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Lowe J, Gillespie D, Aboklaish A, Lau TMM, Consoli C, Babu M, Goddard M, Hood K, Klein N, Thomas-Jones E, Turner M, Hubbard M, Marchesi J, Berrington J, Kotecha S. Azithromycin therapy for prevention of chronic lung disease of prematurity (AZTEC): a multicentre, double-blind, randomised, placebo-controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00079-1. [PMID: 38679042 DOI: 10.1016/s2213-2600(24)00079-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Systematic reviews have reported conflicting evidence on whether macrolide antibiotics reduce rates of chronic lung disease of prematurity (CLD) in at-risk preterm infants born at less than 30 weeks' gestation, including in those colonised with pulmonary Ureaplasma spp. Since an adequately powered trial has been lacking, we aimed to assess if the macrolide azithromycin improved survival without the development of physiologically defined moderate or severe CLD in preterm infants. METHODS AZTEC was a multicentre, double-blind, randomised, placebo-controlled trial conducted in 28 tertiary neonatal intensive care units in the UK. Infants were eligible if they were born at less than 30 weeks' gestation and had received at least 2 h of either non-invasive (continuous positive airway pressure or humidified high flow nasal cannula therapy) or invasive respiratory support (via endotracheal tube) within 72 h of birth. Eligible infants were randomly allocated in a 1:1 ratio using random permuted blocks of four to receive either intravenous azithromycin at 20 mg/kg per day for 3 days followed by 10 mg/kg for 7 days, or to placebo. Allocation was stratified by centre and gestational age at birth (<28 weeks vs ≥28 weeks). Azithromycin and placebo vials were encased in tamper-evident custom cardboard cartons to ensure masking for clinicians, parents, and the research team. The primary outcome was survival without development of physiologically defined moderate or severe CLD at 36 weeks' postmenstrual age. Outcomes and safety were analysed on an intention-to-treat basis (all randomly allocated infants, regardless of any post-randomisation events). The study was registered with ISRCRN (11650227) and is closed. FINDINGS Infants were recruited between Oct 9, 2019, and March 22, 2022. 799 (53·1%) of 1505 eligible infants underwent random allocation; three infants were withdrawn, including consent to use their data, leaving 796 infants for analysis. Survival without moderate or severe CLD occurred in 166 (42%) of 394 infants in the intervention group and 179 (45%) of 402 in the placebo group (three-level adjusted OR [aOR] 0·84, 95% CI 0·55-1·29, p=0·43). Pulmonary Ureaplasma spp colonisation did not influence treatment effect. Overall, seven serious adverse events were reported for the azithromycin group (five graded as severe, two as moderate), and six serious adverse events were reported in the placebo group (two severe, two moderate, and two mild), as assessed by the local principal investigators. INTERPRETATION Since prophylactic use of azithromycin did not improve survival without development of physiologically-defined CLD, regardless of Ureaplasma spp colonisation, it cannot be recommended in clinical practice. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- John Lowe
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | | | - Ali Aboklaish
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK
| | | | - Claudia Consoli
- Central Biotechnology Services, Cardiff University, Cardiff, UK
| | - Malavika Babu
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Mark Goddard
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Nigel Klein
- Institute of Child Health, University College London, London, UK
| | | | - Mark Turner
- Women and Children's Health, University of Liverpool, Liverpool, UK
| | - Marie Hubbard
- Neonatal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Julian Marchesi
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Janet Berrington
- Neonatal Medicine, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK.
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2
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Pavlinac PB, Platts-Mills JA, Liu J, Atlas HE, Gratz J, Operario D, Rogawski McQuade ET, Ahmed D, Ahmed T, Alam T, Ashorn P, Badji H, Bahl R, Bar-Zeev N, Chisti MJ, Cornick J, Chauhan A, De Costa A, Deb S, Dhingra U, Dube Q, Duggan CP, Freyne B, Gumbi W, Hotwani A, Kabir M, Islam O, Kabir F, Kasumba I, Kibwana U, Kotloff KL, Khan SS, Maiden V, Manji K, Mehta A, Ndeketa L, Praharaj I, Qamar FN, Sazawal S, Simon J, Singa BO, Somji S, Sow SO, Tapia MD, Tigoi C, Toure A, Walson JL, Yousafzai MT, Houpt ER. Azithromycin for Bacterial Watery Diarrhea: A Reanalysis of the AntiBiotics for Children With Severe Diarrhea (ABCD) Trial Incorporating Molecular Diagnostics. J Infect Dis 2024; 229:988-998. [PMID: 37405406 PMCID: PMC11011181 DOI: 10.1093/infdis/jiad252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/25/2023] [Accepted: 07/03/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Bacterial pathogens cause substantial diarrhea morbidity and mortality among children living in endemic settings, yet antimicrobial treatment is only recommended for dysentery or suspected cholera. METHODS AntiBiotics for Children with severe Diarrhea was a 7-country, placebo-controlled, double-blind efficacy trial of azithromycin in children 2-23 months of age with watery diarrhea accompanied by dehydration or malnutrition. We tested fecal samples for enteric pathogens utilizing quantitative polymerase chain reaction to identify likely and possible bacterial etiologies and employed pathogen-specific cutoffs based on genomic target quantity in previous case-control diarrhea etiology studies to identify likely and possible bacterial etiologies. RESULTS Among 6692 children, the leading likely etiologies were rotavirus (21.1%), enterotoxigenic Escherichia coli encoding heat-stable toxin (13.3%), Shigella (12.6%), and Cryptosporidium (9.6%). More than one-quarter (1894 [28.3%]) had a likely and 1153 (17.3%) a possible bacterial etiology. Day 3 diarrhea was less common in those randomized to azithromycin versus placebo among children with a likely bacterial etiology (risk difference [RD]likely, -11.6 [95% confidence interval {CI}, -15.6 to -7.6]) and possible bacterial etiology (RDpossible, -8.7 [95% CI, -13.0 to -4.4]) but not in other children (RDunlikely, -0.3% [95% CI, -2.9% to 2.3%]). A similar association was observed for 90-day hospitalization or death (RDlikely, -3.1 [95% CI, -5.3 to -1.0]; RDpossible, -2.3 [95% CI, -4.5 to -.01]; RDunlikely, -0.6 [95% CI, -1.9 to .6]). The magnitude of risk differences was similar among specific likely bacterial etiologies, including Shigella. CONCLUSIONS Acute watery diarrhea confirmed or presumed to be of bacterial etiology may benefit from azithromycin treatment. CLINICAL TRIALS REGISTRATION NCT03130114.
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Affiliation(s)
- Patricia B Pavlinac
- Department of Global Health
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | | | - Jean Gratz
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Darwin Operario
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Tahmina Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Per Ashorn
- Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Henry Badji
- Centre pour le Développement des Vaccines, Bamako, Mali
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Naor Bar-Zeev
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jen Cornick
- Clinical Research Programme, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | | | - Ayesha De Costa
- Department of Maternal, Newborn, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Saikat Deb
- Center for Public Health Kinetics, New Delhi, India
| | - Usha Dhingra
- Center for Public Health Kinetics, New Delhi, India
| | - Queen Dube
- Department of Pediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Nutrition, Boston Children's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bridget Freyne
- Clinical Research Programme, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Women and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland
| | - Wilson Gumbi
- Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Mamun Kabir
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ohedul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Furqan Kabir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Irene Kasumba
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Upendo Kibwana
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Shaila S Khan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Victor Maiden
- Clinical Research Programme, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ashka Mehta
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Latif Ndeketa
- Clinical Research Programme, Malawi Liverpool Wellcome Trust, Blantyre, Malawi
| | - Ira Praharaj
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Farah Naz Qamar
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Jonathon Simon
- Department of Maternal, Newborn, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Benson O Singa
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Samba O Sow
- Centre pour le Développement des Vaccines, Bamako, Mali
| | - Milagritos D Tapia
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Caroline Tigoi
- Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Aliou Toure
- Centre pour le Développement des Vaccines, Bamako, Mali
| | - Judd L Walson
- Department of Global Health
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Infectious Diseases, Department of Pediatrics and Medicine, University of Washington, Seattle
| | | | - Eric R Houpt
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
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Meesters K, Chappell F, Demirjian A. Trends in Antibiotic Use in a Large Children's Hospital in London (United Kingdom): 5 Years of Point Prevalence Surveys. Antibiotics (Basel) 2024; 13:172. [PMID: 38391558 PMCID: PMC10886203 DOI: 10.3390/antibiotics13020172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Background: Antibiotics are commonly prescribed in paediatrics. As their excessive use contributes to adverse drug events, increased healthcare costs, and antimicrobial resistance, antimicrobial stewardship initiatives are essential to optimising medical care. These single-centre point prevalence surveys aimed to provide insights into antibiotic prescribing trends and identify targets for paediatric AMS activities. Methods: 14 point prevalence surveys were conducted from March 2016-April 2021, collecting data on antibiotic prescriptions, indication, adherence to guidelines, and route of administration. The UK adapted the World Health Organisation's AWaRe classification-guided antibiotic categorization. Results: 32.5% of all inpatients were on at least one antimicrobial; this remained stable during all surveys (range: 20-44%, p = 0.448). Of all prescriptions, 67.2% had an end- or review-date, and the majority was for agents in the Watch category (46.8-70.5%). Amoxicillin and clavulanate were the most frequently prescribed antibiotics (20.8%), followed by gentamicin (15.3%). Approximately 28.8% of all prescriptions were for prophylactic indications, while 7.6% of the prescriptions were not adherent to the hospital guidelines. Conclusions: This study highlights the importance of ongoing monitoring and robust AMS initiatives to ensure prudent antibiotic prescribing in paediatric healthcare. It underscores the need for tailored guidelines, educational efforts, and targeted interventions to enhance the quality of antibiotic usage, ultimately benefiting both individual patients and public health.
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Affiliation(s)
- Kevin Meesters
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London SE1 7EH, UK
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
| | - Faye Chappell
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London SE1 7EH, UK
| | - Alicia Demirjian
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London SE1 7EH, UK
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London NW9 5EQ, UK
- Faculty of Life Sciences & Medicine, King's College London, London WC2R 2LS, UK
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4
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Gallacher DJ, Zhang L, Aboklaish AF, Mitchell E, Wach R, Marchesi JR, Kotecha S. Baseline azithromycin resistance in the gut microbiota of preterm born infants. Pediatr Res 2024; 95:205-212. [PMID: 37550487 PMCID: PMC10798878 DOI: 10.1038/s41390-023-02743-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Macrolides, including azithromycin, are increasingly used in preterm-born infants to treat Ureaplasma infections. The baseline carriage of macrolide resistance genes in the preterm stool microbiota is unknown. OBJECTIVES Identify carriage of azithromycin resistant bacteria and the incidence of macrolide resistant genes. METHODS Azithromycin resistant bacteria were isolated from serial stool samples obtained from preterm infants (≤32 weeks' gestation) by culturing aerobically/anaerobically, in the presence/absence of azithromycin. Using quantitative PCR, we targeted 6 common macrolide resistance genes (erm(A), erm(B), erm(C), erm(F), mef(A/E), msr(A)) in DNA extracted from selected bacteria resistant to azithromycin. RESULTS From 89 stool samples from 37 preterm-born infants, 93.3% showed bacterial growth in aerobic or anaerobic conditions. From the 280 azithromycin resistant isolates that were identified, Staphylococcus (75%) and Enterococcus (15%) species dominated. Macrolide resistance genes were identified in 91% of resistant isolates: commonest were erm(C) (46% of isolates) and msr(A) (40%). Multiple macrolide resistance genes were identified in 18% of isolates. CONCLUSION Macrolide resistance is common in the gut microbiota of preterm-born infants early in life, most likely acquired from exposure to the maternal microbiota. It will be important to assess modulation of macrolide resistance, if macrolide treatment becomes routine in the management of preterm infants. IMPACT STATEMENT Azithromycin resistance is present in the stool microbiota in the first month of life in preterm infants 91% of azithromycin resistant bacteria carried at least one of 6 common macrolide resistant genes Increasing use of macrolides in the preterm population makes this an important area of study.
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Affiliation(s)
- David J Gallacher
- Neonatal Unit, University Hospital of Wales, Cardiff, UK
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK
| | - Lei Zhang
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK
| | - Ali F Aboklaish
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK
| | - Emma Mitchell
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK
| | | | - Julian R Marchesi
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK.
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Köstlin-Gille N, Serna-Higuita LM, Bubser C, Arand J, Haag L, Schwarz CE, Heideking M, Poets CF, Gille C. Early initiation of antibiotic therapy and short-term outcomes in preterm infants: a single-centre retrospective cohort analysis. Arch Dis Child Fetal Neonatal Ed 2023; 108:623-630. [PMID: 37137680 PMCID: PMC10646875 DOI: 10.1136/archdischild-2022-325113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Sepsis is one of the most important complications in preterm infants. For this reason, many such infants receive antibiotics during their hospital stay. However, early antibiotic therapy has also been associated with adverse outcome. It is yet largely unclear if the time of onset of antibiotic therapy influences the outcome. We here investigated whether the timing of initiation of antibiotic therapy plays a role in the association between antibiotic exposure and short-term outcome. METHODS Retrospective analysis of data from 1762 very low birthweight infants born in a German neonatal intensive care unit (NICU) between January 2004 and December 2021. RESULTS Antibiotics were administered to 1214 of the 1762 (68.9%) infants. In 973 (55.2%) of the 1762 of infants, antibiotic therapy was initiated within the first two postnatal days. Only 548 (31.1%) infants did not have any antibiotic prescription during their stay in the NICU. Antibiotic exposure at every timepoint was associated with an increased risk of all short-term outcomes analysed in univariable analyses. In multivariable analyses, initiation of antibiotic therapy within the first two postnatal days and initiation between postnatal days 3 and 6 was independently associated with an increased risk of developing bronchopulmonary dysplasia (BPD) (OR 3.1 and 2.8), while later initiation of antibiotic therapy was not. CONCLUSION Very early initiation of antibiotic therapy was associated with an increased risk of BPD. Due to the study design, no conclusions on causality can be drawn. If confirmed, our data suggest that an improved identification of infants at low risk of early-onset sepsis is needed to reduce antibiotic exposure.
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Affiliation(s)
| | - Lina Maria Serna-Higuita
- Department of Clinical Epidemiology and Applied Biostatistics, Eberhard Karls University, Tübingen, Germany
| | - Caren Bubser
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Joerg Arand
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Laura Haag
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | | | - Martin Heideking
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Christian F Poets
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Christian Gille
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
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Li S, Huang L, Zeng L, Yu D, Jia ZJ, Cheng G, Wang H, Zhang L. Potentially inappropriate prescribing in hospitalised children: a retrospective, cross-sectional study at a tertiary children's hospital in China. BMJ Open 2023; 13:e068680. [PMID: 37130666 PMCID: PMC10163496 DOI: 10.1136/bmjopen-2022-068680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
INTRODUCTION For improving and optimising drug use in children, we previously developed a tool (including a series of criteria for identifying potentially inappropriate prescribing in children) by literature review and the two-round Delphi technique to prevent inappropriate medication prescriptions at the prescribing stage. OBJECTIVE To assess the prevalence of potentially inappropriate prescription (PIP) among hospitalised children and explore risk factors associated with PIP. DESIGN A retrospective cross-sectional study. SETTING A tertiary children's hospital in China. PARTICIPANTS Hospitalised children with complete medical records who received drug treatment and discharged from 1 January to 31 December 2021. OUTCOME MEASURES We evaluated the medication prescriptions by using a series of previously developed criteria for detecting the prevalence of PIP in hospitalised children and used logistic regression to explore the risk factors (including sex, age, number of drugs, number of comorbidities, days of hospitalisation and admission departments) for PIP in children. RESULTS A total of 87 555 medication prescriptions for 16 995 hospitalised children were analysed, and 19 722 PIPs were detected. The prevalence of PIP was 22.53%, and 36.92% of the children had at least one PIP during hospitalisation. The department with the highest prevalence of PIP was the surgical department (OR 9.413; 95% CI 5.521 to 16.046), followed by the paediatric intensive care unit (PICU; OR 8.206; 95% CI 6.643 to 10.137). 'Inhaled corticosteroids for children with respiratory infections but without chronic respiratory diseases' was the most frequent PIP. Logistic regression results showed that PIP was more likely to occur in male patients (OR 1.128, 95% CI 1.059 to 1.202) and younger patients (<2 years old; OR 1.974; 95% CI 1.739 to 2.241), and in those with more comorbidities (≥11 types; OR 4.181; 95% CI 3.671 to 4.761), concomitant drugs (≥11 types; OR 22.250; 95% CI 14.468 to 34.223) or longer hospital stay (≥30 days; OR 8.130; 95% CI 6.727 to 9.827). CONCLUSIONS Medications for long-term hospitalised young children with multiple comorbidities should be minimised and optimised, to avoid PIP, reduce adverse drug reactions and ensure children's medication safety. The surgery department and PICU had a high prevalence of PIP in the studied hospital and should be the focus of supervision and management in routine prescription review.
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Affiliation(s)
- Siyu Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
| | - Dan Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhi-Jun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Guo Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - Huiqing Wang
- Medical Simulation Centre, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Ministry of Education, Chengdu, China
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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7
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Calthorpe RJ, Poulter C, Smyth AR, Sharkey D, Bhatt J, Jenkins G, Tatler AL. Complex roles of TGF-β signaling pathways in lung development and bronchopulmonary dysplasia. Am J Physiol Lung Cell Mol Physiol 2023; 324:L285-L296. [PMID: 36625900 PMCID: PMC9988523 DOI: 10.1152/ajplung.00106.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
As survival of extremely preterm infants continues to improve, there is also an associated increase in bronchopulmonary dysplasia (BPD), one of the most significant complications of preterm birth. BPD development is multifactorial resulting from exposure to multiple antenatal and postnatal stressors. BPD has both short-term health implications and long-term sequelae including increased respiratory, cardiovascular, and neurological morbidity. Transforming growth factor β (TGF-β) is an important signaling pathway in lung development, organ injury, and fibrosis and is implicated in the development of BPD. This review provides a detailed account on the role of TGF-β in antenatal and postnatal lung development, the effect of known risk factors for BPD on the TGF-β signaling pathway, and how medications currently in use or under development, for the prevention or treatment of BPD, affect TGF-β signaling.
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Affiliation(s)
- Rebecca J Calthorpe
- Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,NIHR Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Caroline Poulter
- Department of Pediatrics, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Alan R Smyth
- Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,NIHR Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Don Sharkey
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Jayesh Bhatt
- Department of Pediatrics, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Amanda L Tatler
- NIHR Nottingham Biomedical Research Centre, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
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8
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Van Mechelen K, van Westering-Kroon E, Hütten M, Mahieu L, Villamor E. Placing Ureaplasma within the Context of Bronchopulmonary Dysplasia Endotypes and Phenotypes. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020256. [PMID: 36832386 PMCID: PMC9955705 DOI: 10.3390/children10020256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023]
Abstract
Different pathophysiological pathways (endotypes), leading to very preterm birth may result in distinct clinical phenotypes of bronchopulmonary dysplasia (BPD). Ureaplasma is a unique player in the pathogenesis of BPD. The interaction between factors inherent to Ureaplasma (virulence, bacterial load, duration of exposure), and to the host (immune response, infection clearance, degree of prematurity, respiratory support, concomitant infections) may contribute to BPD development in a variable manner. The data reviewed herein support the hypothesis that Ureaplasma, as a representative of the infectious/inflammatory endotype, may produce pulmonary damage predominantly in parenchyma, interstitium, and small airways. In contrast, Ureaplasma may have a very limited role in the pathogenesis of the vascular phenotype of BPD. In addition, if Ureaplasma is a key factor in BPD pathogenesis, its eradication by macrolides should prevent BPD. However, various meta-analyses do not show consistent evidence that this is the case. The limitations of current definitions and classifications of BPD, based on respiratory support needs instead of pathophysiology and phenotypes, may explain this and other failures in strategies aimed to prevent BPD. The precise mechanisms through which Ureaplasma infection leads to altered lung development and how these pathways can result in different BPD phenotypes warrant further investigation.
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Affiliation(s)
- Karen Van Mechelen
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Elke van Westering-Kroon
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Matthias Hütten
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Ludo Mahieu
- Department of Neonatology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
- Correspondence:
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9
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Matsyura O, Besh L, Borysiuk O, Besh O, Kondratyuk M, Sorokopud O, Zubchenko S. EFFICACY OF PRIMARY REHABILITATION MEASURES ASSOCIATED WITH THE DEVELOPMENT OF RECURRENT BRONCHIAL OBSTRUCTION SYNDROME IN YOUNG CHILDREN WITH RESPIRATORY DISORDERS IN NEONATAL PERIOD. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:17-25. [PMID: 36883485 DOI: 10.36740/wlek202301102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The aim: To improve primary prophylactic measures associated with the development and progression of recurrent bronchial obstruction syndrome in young children, who had suffered respiratory disorders in neonatal period. PATIENTS AND METHODS Materials and methods: Algorithm of primary prophylactic measures implied adequate balanced nutrition, sanation of living conditions, restriction of contact with infectious agents, sanation of chronic foci of infection, systematic training and general fitness. The investigation included 160 young children (1 day - 3 years of age). The basic group (n=80) involved children, who had experienced respiratory disorders in neonatal period and received appropriate respiratory therapy (artificial ventilation and / or spontaneous breathing with continuous positive airway pressure and supply of free oxygen), control group - children, who did not have respiratory disorders and respiratory therapy (n=80). RESULTS Results: Conducted investigation throughout 12-month monitoring enabled to record the development of recurrent bronchial obstruction syndrome in 43 children (respectively, 30 - 37.50% patients of the basic group versus 13 - 16.25% of control group; p 0.05), could not be obtained. CONCLUSION Conclusions: Comparative analysis within groups did not show a reliable difference in the development of recurrent bronchial obstruction syndrome in children (р>0.05), which can be explained by partial following of doctor's recommendations. There is the need in further study of the issue involving more patients for a longer period of monitoring.
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Affiliation(s)
- Oksana Matsyura
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | - Lesya Besh
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | - Olena Borysiuk
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | - Olesia Besh
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | | | - Olena Sorokopud
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
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10
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Kotecha SJ, Course CW, Jones KE, Watkins WJ, Berrington J, Gillespie D, Kotecha S. Follow-up study of infants recruited to the randomised, placebo-controlled trial of azithromycin for the prevention of chronic lung disease of prematurity in preterm infants-study protocol for the AZTEC-FU study. Trials 2022; 23:796. [PMID: 36131325 PMCID: PMC9490707 DOI: 10.1186/s13063-022-06730-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background Preterm birth, especially at less than 30 weeks’ gestation, is significantly associated with respiratory, neurodevelopmental and growth abnormalities. The AZTEC study has recruited 799 infants born at < 30 weeks’ gestation to determine if a ten-day intravenous treatment with azithromycin improves survival without development of chronic lung disease of prematurity (CLD) at 36 weeks’ post menstrual age (PMA) when compared to placebo. The follow-up studies will compare respiratory, neurodevelopmental and growth outcomes up to 2 years of corrected age between infants who received azithromycin and those who received placebo in the early neonatal period. Methods Survivors at 36 weeks’ PMA from the main Azithromycin Therapy for Chronic Lung Disease of Prematurity (AZTEC) study with parental consent will continue to be followed up to discharge from the neonatal unit and to 2 years of corrected age. Length of stay, rates of home oxygen, length of supplemental oxygen requirement, hospital admissions, drug usage, respiratory illness, neurodevelopmental disability and death rates will be reported. Data is being collected via parentally completed respiratory and neurodevelopmental questionnaires at 1 and 2 years of corrected age respectively. Additional information is being obtained from various sources including hospital discharge and clinical letters from general practitioners and hospitals as well as from national databases including the National Neonatal Research Database and NHS Digital. Discussion The AZTEC-FU study will assess mortality and important neonatal morbidities including respiratory, neurodevelopmental and growth outcomes. Important safety data will also be collected, including the incidence of potential consequences of early macrolide use, primarily pyloric stenosis. This study may have implications on future neonatal care. Trial registration The study was retrospectively registered on ISRCTN (ISRCTN47442783).
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Affiliation(s)
- Sarah J Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - Christopher W Course
- Department of Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - Kathryn E Jones
- Department of Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - W John Watkins
- Department of Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - Janet Berrington
- Neonatal Intensive Care Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - David Gillespie
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK.
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11
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Lau TMM, Lowe J, Pickles T, Hood K, Kotecha S, Gillespie D. AZTEC-azithromycin therapy for prevention of chronic lung disease of prematurity: a statistical analysis plan for clinical outcomes. Trials 2022; 23:704. [PMID: 35999617 PMCID: PMC9396905 DOI: 10.1186/s13063-022-06604-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background The AZTEC trial is a multi-centre, randomised, placebo-controlled trial of azithromycin to improve survival without development of chronic lung disease of prematurity (CLD) in preterm infants. The statistical analysis plan for the clinical outcomes of the AZTEC trial is described. Methods and design A double-blind, randomised, placebo-controlled trial of a 10-day course of intravenous azithromycin (20 mg/kg for 3 days; 10 mg/kg for 7 days) administered to preterm infants born at < 30 weeks’ gestational age across UK tertiary neonatal units. Following parental consent, infants are randomly allocated to azithromycin or placebo, with allocated treatment starting within 72 h of birth. The primary outcome is survival without moderate/severe CLD at 36 weeks’ postmenstrual age (PMA). Serial respiratory fluid and stool samples are being collected up to 21 days of life. The target sample size is 796 infants, which is based on detecting a 12% absolute difference in survival without moderate/severe CLD at 36 weeks’ PMA (90% power, two-sided alpha of 0.05) and includes 10% loss to follow-up. Results Baseline demographic and clinical characteristics will be summarised by treatment arm and in total. Categorical data will be summarised by numbers and percentages. Continuous data will be summarised by mean, standard deviation, if data are normal, or median, interquartile range, if data are skewed. Tests of statistical significance will not be undertaken for baseline characteristics. The primary analysis, on the intention to treat (ITT) population, will be analysed using multilevel logistic regression, within a multiple imputation framework. Adjusted odds ratios, 95% confidence intervals, and p-values will be presented. For all other analyses, the analysis population will be based on the complete case population, which is a modified ITT population. All analyses will be adjusted for gestational age and treatment arm and account for any clustering by centre and/or multiple births as a random effect. Conclusion We describe the statistical analysis plan for the AZTEC trial, including the analysis principles, definitions of the key clinical outcomes, methods for primary analysis, pre-specified subgroup analysis, sensitivity analysis, and secondary analysis. The plan has been finalised prior to the completion of recruitment. Trial registration ISRCTN registry ISRCTN11650227. Registered on 31 July 2018.
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Affiliation(s)
| | - John Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
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12
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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13
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Sakaria RP, Dhanireddy R. Pharmacotherapy in Bronchopulmonary Dysplasia: What Is the Evidence? Front Pediatr 2022; 10:820259. [PMID: 35356441 PMCID: PMC8959440 DOI: 10.3389/fped.2022.820259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Bronchopulmonary Dysplasia (BPD) is a multifactorial disease affecting over 35% of extremely preterm infants born each year. Despite the advances made in understanding the pathogenesis of this disease over the last five decades, BPD remains one of the major causes of morbidity and mortality in this population, and the incidence of the disease increases with decreasing gestational age. As inflammation is one of the key drivers in the pathogenesis, it has been targeted by majority of pharmacological and non-pharmacological methods to prevent BPD. Most extremely premature infants receive a myriad of medications during their stay in the neonatal intensive care unit in an effort to prevent or manage BPD, with corticosteroids, caffeine, and diuretics being the most commonly used medications. However, there is no consensus regarding their use and benefits in this population. This review summarizes the available literature regarding these medications and aims to provide neonatologists and neonatal providers with evidence-based recommendations.
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Affiliation(s)
- Rishika P. Sakaria
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, United States
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14
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Gandecha H, Boyle EM. Randomised trial of azithromycin to eradicate Ureaplasma in preterm infants. Acta Paediatr 2022; 111:696-697. [PMID: 34762753 DOI: 10.1111/apa.16159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Hema Gandecha
- University Hospitals of Leicester NHS Trust Leicester UK
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15
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Naples R, Ramaiah S, Rankin J, Berrington J, Harigopal S. Life-threatening bronchopulmonary dysplasia: a British Paediatric Surveillance Unit Study. Arch Dis Child Fetal Neonatal Ed 2022; 107:13-19. [PMID: 34183433 PMCID: PMC8685630 DOI: 10.1136/archdischild-2021-322001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/25/2021] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To assess the minimum incidence of life-threatening bronchopulmonary dysplasia (BPD), defined as need for positive pressure respiratory support or pulmonary vasodilators at 38 weeks corrected gestational age (CGA), in infants born <32 weeks gestation in the UK and Ireland; and to describe patient characteristics, management and outcomes to 1 year. METHODS Prospective national surveillance study performed via the British Paediatric Surveillance Unit from June 2017 to July 2018. Data were collected in a series of three questionnaires from notification to 1 year of age. RESULTS 153 notifications met the case definition, giving a minimum incidence of 13.9 (95% CI: 11.8 to 16.3) per 1000 live births <32 weeks' gestation. Median gestation was 26.1 (IQR 24.6-28) weeks, and birth weight 730 g (IQR 620-910 g). More affected infants were male (95 of 153, 62%; p<0.05). Detailed management and outcome data were provided for 94 infants. Fifteen died at median age 159 days (IQR 105-182) or 49.6 weeks CGA (IQR 43-53). Median age last receiving invasive ventilation was 50 days (IQR 22-98) and total duration of pressure support for surviving infants 103 (IQR 87-134) days. Fifty-seven (60.6%) received postnatal steroids and 22 (23.4%) pulmonary vasodilators. Death (16%) and/or major neurodevelopmental impairment (37.3%) or long-term ventilation (23.4%) were significantly associated with need for invasive ventilation near term and pulmonary hypertension. CONCLUSIONS This definition of life-threatening BPD identified an extremely high-risk subgroup, associated with serious morbidity and mortality. Wide variability in management was demonstrated, and future prospective study, particularly in key areas of postnatal steroid use and pulmonary hypertension management, is required.
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Affiliation(s)
- Rebecca Naples
- Neonatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sridhar Ramaiah
- Neonatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Janet Berrington
- Neonatology, Royal Victoria Infirmary, Newcastle upon Tyne, UK,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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16
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Randomized trial of azithromycin to eradicate Ureaplasma respiratory colonization in preterm infants: 2-year outcomes. Pediatr Res 2022; 91:178-187. [PMID: 33658655 PMCID: PMC8413397 DOI: 10.1038/s41390-021-01437-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND To assess the potential impact of azithromycin treatment in the first week following birth on 2-year outcomes in preterm infants with and without Ureaplasma respiratory colonization who participated in a double-blind, placebo-controlled randomized controlled trial. METHODS Respiratory morbidity was assessed at NICU discharge and at 6, 12, and 22-26 months corrected age using pulmonary questionnaires. Comprehensive neurodevelopmental assessments were completed between 22 and 26 months corrected age. The primary and secondary composite outcomes were death or severe respiratory morbidity and death or moderate-severe neurodevelopmental impairment, respectively, at 22-26 months corrected age. RESULTS One hundred and twenty-one randomized participants (azithromycin, N = 60; placebo, N = 61) were included in the intent-to-treat analysis. There were no significant differences in death or serious respiratory morbidity (34.8 vs 30.4%, p = 0.67) or death or moderate-severe neurodevelopmental impairment (47 vs 33%, p = 0.11) between the azithromycin and placebo groups. Among all trial participants, tracheal aspirate Ureaplasma-positive infants experienced a higher frequency of death or serious respiratory morbidity at 22-26 months corrected age (58%) than tracheal aspirate Ureaplasma-negative infants (34%) or non-intubated infants (21%) (p = 0.028). CONCLUSIONS We did not observe strong evidence of a difference in long-term pulmonary and neurodevelopment outcomes in preterm infants treated with azithromycin in the first week of life compared to placebo. IMPACT No strong evidence of a difference in long-term pulmonary and neurodevelopment outcomes was identified at 22-26 months corrected age in infants treated with azithromycin in the first week of life compared to placebo. The RCT is the first study of 2-year pulmonary and neurodevelopmental outcomes of azithromycin treatment in ELGANs. Provides evidence that ELGANs with lower respiratory tract Ureaplasma have the most frequent serious respiratory morbidity in the first 2 years of life, suggesting that a Phase III trial of azithromycin to prevent BPD targeting this population is warranted.
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17
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Fobe C, Van Grambezen B, Moniotte S, Vo C, Dussart A, Danhaive O, Piersigilli F. Torsade de pointe due to QT prolongation following erythromycin administration in a preterm infant. Acta Cardiol 2021; 77:597-601. [PMID: 34420486 DOI: 10.1080/00015385.2021.1968153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality in preterm infants. Chorioamnionitis is an important risk factor for the development of sepsis, therefore neonates born to mothers developing signs of amnionitis need to be treated with antibiotics immediately after birth. Ureaplasma spp can be a causative agent of vaginal or intra amniotic infection needing antibiotic treatment. Macrolides are frequently used to treat maternal intrauterine infection, but antibiotic treatment of the neonate should be consciously chosen with consideration of potential side effects. Indeed, macrolides are great purveyors of heart rhythm disorders. CASE PRESENTATION We describe the case of a 29 weeks preterm infant born to a mother with Ureaplasma spp infection. The baby was treated with erythromycin immediately after birth. During the second day of life, the baby presented some episodes of tachyarrhythmia with premature ventricular beats (PVBs) that were followed by a non-sustained ventricular tachycardia as high as 270 bpm leading to a cardiac arrest. After resuscitation, tachycardia resolved but the rhythm was characterised by numerous PVBs and an electrocardiogram (ECG) diagnosed a Long QT Syndrome (LQTS). Erythromycin was discontinued, and the rhythm normalised a few days after withdrawal. CONCLUSIONS Erythromycin should be administered in neonates only if no other choice is available, as although generally well tolerated, its administration can be associated with QTc interval prolongation. When no other option is available, paediatricians should be aware to perform cardiac monitoring or at least serial ECGs before and during erythromycin administration.
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Affiliation(s)
- Caroline Fobe
- Department of Neonatology, Cliniques Universitaires Saint Luc, Bruxelles, Belgium
| | | | - Stéphane Moniotte
- Department of Pediatric Cardiology, Cliniques Universitaires Saint Luc, Bruxelles, Belgium
| | - Christophe Vo
- Department of Pediatric Cardiology, Cliniques Universitaires Saint Luc, Bruxelles, Belgium
| | | | - Olivier Danhaive
- Department of Neonatology, Cliniques Universitaires Saint Luc, Bruxelles, Belgium
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18
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Hennelly M, Greenberg RG, Aleem S. An Update on the Prevention and Management of Bronchopulmonary Dysplasia. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2021; 12:405-419. [PMID: 34408533 PMCID: PMC8364965 DOI: 10.2147/phmt.s287693] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 12/22/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a common morbidity affecting preterm infants and is associated with substantial long-term disabilities. There has been no change in the incidence of BPD over the past 20 years, despite improvements in survival and other outcomes. The preterm lung is vulnerable to injuries occurring as a result of invasive ventilation, hyperoxia, and infections that contribute to the development of BPD. Clinicians caring for infants in the neonatal intensive care unit use multiple therapies for the prevention and management of BPD. Non-invasive ventilation strategies and surfactant administration via thin catheters are treatment approaches that aim to avoid volutrauma and barotrauma to the preterm developing lung. Identifying high-risk infants to receive postnatal corticosteroids and undergo patent ductus arteriosus closure may help to individualize care and promote improved lung outcomes. In infants with established BPD, outpatient management is complex and requires coordination from several specialists and therapists. However, most current therapies used to prevent and manage BPD lack solid evidence to support their effectiveness. Further research is needed with appropriately defined outcomes to develop effective therapies and impact the incidence of BPD.
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Affiliation(s)
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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19
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Villosis MFB, Barseghyan K, Ambat MT, Rezaie KK, Braun D. Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle. JAMA Netw Open 2021; 4:e2114140. [PMID: 34181013 PMCID: PMC8239950 DOI: 10.1001/jamanetworkopen.2021.14140] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019). INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURES The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTS The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCE A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.
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Affiliation(s)
- Maria Fe B. Villosis
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Karine Barseghyan
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Ma. Teresa Ambat
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Kambiz K. Rezaie
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - David Braun
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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Association between maternal cervicovaginal swab positivity for Ureaplasma spp. or other microorganisms and neonatal respiratory outcome and mortality. J Perinatol 2021; 41:1-11. [PMID: 32908191 DOI: 10.1038/s41372-020-00808-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/04/2020] [Accepted: 08/27/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We investigated the association between maternal cervicovaginal cultures, its antibiotic treatment, and neonatal outcome. STUDY DESIGN This retrospective cohort study enrolled 480 neonates born prior to 32 weeks' gestation. They were divided into groups according to maternal cervicovaginal culture results. Multivariate logistic regression analysis was used to predict neonatal outcome based on maternal culture results, adjusted for perinatal risk factors and neonatal morbidities. RESULT Maternal cervicovaginal Ureaplasma colonization was independently associated with bronchopulmonary dysplasia at 36 weeks (BPD) (OR 8.34; 95% CI 1.21-57.45). In neonates with and without maternal cervicovaginal Ureaplasma colonization BPD occurred in 12.3% and 3.8%, respectively. Maternal colonization with other microorganisms was associated with a higher neonatal mortality (p = 0.002), lower gestational age (p = 0.026), and birth weight (p = 0.036). CONCLUSIONS This study underscores the role of the maternal cervicovaginal microbiome as a predictor of neonatal outcome. Cervicovaginal Ureaplasma colonization seems not to be an innocent bystander in the multifactorial etiology of BPD.
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21
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Razak A, Alshehri N. Azithromycin for preventing bronchopulmonary dysplasia in preterm infants: A systematic review and meta-analysis. Pediatr Pulmonol 2021; 56:957-966. [PMID: 33382534 DOI: 10.1002/ppul.25230] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 11/30/2020] [Accepted: 12/11/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT Azithromycin has anti-Ureaplasma and anti-inflammatory properties that might help reduce lung injury in preterm infants. OBJECTIVE To test the efficacy and safety of prophylactic or therapeutic azithromycin in preventing bronchopulmonary dysplasia (BPD) in preterm infants with unknown or proven Ureaplasma status. METHODS We searched PubMed, Web of Science, and Cochrane Library until 13 September 2020. Two authors independently assessed the eligibility, risk of bias, and extracted the data. We performed a random-effects model meta-analysis to yield pooled relative risk (RR) or mean difference (MD) with 95% confidence interval (CI). We used the Cochrane GRADE methodology for summarizing the results. RESULTS We included five randomized clinical trials. The meta-analysis revealed no significant differences in BPD (RR, 0.92; 95% CI, 0.71, 1.19; low-quality evidence), death (RR, 0.75; 95% CI, 0.52, 1.10; low-quality evidence), and BPD or death (RR, 0.90; 95% CI, 0.74, 1.10; low-quality evidence). However, a significantly lower BPD or death (RR, 0.83; 95% CI, 0.70, 0.99) and a trend toward lower BPD (RR, 0.83; 95% CI, 0.66, 1.03) with azithromycin therapy was noted in Ureoplasma positive neonates. No differences in secondary outcomes were noted, except for significantly lower supplemental oxygen days with azithromycin (MD, -6.06; 95% CI, -7.40, -4.72; moderate-quality evidence). The test for subgroup differences between short (<7 days) and long (>7 days) course of azithromycin were nonsignificant for all the outcomes. CONCLUSION Low-quality evidence suggests azithromycin therapy reduces BPD or death in preterm infants with positive Ureoplasma, but not in all preterm infants.
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Affiliation(s)
- Abdul Razak
- Division of Neonatology, Department of Pediatrics, Princess Nourah Bint Abdulrahman University, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Norah Alshehri
- Division of Neonatology, Department of Pediatrics, Princess Nourah Bint Abdulrahman University, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
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22
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Abstract
Ureaplasma species are increasingly recognized as relevant pathogens in prenatal, perinatal and postnatal morbidity. They are commonly found as commensals on the mucous membranes of the lower urogenital tract of pregnant women, but when ascending, they can cause bacterial vaginosis, chorioamnionitis, premature birth and postnatal morbidities such as bronchopulmonary dysplasia, and early-onset neonatal sepsis and meningitis. The detection of Ureaplasma species is challenging and is not covered by routine diagnostics, and current empiric antibiotic treatment in neonates suspected of infection is not directed against Ureaplasma species. The aim of this review is to discuss the pathophysiology of Ureaplasma infections, the clinical consequences and the current difficulties in diagnosis and treatment by providing an overview of the current literature.
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Affiliation(s)
- Kim Stol
- From the Division of Pediatric Infectious Diseases, Immunology and Rheumatology, Department of Pediatrics
| | - Jop Jans
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Lisa Ott de Bruin
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wendy Unger
- Laboratory of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Annemarie van Rossum
- From the Division of Pediatric Infectious Diseases, Immunology and Rheumatology, Department of Pediatrics
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN-BASEL 2021; 8:children8040298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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Mikami Y, Fuwa K, Arima E, Suda Y, Yanagihara I, Ibara S. Validation of the loop-mediated isothermal amplification method for rapid and sensitive detection of Ureaplasma species in respiratory tracts of preterm infants. PLoS One 2021; 16:e0247618. [PMID: 33661943 PMCID: PMC7932158 DOI: 10.1371/journal.pone.0247618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/09/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction A simple and rapid diagnosis of Ureaplasma spp. is required for the choice of the appropriate antibiotic. However, an ideal detection method has not been available. This study examines the efficacy of the loop-mediated isothermal amplification (LAMP) assay, which provides rapid and sensitive results, to detect Ureaplasma spp. in respiratory tract samples of preterm infants. Methods The study included preterm infants born before 32 weeks of gestation admitted Kagoshima City Hospital from June 2018 to March 2020. Nasopharyngeal swabs and/or tracheal aspirates were obtained in the first seven postnatal days. One hundred sixty-seven nasopharyngeal swabs and 101 tracheal aspirates were analyzed by LAMP, culture, and quantitative real-time polymerase chain reaction. Results All 167 infants had a median (range) gestational age of 28.7 weeks (22.3–30.9) and birthweight 1030g (322–1828). One hundred sixty-seven nasopharyngeal swabs and 101 tracheal aspirates were obtained. In the results of nasopharyngeal swabs, the sensitivity and specificity of LAMP were 73.9% (17/23) and 97.2% (140/144), whereas those of quantitative real-time polymerase chain reaction were 73.9% (17/23) and 95.8% (138/144), compared to culture. In the results of tracheal aspirates, the sensitivity and specificity of LAMP were 89.5% (17/19) and 92.7% (76/82), whereas those of quantitative real-time polymerase chain reaction were 89.5% (17/19) and 93.9% (77/82), compared to culture. Conclusions The LAMP assay showed similar sensitivity and specificity with quantitative real-time polymerase chain reaction in the respiratory tracts of preterm infants including extremely preterm infants during the immediate postnatal period. Therefore, the LAMP is a practical alternative for the early detection so that appropriate antibiotics can be administered for preventing BPD.
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Affiliation(s)
- Yuta Mikami
- Department of Neonatal Medicine, Kagoshima City Hospital, Kagoshima, Japan
- Department of Creation of Community Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Kazumasa Fuwa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Itabashi, Tokyo, Japan
- * E-mail:
| | - Eriko Arima
- Department of Chemistry, Biotechnology and Chemical Engineering, Graduate School of Science and Engineering, Kagoshima University, Kagoshima, Japan
| | - Yasuo Suda
- Department of Chemistry, Biotechnology and Chemical Engineering, Graduate School of Science and Engineering, Kagoshima University, Kagoshima, Japan
| | - Itaru Yanagihara
- Department of Developmental Medicine, Research Institute, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Satoshi Ibara
- Department of Neonatal Medicine, Kagoshima City Hospital, Kagoshima, Japan
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MSC Based Therapies to Prevent or Treat BPD-A Narrative Review on Advances and Ongoing Challenges. Int J Mol Sci 2021; 22:ijms22031138. [PMID: 33498887 PMCID: PMC7865378 DOI: 10.3390/ijms22031138] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) remains one of the most devastating consequences of preterm birth resulting in life-long restrictions in lung function. Distorted lung development is caused by its inflammatory response which is mainly provoked by mechanical ventilation, oxygen toxicity and bacterial infections. Dysfunction of resident lung mesenchymal stem cells (MSC) represents one key hallmark that drives BPD pathology. Despite all progress in the understanding of pathomechanisms, therapeutics to prevent or treat BPD are to date restricted to a few drugs. The limited therapeutic efficacy of established drugs can be explained by the fact that they fail to concurrently tackle the broad spectrum of disease driving mechanisms and by the huge overlap between distorted signal pathways of lung development and inflammation. The great enthusiasm about MSC based therapies as novel therapeutic for BPD arises from the capacity to inhibit inflammation while simultaneously promoting lung development and repair. Preclinical studies, mainly performed in rodents, raise hopes that there will be finally a broadly acting, efficient therapy at hand to prevent or treat BPD. Our narrative review gives a comprehensive overview on preclinical achievements, results from first early phase clinical studies and challenges to a successful translation into the clinical setting.
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Sun T, Yu H, Fu J. Respiratory Tract Microecology and Bronchopulmonary Dysplasia in Preterm Infants. Front Pediatr 2021; 9:762545. [PMID: 34966701 PMCID: PMC8711720 DOI: 10.3389/fped.2021.762545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/22/2021] [Indexed: 12/23/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a severe respiratory complication in preterm infants. Although the etiology and pathogenesis of BPD are complex and remain to be clarified, recent studies have reported a certain correlation between the microecological environment of the respiratory tract and BPD. Changes in respiratory tract microecology, such as abnormal microbial diversity and altered evolutional patterns, are observed prior to the development of BPD in premature infants. Therefore, research on the colonization and evolution of neonatal respiratory tract microecology and its relationship with BPD is expected to provide new ideas for its prevention and treatment. In this paper, we review microecological changes in the respiratory tract and the mechanisms by which they can lead to BPD in preterm infants.
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Affiliation(s)
- Tong Sun
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Haiyang Yu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jianhua Fu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
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27
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Lowe J, Gillespie D, Hubbard M, Zhang L, Kirby N, Pickles T, Thomas-Jones E, Turner MA, Klein N, Marchesi JR, Hood K, Berrington J, Kotecha S. Study protocol: azithromycin therapy for chronic lung disease of prematurity (AZTEC) - a randomised, placebo-controlled trial of azithromycin for the prevention of chronic lung disease of prematurity in preterm infants. BMJ Open 2020; 10:e041528. [PMID: 33028566 PMCID: PMC7539578 DOI: 10.1136/bmjopen-2020-041528] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Chronic lung disease of prematurity (CLD), also known as bronchopulmonary dysplasia (BPD), is a cause of significant respiratory morbidity in childhood and beyond. Coupled with lung immaturity, infections (especially by Ureaplasma spp) are implicated in the pathogenesis of CLD through promotion of pulmonary inflammation. Azithromycin, which is a highly effective against Ureaplasma spp also has potent anti-inflammatory properties. Thus, azithromycin therapy may improve respiratory outcomes by targeting infective and inflammatory pathways. Previous trials using macrolides have not been sufficiently powered to definitively assess CLD rates. To address this, the azithromycin therapy for chronic lung disease of prematurity (AZTEC) trial aims to determine if a 10-day early course of intravenous azithromycin improves rates of survival without CLD when compared with placebo with an appropriately powered study. METHODS AND ANALYSIS 796 infants born at less than 30 weeks' gestational age who require at least 2 hours of continuous respiratory support within the first 72 hours following birth are being enrolled by neonatal units in the UK. They are being randomised to receive a double-blind, once daily dose of intravenous azithromycin (20 mg/kg for 3 days, followed by 10 mg/kg for a further 7 days), or placebo. CLD is being assessed at 36 weeks' PMA. Whether colonisation with Ureaplasma spp prior to randomisation modifies the treatment effect of azithromycin compared with placebo will also be investigated. Secondary outcomes include necrotising enterocolitis, intraventricular/cerebral haemorrhage, retinopathy of prematurity and nosocomial infections, development of antibiotic resistance and adverse reactions will be monitored. ETHICS AND DISSEMINATION Ethics permission has been granted by Wales Research Ethics Committee 2 (Ref 18/WA/0199), and regulatory permission by the Medicines and Healthcare Products Regulatory Agency (Clinical Trials Authorisation reference 21323/0050/001-0001). The study is registered on ISRCTN (ISRCTN11650227). The study is overseen by an independent Data Monitoring Committee and an independent Trial Steering Committee. We shall disseminate our findings via national and international peer-reviewed journals, and conferences. A summary of the findings will also be posted on the trial website.
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Affiliation(s)
- John Lowe
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - David Gillespie
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Marie Hubbard
- Neonatal Intensive Care Unit, University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
| | - Lei Zhang
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Nigel Kirby
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Timothy Pickles
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Nigel Klein
- GOS Institute of Child Health, University College London, London, London, UK
| | | | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Janet Berrington
- Neonatal Intensive Care Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
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28
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Abstract
Fetal exposure to infection and inflammation can result in accelerated lung maturation and simultaneously altered lung development. This alteration is characterized by reduced alveolar and vascular formation that is one of the hallmarks of the changes observed in animal models and in infants with bronchopulmonary dysplasia (BPD). These opposite effects on maturation and on lung development can explain the reduced severity of respiratory distress syndrome (RDS) but increased incidence of BPD observed in infants exposed to antenatal infections. This also explains why infants born to mothers with chorioamnionitis or colonized with ureaplasma urealitycum have an increased risk of lung injury and BPD. Despite the negative effects of infection on lung development, there is no clear evidence that antibiotic therapy improves the respiratory course in these infants. While the administration of azithromycin to ureaplasma colonized infants is effective in eradicating airway colonization, the effect on BPD is inconclusive. One of the few interventions that have been shown to improve respiratory outcome and reduce BPD in infants with severe RDS is the modulation of inflammation by the administration of systemic or intratracheal steroids early after birth. KEY POINTS: · Antenatal infection can reduce RDS.. · Fetal exposure to infection can alter lung development and increase BPD.. · The detrimental effect of infection is enhanced by mechanical ventilation..
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Affiliation(s)
- Eduardo Bancalari
- Division of Neonatology, University of Miami Miller School of Medicine, Miami, Florida
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29
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Abstract
Mycoplasma species (spp.) can be commensals or opportunistic pathogens of the urogenital tract, and they can be commonly isolated from amniotic fluid, placenta, and fetal/neonatal tissue or blood in mothers delivering prematurely or their preterm infants. Although the presence of Mycoplasma spp. has been associated with adverse maternal-fetal outcomes such as preterm birth and maternal chorioamnionitis, it is less clear whether vertical transmission to the neonate results in colonization or active infection/inflammation. Moreover, the presence of Mycoplasma spp. in neonatal blood, cerebrospinal fluid, or tissue has been variably associated with increased risk of neonatal comorbidities, especially bronchopulmonary dysplasia (BPD). Although the treatment of the mother or neonate with antibiotics is effective in eradicating ureaplasma, it is not clear that the treatment is effective in reducing the incidence of major morbidities of the preterm neonate (eg, BPD). In this article, we review the animal and clinical data for ureaplasma-related complications and treatment strategies. [Pediatr Ann. 2020;49(7):e305-e312.].
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30
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Bonadies L, Zaramella P, Porzionato A, Perilongo G, Muraca M, Baraldi E. Present and Future of Bronchopulmonary Dysplasia. J Clin Med 2020; 9:jcm9051539. [PMID: 32443685 PMCID: PMC7290764 DOI: 10.3390/jcm9051539] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/04/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common respiratory disorder among infants born extremely preterm. The pathogenesis of BPD involves multiple prenatal and postnatal mechanisms affecting the development of a very immature lung. Their combined effects alter the lung's morphogenesis, disrupt capillary gas exchange in the alveoli, and lead to the pathological and clinical features of BPD. The disorder is ultimately the result of an aberrant repair response to antenatal and postnatal injuries to the developing lungs. Neonatology has made huge advances in dealing with conditions related to prematurity, but efforts to prevent and treat BPD have so far been only partially effective. Seeing that BPD appears to have a role in the early origin of chronic obstructive pulmonary disease, its prevention is pivotal also in long-term respiratory outcome of these patients. There is currently some evidence to support the use of antenatal glucocorticoids, surfactant therapy, protective noninvasive ventilation, targeted saturations, early caffeine treatment, vitamin A, and fluid restriction, but none of the existing strategies have had any significant impact in reducing the burden of BPD. New areas of research are raising novel therapeutic prospects, however. For instance, early topical (intratracheal or nebulized) steroids seem promising: they might help to limit BPD development without the side effects of systemic steroids. Evidence in favor of stem cell therapy has emerged from several preclinical trials, and from a couple of studies in humans. Mesenchymal stromal/stem cells (MSCs) have revealed a reparatory capability, preventing the progression of BPD in animal models. Administering MSC-conditioned media containing extracellular vesicles (EVs) have also demonstrated a preventive action, without the potential risks associated with unwanted engraftment or the adverse effects of administering cells. In this paper, we explore these emerging treatments and take a look at the revolutionary changes in BPD and neonatology on the horizon.
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Affiliation(s)
- Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (L.B.); (P.Z.)
| | - Patrizia Zaramella
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (L.B.); (P.Z.)
| | - Andrea Porzionato
- Human Anatomy Section, Department of Neurosciences, University of Padova, 35128 Padova, Italy;
| | - Giorgio Perilongo
- Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy;
| | - Maurizio Muraca
- Institute of Pediatric Research “Città della Speranza”, Stem Cell and Regenerative Medicine Laboratory, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy;
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (L.B.); (P.Z.)
