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Clarke P, Soe A, Nichols A, Harizaj H, Webber MA, