBJECTIVES

To compare demographics and mortality of infants with invasive methicillin-resistant S aureus (MRSA) and methicillin-susceptible S aureus (MSSA), to determine the annual proportion of S aureus infections that were MRSA, and to contrast the risk of death after an invasive MRSA infection with the risk after an invasive MSSA infection.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter retrospective study of a large, nationally representative cohort at 348 neonatal intensive care units managed by the Pediatrix Medical Group. Participants were 3888 infants with an invasive S aureus infection who were discharged from calendar year 1997 through calendar year 2012.

EXPOSURE

Invasive S aureus infection.

MAIN OUTCOMES AND MEASURES

The incidence of invasive S aureus infections, as well as infant characteristics and mortality after MRSA or MSSA infection.

RESULTS

The 3888 infants had 3978 invasive S aureus infections (2868 MSSA and 1110 MRSA). The incidence of invasive S aureus infection was 44.8 infections per 10,000 infants. The yearly proportion of invasive infections caused by MRSA increased from calendar year 1997 through calendar year 2006 and has moderately decreased since then. Infants with invasive MRSA or MSSA infections had similar gestational ages and birth weights. Invasive MRSA infections occurred more often at a younger postnatal age. For infants with available mortality data, more infants with invasive MSSA infections (n = 237) died before hospital discharge than infants with invasive MRSA infections (n = 110). The proportions of infants who died after invasive MSSA and MRSA infections were similar at 237 of 2474 (9.6%) and 110 of 926 (11.9%), respectively (P = .05). The adjusted risk of death before hospital discharge was similar after invasive MSSA and MRSA infections (risk ratio, 1.19; 95% CI, 0.96-1.49). The risks of death at 7 and 30 days after invasive infection were similar between infants with invasive MSSA infection and infants with invasive MRSA infection.

CONCLUSIONS AND RELEVANCE

Infant mortality after invasive MRSA and MSSA infections is similar, but MSSA causes more infections and more deaths in infants than MRSA. Measures to prevent S aureus infection should include MSSA in addition to MRSA.

Antimicrobial-impregnated central venous catheters for prevention of catheter-related bloodstream infection in newborn infants

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.

Staphylococcal infections in infants: updates and current challenges

Staphylococci are common pathogens in the neonatal period. Increased survival of premature infants leads to prolonged hospital stay with associated risk factors for developing invasive staphylococcal disease. Challenges of diagnosing coagulase-negative staphylococcal infections result in conflicting definitions and inconsistent clinical practice. Resistance to methicillin influences the choice of empirical therapy.

Invasive Staphylococcus aureus Infections in Children in Tropical Northern Australia

BACKGROUND

Despite a high burden of staphylococcal skin disease in children and high incidence of Staphylococcus aureus bacteremia in adult Indigenous populations in northern Australia, there are few studies describing incidence or clinical information of invasive S aureus (ISA) infections in children.

METHODS

We conducted a retrospective review for all cases of S aureus bacteremia and sterile site infections, for children under 15 years, in northern Australia over a 4-year period (2007-2010). Cases were categorized as neonatal (<28 days) and pediatric (≥28 days).

RESULTS

Forty-four cases (9 neonatal, 35 pediatric) were identified. The annual incidence of ISA was 27.9 cases per 100 000 population. Among pediatric cases, the annual incidence was significantly higher in the Indigenous (46.6) compared with the non-Indigenous (4.4) population (IRR: 10.6 [95% confidence interval, 3.8-41.4]). Pediatric infections were predominantly community-associated (86%). Clinical infection sites included osteoarticular (66%), pleuropulmonary (29%), and endocarditis (9%), and multifocal disease was common (20%). Eighty-three percent of pediatric cases presented with sepsis; 34% resulted in intensive care admission. Neonatal cases were all born prematurely; 89% were late-onset infections. Overall, 27% of infections were due to methicillin-resistant S aureus (MRSA). Compared with methicillin-sensitive S aureus (MSSA), there was no difference in severity or presentation in pediatric MRSA cases, but a higher proportion of MRSA cases were readmitted.

CONCLUSIONS

The annual incidence of ISA infection in this study is among the highest described, largely due to a disproportionate burden in Indigenous children. Infections are frequently severe and infection with MRSA is common. Children presenting with suspected ISA in this region should be treated empirically for MRSA.

Impact of Methicillin-Resistance on Mortality in Children and Neonates with Staphylococcus aureus Bacteremia: A Meta-analysis

Background

Staphylococcus aureus bacteremia (SAB) is the Staphylococcal infections in blood, one of the most common and fatal bacterial infectious diseases worldwide in adults as well as children or neonates. Recently, some studies have yielded inconsistent findings about the association between methicillin-resistance and mortality in patients with SAB. We performed a meta-analysis to assess the impact of methicillin-resistance on mortality in children or neonates with S. aureus bacteremia.

Materials and Methods

We searched using electronic databases such as Ovid-Medline, EMBASE-Medline, and Cochrane Library, as well as five local databases for published studies during the period of 1 January 2000 to 15 September 2011. Two reviewers independently selected articles in accordance with predetermined criteria and extracted prespecified data based on standardized forms. All cohort studies, which compared in-hospital mortality or SAB-related mortality in children and neonates with methicillin-resistant S. aureus (MRSA) infection to those with methicillin-susceptible S. aureus (MSSA), were included. We conducted meta-analysis using the fixed-effect model to obtain pooled estimates of effect.

Results

Of 2,841 screened studies, seven cohort studies were finally selected for analysis. In children or neonates, MRSA bacteremia was associated with a higher mortality compared with MSSA bacteremia (pooled odds ratio [OR] 2.33, P = 0.0008, 95% confidence interval [CI] 1.42 to 3.82, I² = 0%). Four studies reported SAB-related mortality, the pooled OR of these studies was 2.03 (P = 0.29, 95% CI 0.55 to 7.53, I² = 0%). A significant increase in mortality associated with methicillin resistance was found in the subgroup analyses of the studies with only neonates (OR: 2.66, 95% CI: 1.46 to 4.85, P = 0.001), prospectively design ones (OR: 3.20, 95% CI: 1.66 to 6.15, P = 0.0005,), the larger studies (OR: 2.89, 95% CI: 1.62 to 5.16, P = 0.0003) and the higher quality studies (OR: 2.76, 95% CI: 1.50 to 5.06, P = 0.001).

Conclusions

MRSA bacteremia is associated with increased mortality compared with MSSA bacteremia in children or neonates. Due to limited studies for mortality in children or neonates with SAB, further research is needed to evaluate the impact of methicillin resistance on mortality in those populations.

Staphylococcus aureus bloodstream infections in children: A population-based assessment

BACKGROUND

Although Staphylococcus aureus is a major cause of bloodstream infections, population-based data on these infections in children are limited.

OBJECTIVE

To describe the epidemiology of S aureus bacteremia in children.

METHODS

Population-based surveillance for all incident S aureus bacteremias was conducted among children (18 years of age or younger) living in the Calgary Health Region (Alberta) from 2000 to 2006.

RESULTS

During the seven-year study, 120 S aureus bloodstream infections occurred among 119 patients; 27% were nosocomial, 18% health care associated and 56% community acquired. The annual incidence was 6.5/100,000 population and 0.094/1000 live births. A total of 52% had a significant underlying condition, and this was higher for nosocomial cases. Bone and joint (40%), bacteremia without a focus (33%), and skin and soft tissue infections (15%) were the most common clinical syndromes. Infections due to methicillin-resistant S aureus were uncommon (occurring in one infection) and three patients (2.5%) died.

CONCLUSIONS

S aureus bacteremia is an important cause of morbidity in the paediatric age group. Underlying medical conditions and implanted devices are important risk factors. Methicillin-resistant S aureus and mortality rates are low.

Predictors of mortality in Staphylococcus aureus Bacteremia

Staphylococcus aureus bacteremia (SAB) is an important infection with an incidence rate ranging from 20 to 50 cases/100,000 population per year. Between 10% and 30% of these patients will die from SAB. Comparatively, this accounts for a greater number of deaths than for AIDS, tuberculosis, and viral hepatitis combined. Multiple factors influence outcomes for SAB patients. The most consistent predictor of mortality is age, with older patients being twice as likely to die. Except for the presence of comorbidities, the impacts of other host factors, including gender, ethnicity, socioeconomic status, and immune status, are unclear. Pathogen-host interactions, especially the presence of shock and the source of SAB, are strong predictors of outcomes. Although antibiotic resistance may be associated with increased mortality, questions remain as to whether this reflects pathogen-specific factors or poorer responses to antibiotic therapy, namely, vancomycin. Optimal management relies on starting appropriate antibiotics in a timely fashion, resulting in improved outcomes for certain patient subgroups. The roles of surgery and infectious disease consultations require further study. Although the rate of mortality from SAB is declining, it remains high. Future international collaborative studies are required to tease out the relative contributions of various factors to mortality, which would enable the optimization of SAB management and patient outcomes.

Characteristics of Invasive Staphylococcus aureus in United Kingdom Neonatal Units

BACKGROUND

In industrialized countries, Staphylococcus aureus (SA) is a leading cause of late-onset neonatal sepsis.

METHODS

Culture-proven episodes were identified prospectively from neonatal units participating in the neonatal infection surveillance network. Demographic, risk factor, and outcome data were collected.

RESULTS

Between 2004 and 2009, there were 117 episodes of SA infections (including 8 methicillin-resistant SA) in 116 infants from 13 units. The median gestational age and birth-weight were 27 weeks (90% ≤ 37 weeks, 85% ≤ 32 weeks) and 850 g (90% ≤ 2500 g), respectively. The overall incidence was 0.6 per 1000 live births and 23/1000 in infants <1500 g. Most episodes (94%) occurred more than 48 hours after birth (late onset). There were 7 early-onset episodes (< 48 hours) (median gestational age, 38.5 weeks), all due to methicillin-susceptible SA. At the time of culture, 67 of 95 (71%) infants were receiving respiratory support and 47 of 94 (50%) had a central line in situ. The majority of infants had nonspecific clinical features although evidence of focal infection (skin, soft tissue, bone, joint, or pneumonia) was ultimately seen in 41 of 91 (45%). There were 18 deaths, 4 (all late onset) directly due to methicillin-susceptible SA sepsis (4.4%).

CONCLUSIONS

SA is the second most common pathogen causing late-onset neonatal infections in this neonatal network. Infants who weigh < 1500 g in intensive care settings are the most vulnerable group. Clinical signs are not sufficiently distinctive to allow targeted therapy, suggesting that an antistaphylococcal agent should be part of empiric therapy for late-onset sepsis in premature infants.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

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.

Antibiotic susceptibility patterns of Staphylococcus aureus isolates from Australian children

AIM

Staphylococcus aureus is an important cause of serious illness in children. Antibiotic resistance is an international problem and affects initial antibiotic choice. We aimed to describe susceptibility patterns of S. aureus isolates from Australian children to inform optimal empiric treatment of staphylococcal infections in this population.

METHODS

We analysed susceptibility data for all S. aureus isolates from children at Australian tertiary paediatric hospitals in 2006. Susceptibility rates were compared between hospitals and states, and with published studies of S. aureus isolates from Australian adults.

RESULTS

Overall, the proportion of methicillin-resistant S. aureus (MRSA) in Australian children was low (9.8%), and in each state it was less than for the comparable adult population. There were significant differences in susceptibility patterns between different states. Most MRSA isolates were susceptible to clindamycin (73%) and all isolates were reported as susceptible to vancomycin. Susceptibility patterns for isolates from bacteraemic patients were similar to those for isolates from all patients.

CONCLUSIONS

These data support current Australian recommendations for the use of flucloxacillin or a first-generation cephalosporin as initial treatment of non-life-threatening staphylococcal infections. However, broad spectrum antibiotic therapy including agents that are effective against MRSA should be considered for more serious infections. Appropriate specimens should be collected for susceptibility testing to enable directed treatment for MRSA and other resistant organisms. This study highlights the importance of using local, age-specific data in planning antibiotic treatment guidelines, as results vary substantially from city to city and between adults and children.

The potential economic value of a Staphylococcus aureus vaccine for neonates

The continuing morbidity and mortality associated with Staphylococcus aureus (S. aureus) infections, especially methicillin-resistant S. aureus (MRSA) infections, have motivated calls to make S. aureus vaccine development a research priority. We developed a decision analytic computer simulation model to determine the potential economic impact of a S. aureus vaccine for neonates. Our results suggest that a S. aureus vaccine for the neonatal population would be strongly cost-effective (and in many situations dominant) over a wide range of vaccine efficacies (down to 10%) for vaccine costs (or=1%).

First outbreak of PVL-positive nonmultiresistant MRSA in a neonatal ICU in Australia: comparison of MALDI-TOF and SNP-plus-binary gene typing

The purpose of this brief report is to describe the first outbreak of a community-associated nonmultiresistant and PVL-positive MRSA strain (CC30) in a neonatal intensive care unit in Australia. The utility of matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF-MS) for microbial typing is compared with single nucleotide polymorphism (SNP) plus binary gene analysis. The composite correlation index analysis of the MALDI-TOF-MS data demonstrated the similar inter-strain relatedness found with the SNP-plus-binary gene typing used to confirm the outbreak. The evolving spread of MRSA emphasizes the importance of surveillance, infection control vigilance and the ongoing investigation of rapid typing methods for MRSA.