- Correspondence: ; Tel.: +39-049-821-3560; Fax: +39-049-821-3502
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Ericsson AC. Bronchopulmonary dysplasia: a crime of opportunity? Eur Respir J 2020; 55:55/5/2000551. [PMID: 32381633 DOI: 10.1183/13993003.00551-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/01/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Aaron C Ericsson
- University of Missouri Metagenomics Center (MUMC), Dept of Veterinary Pathobiology, University of Missouri, Columbia, MO, USA
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Gallacher D, Mitchell E, Alber D, Wach R, Klein N, Marchesi JR, Kotecha S. Dissimilarity of the gut-lung axis and dysbiosis of the lower airways in ventilated preterm infants. Eur Respir J 2020; 55:13993003.01909-2019. [PMID: 32060060 PMCID: PMC7236867 DOI: 10.1183/13993003.01909-2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/01/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic lung disease of prematurity (CLD), also called bronchopulmonary dysplasia, is a major consequence of preterm birth, but the role of the microbiome in its development remains unclear. Therefore, we assessed the progression of the bacterial community in ventilated preterm infants over time in the upper and lower airways, and assessed the gut-lung axis by comparing bacterial communities in the upper and lower airways with stool findings. Finally, we assessed whether the bacterial communities were associated with lung inflammation to suggest dysbiosis. METHODS We serially sampled multiple anatomical sites including the upper airway (nasopharyngeal aspirates), lower airways (tracheal aspirate fluid and bronchoalveolar lavage fluid) and the gut (stool) of ventilated preterm-born infants. Bacterial DNA load was measured in all samples and sequenced using the V3-V4 region of the 16S rRNA gene. RESULTS From 1102 (539 nasopharyngeal aspirates, 276 tracheal aspirate fluid, 89 bronchoalveolar lavage, 198 stool) samples from 55 preterm infants, 352 (32%) amplified suitably for 16S RNA gene sequencing. Bacterial load was low at birth and quickly increased with time, but was associated with predominant operational taxonomic units (OTUs) in all sample types. There was dissimilarity in bacterial communities between the upper and lower airways and the gut, with a separate dysbiotic inflammatory process occurring in the lower airways of infants. Individual OTUs were associated with increased inflammatory markers. CONCLUSIONS Taken together, these findings suggest that targeted treatment of the predominant organisms, including those not routinely treated, such as Ureaplasma spp., may decrease the development of CLD in preterm-born infants.
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Affiliation(s)
- David Gallacher
- Dept of Child Health, School of Medicine, Cardiff University, Cardiff, UK.,Joint first authors
| | - Emma Mitchell
- Dept of Child Health, School of Medicine, Cardiff University, Cardiff, UK.,Joint first authors
| | - Dagmar Alber
- Institute of Child Health, University College London, London, UK
| | - Richard Wach
- Neonatal Unit, North Bristol NHS Trust, Bristol, UK
| | - Nigel Klein
- Institute of Child Health, University College London, London, UK
| | - Julian R Marchesi
- School of Biosciences, Cardiff University, Cardiff, UK.,Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London, UK
| | - Sailesh Kotecha
- Dept of Child Health, School of Medicine, Cardiff University, Cardiff, UK
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Meyers RS, Thackray J, Matson KL, McPherson C, Lubsch L, Hellinga RC, Hoff DS. Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List. J Pediatr Pharmacol Ther 2020; 25:175-191. [PMID: 32265601 DOI: 10.5863/1551-6776-25.3.175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The safe use of medications in pediatric patients requires practitioners to consider the unique pharmacokinetics and pharmacodynamics of drugs prescribed in this age group. In an effort to create a standard of care for the safe use of medications in this population, a list of drugs that are potentially inappropriate for use in pediatric patients has been developed and titled the "KIDs List." METHODS A panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association were recruited to evaluate primary, secondary, and tertiary literature; FDA Pediatric Safety Communications; the Lexicomp electronic database; and product information for drugs that should be considered potentially inappropriate for use in pediatric patients. Information was rated using predefined criteria. A PubMed search was conducted using the following terms: adverse drug events OR adverse drug reactions. The search was limited to humans; age <18 years; case reports, observational studies, or clinical trials; and English language. No date range was used. Results were used to create an evidence-based list of candidate drugs that was then peer-reviewed and subjected to a 30-day public comment period prior to being finalized. RESULTS A PubMed search yielded 4049 unique titles, of which 210 were deemed relevant for full review. Practitioner recommendations highlighted an additional 77 drugs. FDA Pediatric Safety Communications and the Lexicomp database yielded 22 and 619 drugs, respectively. After critical analysis, peer review, and public review the final KIDs List contains 67 drugs and/or drug classes and 10 excipients. CONCLUSIONS This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients. If avoidance is not clinically possible, the drug should be used with caution and accompanied by appropriate monitoring.
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Piersigilli F, Van Grambezen B, Hocq C, Danhaive O. Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta-Gut-Lung Triangle. Nutrients 2020; 12:E469. [PMID: 32069822 PMCID: PMC7071142 DOI: 10.3390/nu12020469] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023] Open
Abstract
Cardiorespiratory function is not only the foremost determinant of life after premature birth, but also a major factor of long-term outcomes. However, the path from placental disconnection to nutritional autonomy is enduring and challenging for the preterm infant and, at each step, will have profound influences on respiratory physiology and disease. Fluid and energy intake, specific nutrients such as amino-acids, lipids and vitamins, and their ways of administration -parenteral or enteral-have direct implications on lung tissue composition and cellular functions, thus affect lung development and homeostasis and contributing to acute and chronic respiratory disorders. In addition, metabolomic signatures have recently emerged as biomarkers of bronchopulmonary dysplasia and other neonatal diseases, suggesting a profound implication of specific metabolites such as amino-acids, acylcarnitine and fatty acids in lung injury and repair, inflammation and immune modulation. Recent advances have highlighted the profound influence of the microbiome on many short- and long-term outcomes in the preterm infant. Lung and intestinal microbiomes are deeply intricated, and nutrition plays a prominent role in their establishment and regulation. There is an emerging evidence that human milk prevents bronchopulmonary dysplasia in premature infants, potentially through microbiome composition and/or inflammation modulation. Restoring antibiotic therapy-mediated microbiome disruption is another potentially beneficial action of human milk, which can be in part emulated by pre- and probiotics and supplements. This review will explore the many facets of the gut-lung axis and its pathophysiology in acute and chronic respiratory disorders of the prematurely born infant, and explore established and innovative nutritional approaches for prevention and treatment.
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Affiliation(s)
- Fiammetta Piersigilli
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels 1200, Belgium; (F.P.); (B.V.G.); (C.H.)
| | - Bénédicte Van Grambezen
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels 1200, Belgium; (F.P.); (B.V.G.); (C.H.)
| | - Catheline Hocq
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels 1200, Belgium; (F.P.); (B.V.G.); (C.H.)
| | - Olivier Danhaive
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels 1200, Belgium; (F.P.); (B.V.G.); (C.H.)
- Department of Pediatrics, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA 94158, USA
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Nunes CR, Procianoy RS, Corso AL, Silveira RC. Use of Azithromycin for the Prevention of Lung Injury in Mechanically Ventilated Preterm Neonates: A Randomized Controlled Trial. Neonatology 2020; 117:522-528. [PMID: 32894857 DOI: 10.1159/000509462] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Macrolides have anti-inflammatory and immunomodulatory properties that give this class of antibiotics a role that differs from its classical use as an antibiotic, which opens new therapeutic possibilities. OBJECTIVE The aim of this study was to evaluate the anti-inflammatory effect of azithromycin in preventing mechanical ventilation (MV)-induced lung injury in very-low-birth-weight preterm neonates. METHODS This is a randomized, double-blind, placebo-controlled trial of preterm neonates who received invasive MV within 72 h of birth. Patients were randomized to receive intravenous azithromycin (at a dose of 10/mg/kg/day for 5 days) or placebo (0.9% saline) within 12 h of the start of MV. Two blood samples were collected (before and after intervention) for measurement of interleukins (ILs) and PCR for Ureaplasma. Patients were followed up throughout the hospital stay for the outcomes of death and broncho-pulmonary dysplasia defined as need for oxygen for a period of ≥28 days of life (registered at ClinicalTrials.gov, No. NCT03485703). RESULTS Forty patients were analyzed in the azithromycin group and 40 in the placebo group. Five days after the last dose, serum IL-2 and IL-8 levels dropped significantly in the azithromycin group. There was a significant reduction in the incidence of death and O2 dependency at 28 days/death in azithromycin-treated patients regardless of the detection of Ureaplasma in blood. CONCLUSIONS Azithromycin has anti-inflammatory effects, with a decrease in cytokines after 5 days of use and a reduction in death and O2 dependency at 28 days/death in mechanically ventilated preterm neonates.
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Affiliation(s)
- Cristiane R Nunes
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Renato S Procianoy
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Andréa L Corso
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Rita C Silveira
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil, .,Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil,
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Early-Onset Neonatal Sepsis. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Despite the great progress made in neonatal and perinatal medicine over the last couple of decades, sepsis remains one of the main causes of morbidity and mortality. Sepsis in pediatric population was defined at the Pediatric Sepsis Consensus Conference in 2005. There is still no consensus on the definition of neonatal sepsis. Neonatal sepsis is a sepsis that occurs in the neonatal period. According to the time of occurrence, neonatal sepsis can be of early onset, when it occurs within the first 72 hours of birth and results from vertical transmission, and of late onset, in which the source of infection is found most often in the environment and occurs after the third day of life. The most common causes of early-onset sepsis are Group B Streptococcus (GBS) and E. coli. Risk factors can be mother-related and newborn-related. Clinical symptoms and signs of sepsis are quite unspecific. The dysfunction of different organs may imitate sepsis. On the other hand, infectious and non-infectious factors may exist simultaneously. The start of the antimicrobial therapy in any newborn with suspected sepsis should not be delayed. Pentoxifylline may have potential benefits in preterm newborns with sepsis. The only proven intervention that has been shown to reduce the risk of early-onset neonatal sepsis is intrapartum intravenous antibiotic administration to prevent GBS infection. It is still a great challenge to discontinue antibiotic treatment in non-infected newborns as soon as possible, because any extended antibiotic use may later be associated with other pathological conditions.
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Tantengco OAG, Yanagihara I. Current understanding and treatment of intra-amniotic infection with Ureaplasma spp. J Obstet Gynaecol Res 2019; 45:1796-1808. [PMID: 31313469 DOI: 10.1111/jog.14052] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/23/2019] [Indexed: 12/12/2022]
Abstract
Considerable evidence has shown that intra-amniotic infection with Ureaplasma spp. increases the risk of chorioamnionitis and preterm labor. Ureaplasma spp. are among the smallest organisms, and their isolation is uncommon in routine clinical practice because of their size and high auxotrophy. Although Ureaplasma spp. have been reported as causative agents of preterm birth, they also have a high incidence in vaginal swabs collected from healthy reproductive-age women; this has led to questions on the virulence of Ureaplasma spp. and to them being considered as harmless commensal bacteria. Therefore, many efforts have been made to clarify the pathogenicity of Ureaplasma spp. at the molecular level. Ureaplasma spp. are surrounded by lipoproteins, including multiple-banded antigen. Both multiple-banded antigen and its derivative, that is, the synthetic lipopeptide, UPM-1, induce an inflammatory response in a preterm mice model, which was adequate to cause preterm birth or stillbirth. In this review, we present an overview of the virulence mechanisms of Ureaplasma spp. and treatment of ureaplasma infection during pregnancy to prevent possible serious sequelae in infants. In addition, relevant mechanisms underlying antibiotic resistance in Ureaplasma spp. are discussed. Ureaplasma spp. are naturally resistant against β-lactam antibiotics because of the lack of a cell wall. Azithromycin is one of the effective agents that can control intrauterine ureaplasma infection. In fact, macrolide- and fluoroquinolone-resistant isolates of Ureaplasma spp. have already been observed in perinatal practice in Japan.
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Affiliation(s)
- Ourlad Alzeus G Tantengco
- Department of Developmental Medicine, Research Institute, Osaka Women's and Children's Hospital, Izumi, Japan.,College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Itaru Yanagihara
- Department of Developmental Medicine, Research Institute, Osaka Women's and Children's Hospital, Izumi, Japan
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McPherson C. Pharmacotherapy for the Prevention of Bronchopulmonary Dysplasia: Can Anything Compete with Caffeine and Corticosteroids? Neonatal Netw 2019; 38:242-249. [PMID: 31470395 DOI: 10.1891/0730-0832.38.4.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a morbidity of prematurity with implications for respiratory and neurologic health into adulthood. Multiple risk factors contribute to the development of BPD leading to examination of various prevention strategies. The roles of systemic corticosteroids and caffeine have been addressed by the American Academy of Pediatrics. The place in therapy of other agents commonly utilized in clinical practice remains unclear. Inhaled nitric oxide has been the subject of numerous large, randomized controlled trials in preterm infants. Despite sound rationale, these trials have largely failed to document benefit, suggesting a limited role for inhaled nitric oxide therapy in the preterm population. In contrast, intramuscular vitamin A has been documented to reduce the incidence of BPD in randomized trials. However, the invasiveness and the sporadic availability of this therapy have led to decreased utilization. All macrolide antibiotics do not appear to have a similar impact on the incidence of BPD; however, azithromycin administered to infants colonized with Ureaplasma may have impact. Questions remain about the optimal dosing approach and long-term safety of this intervention. Finally, diuretic therapy is widely used in clinical practice despite significant toxicities and limited data supporting a role in BPD prevention. Taken together, available data suggest that caffeine and selective use of corticosteroids remain the mainstays of pharmacologic BPD prevention.
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Nenna R, Hunt KA, Dassios T, Collins JJ, Rottier RJ, Liu NM, Rottier B, Goutaki M, Karadag B, Prayle A, Fernandes RM, Parisi G, Barben J, Rubbo B, Snijders D, Makrinioti H, Hall G, Pijnenburg MW, Grigg J. Key paediatric messages from the 2018 European Respiratory Society International Congress. ERJ Open Res 2019; 5:00241-2018. [PMID: 31044141 PMCID: PMC6487274 DOI: 10.1183/23120541.00241-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/23/2019] [Indexed: 11/29/2022] Open
Abstract
In this article, the Group Chairs and early career members of the European Respiratory Society (ERS) Paediatric Assembly highlight some of the most interesting findings in the field of paediatrics which were presented at the 2018 international ERS Congress.
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Affiliation(s)
- Raffaella Nenna
- Dept of Paediatrics, Sapienza University of Rome, Rome, Italy
- Asthma and Airway Disease Research Center, The University of Arizona, Tucson, AZ, USA
| | - Katie A. Hunt
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jennifer J.P. Collins
- Dept of Paediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robbert J. Rottier
- Dept of Paediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Norrice M. Liu
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University London, London, UK
| | - Bart Rottier
- Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Bülent Karadag
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Andrew Prayle
- Child Health, Obstetrics and Gynaecology, The University of Nottingham, Nottingham, UK
| | - Ricardo M. Fernandes
- Dept of Pediatrics, Santa Maria Hospital, Lisbon, Portugal
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Jürg Barben
- Division of Paediatric Pulmonology, Children's Hospitals of Eastern Switzerland, St. Gallen, Switzerland
| | - Bruna Rubbo
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton, Faculty of Medicine, Academic Unit of Clinical and Experimental Science, Southampton, UK
| | - Deborah Snijders
- Dept of Women's and Children Health, University of Padova, Padova, Italy
| | | | - Graham Hall
- Telethon Kids Institute and Curtin University, Perth, Australia
| | - Mariëlle W. Pijnenburg
- Dept of Paediatrics, Division of Paediatric Pulmonology and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Jonathan Grigg
- Centre for Paediatrics, Queen Mary University London, London, UK
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic complication associated with extremely preterm birth. Although BPD is now an uncommon condition in infants born with birthweights higher than 1,500 g, among infants born at or near the current limits of viability, BPD rates have not improved over the past 2 to 3 decades and may be increasing. No single therapeutic intervention is effective at preventing BPD. As such, clinicians must use multiple evidence-based strategies to help reduce BPD rates. This review examines current evidence-based approaches to BPD prevention, primarily focusing on data obtained from randomized controlled trials.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics; Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
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41
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Preventing bronchopulmonary dysplasia: new tools for an old challenge. Pediatr Res 2019; 85:432-441. [PMID: 30464331 DOI: 10.1038/s41390-018-0228-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most prevalent chronic lung disease in infants and presents as a consequence of preterm birth. Due to the lack of effective preventive and treatment strategies, BPD currently represents a major therapeutic challenge that requires continued research efforts at the basic, translational, and clinical levels. However, not all very low birth weight premature babies develop BPD, which suggests that in addition to known gestational age and intrauterine and extrauterine risk factors, other unknown factors must be involved in this disease's development. One of the main goals in BPD research is the early prediction of very low birth weight infants who are at risk of developing BPD in order to initiate the adequate preventive strategies. Other benefits of determining the risk of BPD include providing prognostic information and stratifying infants for clinical trial enrollment. In this article, we describe new opportunities to address BPD's complex pathophysiology by identifying prognostic biomarkers and develop novel, complex in vitro human lung models in order to develop effective therapies. These therapies for protecting the immature lung from injury can be developed by taking advantage of recent scientific progress in -omics, 3D organoids, and regenerative medicine.
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Tanaka S, Tsumura K, Nakura Y, Tokuda T, Nakahashi H, Yamamoto T, Ono T, Yanagihara I, Nomiyama M. New antibiotic regimen for preterm premature rupture of membrane reduces the incidence of bronchopulmonary dysplasia. J Obstet Gynaecol Res 2019; 45:967-973. [PMID: 30687995 DOI: 10.1111/jog.13903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/08/2018] [Indexed: 11/27/2022]
Abstract
AIM The optimal antibiotic regimen for preterm premature rupture of membrane (pPROM) is still unclear. This study aimed to determine the effects of ampicillin-sulbactam (SBT/ABPC) and azithromycin (AZM) on the incidence of bronchopulmonary dysplasia (BPD). METHODS This retrospective study included women with singleton gestations and a diagnosis of pPROM between 22 and 27 weeks of gestation. In patients presenting with a high risk of intra-amniotic infection between January 2011 and May 2013, piperacillin or cefmetazole + clindamycin (regimen 1 group; n = 11) was administered, whereas SBT/ABPC and AZM (regimen 2 group; n = 11) were administered in patients presenting a similar risk between June 2013 and May 2016. RESULTS The incidence of moderate or severe infant BPD in the regimen 2 group was significantly lower than that in the regimen 1 group, even when adjusted for gestational age at the time of rupture of membrane, with an odds ratio (95% confidence interval) of 0.02 (1.8 × 10-5 -0.33). The incidence of BPD and total days on mechanical ventilation were significantly lower in the regimen 2 group than in the regimen 1 group. No significant differences were seen in other morbidities. CONCLUSION In patients with pPROM between 22 and 27 weeks of gestation, the administration of SBT/ABPC and AZM may improve the perinatal outcomes.
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Affiliation(s)
- Satoko Tanaka
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga Hospital, Saga, Japan.,Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
| | - Keisuke Tsumura
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga Hospital, Saga, Japan
| | - Yukiko Nakura
- Department of Developmental Medicine, Research Institute, Osaka Medical Center for Maternal and Child Health, Osaka, Japan
| | - Tsugumichi Tokuda
- Department of Obstetrics and Gynecology, National Hospital Organization, Kokura Medical Center, Kokura, Japan
| | - Hiroaki Nakahashi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomoko Yamamoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
| | - Takeshi Ono
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga Hospital, Saga, Japan
| | - Itaru Yanagihara
- Department of Developmental Medicine, Research Institute, Osaka Medical Center for Maternal and Child Health, Osaka, Japan
| | - Makoto Nomiyama
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga Hospital, Saga, Japan
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Nakajima J, Sunohara D, Kawashima H. Efficacy of macrolides on gastric motility in extremely low birth weight infants. J Neonatal Perinatal Med 2019; 12:295-300. [PMID: 30883365 DOI: 10.3233/npm-1849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The efficacy of macrolide treatment on gastrointestinal motility and acquirement of feeding tolerance in extremely low birth weight (ELBW) infants are controversial. This study aimed to evaluate clinical effects of parenterally administered erythromycin (EM) and clarithromycin (CAM) on gastrointestinal motility in ELBW infants. METHODS ELBW infants treated in Tokyo Medical University Hospital were retrospectively studied. Several outcomes of ELBW infants treated with EM or CAM were compared with those recognized before initiation of the medication, as well as with those of patients with no macrolide treatment. The primary outcomes included average gastric residual volume that was evaluated 3 hours after enteral feeding. Secondary outcomes were the number of patients who developed feeding intolerance, stool frequency, and other adverse events, such as respiratory comorbidities and pyloric stenosis. RESULTS Among a total of 53 infants, 20 and 13 were treated with EM and CAM, respectively, whereas 20 infants were not administered macrolides. The gastric residual volume was significantly decreased after initiation of medication compared with before medication in the EM group, whereas that of the untreated group showed no change. When the EM and CAM groups were combined, the gastric residual volume was also significantly decreased after treatment compared with before treatment. An increase in stool frequency and pyloric stenosis were not observed in the groups. CONCLUSION EM might be effective for acquiring feeding tolerance in ELBW infants. A future prospective study with a larger population is required to determine the efficacy of CAM.
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Affiliation(s)
- J Nakajima
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
- Department Neonatology, Kameda Medical Center, Chiba, Japan
| | - D Sunohara
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - H Kawashima
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
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Kim SH, Chun J, Ko KH, Sung TJ. Effect of antenatal azithromycin for Ureaplasma spp. on neonatal outcome at ≤30 weeks' gestational age. Pediatr Int 2019; 61:58-62. [PMID: 30460724 DOI: 10.1111/ped.13738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 08/16/2018] [Accepted: 10/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ureaplasma spp. in the maternal genitourinary tract has come to attention as a cause of preterm labor, spontaneous abortion, chorioamnionitis and adverse outcomes. A few controversies, however, still remain, namely, whether it should be treated aggressively or not. The aim of this study was to evaluate the effect of maternal azithromycin (AZ) treatment for Ureaplasma colonization on neonatal morbidities including bronchopulmonary dysplasia (BPD). METHODS A retrospective case-control study of preterm babies delivered at ≤30 weeks of gestational age (GA) from 2012 to 2016 was conducted. Infants whose mothers had confirmed Ureaplasma colonization and treatment with AZ (m-AZ, cases) were matched by GA to control subjects whose mothers did not have Ureaplasma colonization. A subgroup analysis (nUU(+), infants with neonatal respiratory Ureaplasma colonization; nUU(-), infants without colonization) was also performed. RESULTS Fifty-five control subjects were matched to 110 m-AZ subjects. The incidence of preterm premature rupture of membranes (P = 0.003) and of moderate-severe BPD (P = 0.010) was significantly higher in the m-AZ group. On subgroup analysis with post-hoc analysis (m-AZ + nUU(+) [I, n = 55] vs m-AZ + nUU(-) [II, n = 55] vs controls [n = 55]), the incidence of moderate-severe BPD was significantly different: 26% (I) vs 22% (II) vs 7% (controls), P = 0.033. CONCLUSIONS Maternal Ureaplasma colonization was associated with moderate-severe BPD despite the use of AZ treatment. In addition, if the neonatal respiratory tract was colonized, then moderate-severe BPD developed even with maternal AZ treatment. Hence, selective antenatal and postnatal treatment of Ureaplasma colonization would be needed to control BPD development.