International perspective on early-onset neonatal sepsis

Infections are a major cause of neonatal death in developing countries. High-quality information on the burden of early-onset neonatal sepsis and sepsis-related deaths is limited in most of these settings. Simple preventive and treatment strategies have the potential to save many newborns from sepsis-related death. Implementation of public health programs targeting newborn health will assist attainment of Millennium Development Goals of reduction in child mortality.

Spread of methicillin-resistant Staphylococcus aureus USA300 in a neonatal intensive care unit

BACKGROUND

Reports of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in neonatal intensive care units (NICU) and in otherwise healthy patients without obvious risk factors have been increasing in frequency. Described herein is a cluster of cases of CA-MRSA USA300 strains in an NICU affecting infants, health-care workers and the health-care workers' families.

METHODS

Infants and health-care workers with infection and colonization due to MRSA between 1 January 2004 and 30 June 2005 in a tertiary care center NICU in San Antonio, TX were studied. Antimicrobial susceptibility testing and polymerase chain reaction detection of the mecA gene characterized the MRSA isolates. All MRSA cases were reviewed for clinical severity of infection and outcome.

RESULTS

During the 18 months studied, a total of four (0.6%) of 676 infants had CA-MRSA bacteremia or colonization. One infant with necrotizing pneumonia died and three health-care workers who directly cared for the infected infants developed soft-tissue infections caused by CA-MRSA. Four family members of two health-care workers subsequently developed soft-tissue infections. All of the analyzed isolates (eight of nine) belonged to pulsed-field type USA300 and possessed Panton-Valentine leukocidin genes, which have been associated with severe skin and soft-tissue infections, and necrotizing pneumonia.

CONCLUSIONS

It is likely that the CA-MRSA USA300 strain can be transmitted between NICU patients to health-care workers and their family members. The CA-MRSA cases reported here reinforce the virulence of CA-MRSA USA300 strains and emphasize the need to embrace infection control practices designed to protect hospitalized patients, health-care workers and their family members.

Mortality and neurodevelopmental outcome after Staphylococcus aureus bacteremia in infants

We compared outcomes in infants with methicillin-resistant and methicillin-sensitive Staphylococcus aureus bacteremia. Infants with methicillin-resistant S. aureus infection had a longer median duration of bacteremia (4.5 versus 1 day, P = 0.01), but no difference in length of hospital stay, mortality, or neurodevelopmental impairment.

Synthesis, characterisation and antimicrobial activity of copper(II) and manganese(II) complexes of coumarin-6,7-dioxyacetic acid (cdoaH2) and 4-methylcoumarin-6,7-dioxyacetic acid (4-MecdoaH2): X-ray crystal structures of [Cu(cdoa)(phen)2].8.8H(2)O and [Cu(4-Mecdoa)(phen)2].13H2O (phen=1,10-phenanthroline)

Two novel coumarin-based ligands, coumarin-6,7-dioxyacetic acid (1) (cdoaH(2)) and 4-methylcoumarin-6,7-dioxyacetic acid (2) (4-MecdoaH(2)), were reacted with copper(II) and manganese(II) salts to give [Cu(cdoa)(H(2)O)(2)].1.5H(2)O (3), [Cu(4-Mecdoa)(H(2)O)(2)] (4), [Mn(cdoa)(H(2)O)(2)] (5) and [Mn(4-Mecdoa)(H(2)O)(2)].0.5H(2)O (6). The metal complexes, 3-6, were characterised by elemental analysis, IR and UV-Vis spectroscopy, and magnetic susceptibility measurements and were assigned a polymeric structure. 1 and 2 react with Cu(II) in the presence of excess 1,10-phenanthroline (phen) giving [Cu(cdoa)(phen)(2)].8.8H(2)O (7) and [Cu(4-Mecdoa)(phen)(2)].13H(2)O (8), respectively. The X-ray crystal structures of 7 and 8 confirmed trigonal bipyramidal geometries, with the metals bonded to the four nitrogen atoms of the two chelating phen molecules and to a single carboxylate oxygen of the dicarboxylate ligand. The complexes were screened for their antimicrobial activity against a number of microbial species, including methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli and Candida albicans. The metal-free ligands 1 and 2 were active against all of the microbes. Complexes 3-6 demonstrated no significant activity whilst the phen adducts 7 and 8 were active against MRSA (MIC(80)=12.1microM), E. coli (MIC(80)=14.9microM) and Patonea agglumerans (MIC(80)=12.6microM). Complex 7 also demonstrated anti-Candida activity (MIC(80)=22microM) comparable to that of the commercially available antifungal agent ketoconazole (MIC(80)=25microM).