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Affiliation(s)
- Sung-Ha Kim
- Department of Pediatrics, Hallym University Medical Center, Seoul, Korea
| | - Jiyoung Chun
- Department of Pediatrics, Hallym University Medical Center, Seoul, Korea
| | - Keun-Hyeok Ko
- Department of Pediatrics, Hallym University Medical Center, Seoul, Korea
| | - Tae-Jung Sung
- Department of Pediatrics, Hallym University Medical Center, Seoul, Korea
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45
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Arsan S, Korkmaz A, Oğuz S. Turkish Neonatal Society guideline on prevention and management of bronchopulmonary dysplasia. TURK PEDIATRI ARSIVI 2018; 53:S138-S150. [PMID: 31236027 PMCID: PMC6568289 DOI: 10.5152/turkpediatriars.2018.01814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Scientific and technological advances in perinatology and neonatology have led to an increased rate of survival and decreased incidences of various neonatal morbidities. However, the incidence of bronchopulmonary dysplasia has remained almost the same for years in very-low-birth-weight preterm infants. Although bronchopulmonary dysplasia is the leading cause of chronic respiratory morbidity in small preterms, no substantial improvement has been achieved in prevention and treatment strategies to date. Currently, postnatal very-low-dose corticosteroids, caffeine, and vitamin A seem to be the drugs of choice, and stem cell therapy appears to be the most promising treatment modality for the future. In this guideline, which was prepared by the Turkish Neonatal Society, recent evidence-based recommendations for the prevention and treatment of bronchopulmonary dysplasia are summarized.
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Affiliation(s)
- Saadet Arsan
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Ayşe Korkmaz
- Division of Neonatology, Department of Pediatrics, Acıbadem University, Faculty of Medicine, İstanbul, Turkey
| | - Suna Oğuz
- Zekai Tahir Burak Women’s Health Practice and Research Center, Health Sciences University, Ankara, Turkey
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Michael Z, Spyropoulos F, Ghanta S, Christou H. Bronchopulmonary Dysplasia: An Update of Current Pharmacologic Therapies and New Approaches. Clin Med Insights Pediatr 2018; 12:1179556518817322. [PMID: 30574005 PMCID: PMC6295761 DOI: 10.1177/1179556518817322] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/03/2018] [Indexed: 12/21/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) remains the most prevalent long-term morbidity of surviving extremely preterm infants and is associated with significant health care utilization in infancy and beyond. Recent advances in neonatal care have resulted in improved survival of extremely low birth weight (ELBW) infants; however, the incidence of BPD has not been substantially impacted by novel interventions in this vulnerable population. The multifactorial cause of BPD requires a multi-pronged approach for prevention and treatment. New approaches in assisted ventilation, optimal nutrition, and pharmacologic interventions are currently being evaluated. The focus of this review is the current state of the evidence for pharmacotherapy in BPD. Promising future approaches in need of further study will also be reviewed.
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Affiliation(s)
- Zoe Michael
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fotios Spyropoulos
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Sailaja Ghanta
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Helen Christou
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
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Abstract
BACKGROUND Ureaplasma spp. is a known risk factor for bronchopulmonary dysplasia in premature infants. Emerging research suggests treatment with azithromycin or clarithromycin in the first days of life (DOLs) reduces bronchopulmonary dysplasia in Ureaplasma spp. positive infants. Side effects of these antibiotics make it imperative to optimize reliable noninvasive screening procedures to identify infants who would benefit from treatment. METHODS The aim of this study was to determine the best site and time to screen for Ureaplasma spp. in 24- to 34-week premature infants. Oral, nasal, gastric and tracheal cultures were collected and placed immediately in 10B broth media. Polymerase chain reaction verified culture results and identified the Ureaplasma spp. RESULTS Cultures yielded a Ureaplasma spp. incidence of 80/168 = 47.6% [95% confidence interval (CI): 40-56]. Nasal cultures had greater sensitivity to detect Ureaplasma spp. than oral cultures (P = 0.008): however, a significant proportion of infants with Ureaplasma spp. would have been missed (12/79 = 15.2%, 95% CI: 8%-25%, P < 0.001) if oral cultures were not obtained. For all sites, the collection at DOL 7-10 were more likely to be positive than the collection at DOL 1-2: however, a significant proportion (5/77 = 6.5%, 95% CI: 2-15, P < 0.001) of infants with Ureaplasma spp. would have been missed if the DOL 1-2 cultures were not obtained. CONCLUSIONS For optimal Ureaplasma spp. detection in 24- to 34-week premature infants, cultures need to be taken both early and late in the first 10 DOLs both from nasal and oral secretions.
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Safety of azithromycin in infants under six months of age in Niger: A community randomized trial. PLoS Negl Trop Dis 2018; 12:e0006950. [PMID: 30419040 PMCID: PMC6258425 DOI: 10.1371/journal.pntd.0006950] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/26/2018] [Accepted: 10/27/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mass azithromycin distribution reduces under-5 child mortality. Trachoma control programs currently treat infants aged 6 months and older. Here, we report findings from an infant adverse event survey in 1-5 month olds who received azithromycin as part of a large community-randomized trial in Niger. METHODS AND PRINCIPAL FINDINGS Active surveillance of infants aged 1-5 months at the time of treatment was conducted in 30 randomly selected communities from within a large cluster randomized trial of biannual mass azithromycin distribution compared to placebo to assess the potential impact on child mortality. We compared the distribution of adverse events reported after treatment among azithromycin-treated versus placebo-treated infants. From January 2015 to February 2018, the caregivers of 1,712 infants were surveyed. Approximately one-third of caregivers reported at least one adverse event (azithromycin: 29.6%, placebo: 34.3%, risk ratio [RR] 0.86, 95% confidence interval [CI] 0.68 to 1.10, P = 0.23). The most commonly reported adverse events included diarrhea (azithromycin: 19.3%, placebo: 28.1%, RR 0.68, 95% CI 0.49 to 0.96, P = 0.03), vomiting (azithromycin: 15.9%, placebo: 21.0%, RR 0.76, 95% CI 0.56 to 1.02, P = 0.07), and skin rash (azithromycin: 12.3%, placebo: 13.6%, RR 0.90, 95% CI 0.59 to 1.37, P = 0.63). No cases of infantile hypertrophic pyloric stenosis were reported. CONCLUSIONS Azithromycin given to infants aged 1-5 months appeared to be safe. Inclusion of younger infants in larger azithromycin-based child mortality or trachoma control programs could be considered if deemed effective. TRIAL REGISTRATION ClinicalTrials.gov NCT02048007.
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Oldenburg CE, Arzika AM, Maliki R, Kane MS, Lebas E, Ray KJ, Cook C, Cotter SY, Zhou Z, West SK, Bailey R, Porco TC, Keenan JD, Lietman TM. Safety of azithromycin in infants under six months of age in Niger: A community randomized trial. PLoS Negl Trop Dis 2018. [PMID: 30419040 DOI: 10.7910/dvn/mqym5s.funding] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Mass azithromycin distribution reduces under-5 child mortality. Trachoma control programs currently treat infants aged 6 months and older. Here, we report findings from an infant adverse event survey in 1-5 month olds who received azithromycin as part of a large community-randomized trial in Niger. METHODS AND PRINCIPAL FINDINGS Active surveillance of infants aged 1-5 months at the time of treatment was conducted in 30 randomly selected communities from within a large cluster randomized trial of biannual mass azithromycin distribution compared to placebo to assess the potential impact on child mortality. We compared the distribution of adverse events reported after treatment among azithromycin-treated versus placebo-treated infants. From January 2015 to February 2018, the caregivers of 1,712 infants were surveyed. Approximately one-third of caregivers reported at least one adverse event (azithromycin: 29.6%, placebo: 34.3%, risk ratio [RR] 0.86, 95% confidence interval [CI] 0.68 to 1.10, P = 0.23). The most commonly reported adverse events included diarrhea (azithromycin: 19.3%, placebo: 28.1%, RR 0.68, 95% CI 0.49 to 0.96, P = 0.03), vomiting (azithromycin: 15.9%, placebo: 21.0%, RR 0.76, 95% CI 0.56 to 1.02, P = 0.07), and skin rash (azithromycin: 12.3%, placebo: 13.6%, RR 0.90, 95% CI 0.59 to 1.37, P = 0.63). No cases of infantile hypertrophic pyloric stenosis were reported. CONCLUSIONS Azithromycin given to infants aged 1-5 months appeared to be safe. Inclusion of younger infants in larger azithromycin-based child mortality or trachoma control programs could be considered if deemed effective. TRIAL REGISTRATION ClinicalTrials.gov NCT02048007.
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Affiliation(s)
- Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | | | | | | | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
| | - Catherine Cook
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
| | - Sun Y Cotter
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
| | - Zhaoxia Zhou
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
| | - Sheila K West
- The Dana Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Robin Bailey
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
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Urs R, Kotecha S, Hall GL, Simpson SJ. Persistent and progressive long-term lung disease in survivors of preterm birth. Paediatr Respir Rev 2018; 28:87-94. [PMID: 29752125 DOI: 10.1016/j.prrv.2018.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 02/05/2023]
Abstract
Preterm birth accounts for approximately 11% of births globally, with rates increasing across many countries. Concurrent advances in neonatal care have led to increased survival of infants of lower gestational age (GA). However, infants born <32 weeks of GA experience adverse respiratory outcomes, manifesting with increased respiratory symptoms, hospitalisation and health care utilisation into early childhood. The development of bronchopulmonary dysplasia (BPD) - the chronic lung disease of prematurity - further increases the risk of poor respiratory outcomes throughout childhood, into adolescence and adulthood. Indeed, survivors of preterm birth have shown increased respiratory symptoms, altered lung structure, persistent and even declining lung function throughout childhood. The mechanisms behind this persistent and sometimes progressive lung disease are unclear, and the implications place those born preterm at increased risk of respiratory morbidity into adulthood. This review aims to summarise what is known about the long-term pulmonary outcomes of contemporary preterm birth, examine the possible mechanisms of long-term respiratory morbidity in those born preterm and discuss addressing the unknowns and potentials for targeted treatments.
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Affiliation(s)
- Rhea Urs
- Telethon Kids Institute, Perth, Australia; School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Graham L Hall
- Telethon Kids Institute, Perth, Australia; School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
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