Comparison of community-acquired methicillin-resistant Staphylococcus aureus bacteremia to other staphylococcal species in a neonatal intensive care unit

Hospital acquired infections including staphylococcal species are common in neonatal intensive care units. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) was recently observed in our unit. The clinical and laboratory characteristics of all neonates with Staphylococcus aureus bacteremia during an 11-year period were retrospectively reviewed. Three groups of patients were compared: 1. Patients with CA-MRSA defined as MRSA-resistant only to beta-lactams, but sensitive to all other antibiotic groups and carried SCCmec IV. 2. Patients with multi-drug-resistant (MDR)-MRSA and 3. Patients with MSSA (methicillin-sensitive S. aureus). Forty-three neonates with documented S. aureus bacteremia were included. Of these 41 were preterm babies. Eleven infants had CA-MRSA, 20 had MDR-MRSA and 12 had MSSA bacteremia, the Panton-Valentine-Leukocidine gene (pvl-gene) was not present in any of these strains. Risk factors, clinical manifestations and laboratory tests were similar in all three groups studied. Although neonates infected with CA-MRSA were more premature and had more related diseases, the mortality rate was similar in all groups (9.1% in the CA-MRSA group). Skin infections, osteomyelitis or pneumatocele were not observed more frequently in the CA-MRSA group. We did not find significant differences in risk factors or outcomes in neonates in the three groups. One possible explanation for this observation is that the CA-MRSA outbreak strain did not contain the pvl-gene, which has been suggested to be a significant virulence factor.

Morbidity and mortality of Staphylococcal bacteremia in children

BACKGROUND

Staphylococcal aureus bacteremia (SAB) is a major problem in adult patients with a significant mortality. Less is known about SAB in children. The present study was designed to review a 5-year experience with SAB in a children's hospital.

METHODS

We conducted a retrospective chart review from 2000-2004.

RESULTS

Thirty-six children experienced 42 episodes of SAB and ranged in age from 1 week to 16.7 years with a mean age of 30.5 months. Thirty-two (89%) of the 36 children had preexisting medical conditions. Thirty-six (86%) of 42 episodes of SAB were due to hospital-acquired infections, and 22 (61%) of these 36 episodes occurred in premature infants in the neonatal intensive care unit. Only 3 episodes (7%) of endocarditis were identified, and 2 were community-acquired infections. Fourteen (39%) episodes of SAB were due to methicillin-resistant strains. There were only 3 (8%) deaths, and all were unrelated to SAB.

CONCLUSION

SAB occurred most often as a hospital-acquired infection in the neonatal intensive care unit, and methicillin-resistant Staphylococcal aureus accounted for one third of the episodes. Complications such as endocarditis or other metastatic infections and death because of SAB were infrequent.

Changing trend of neonatal infection: experience at a newly established regional medical center in Korea

BACKGROUND

The purpose of the present paper was to study the natural history of neonatal sepsis in a newly established neonatal intensive care center that started in 1988 at Gyeongsang National University Hospital 9 (GNUH) in Chinju city, Korea.

METHODS

Neonates admitted to GNUH neonatal intensive care unit (NICU) between January 1988 and December 1997 were included. All organisms detected on blood and cerebrospinal fluid cultures were recorded. Neonatal sepsis was defined as 'clinical signs suggestive of sepsis with a positive blood and/or cerebrospinal fluid culture during the neonatal period'. Temporal trends and the distribution of pathogens in identified septic patients during the aforementioned period were studied descriptively.

RESULTS

Between January 1988 and 31 December 1997, 3327 neonates were admitted to the center. A total of 6.7% of neonates (224/3327) had at least one positive blood culture. The vast majority (62%) of septic cases were caused by Gram-positive organisms. Coagulase-negative staphylococci (CONS) were the most common pathogens (24% of all infections, 38% of Gram-positive infections). The pathogen associated with the highest mortality was Klebsiella pneumoniae (25%, 10/39). Sepsis as a result of Gram-negative pathogens (especially K. pneumoniae) were involved in outbreaks that occurred for a few years during the study interval.

CONCLUSIONS

The major outcome of this review was the emergence of CONS in the NICU during a relatively short period of time (10 years) as a common neonatal pathogen. This observation is similar to the experience of other centers over the last two decades.

Topical ointment for preventing infection in preterm infants

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.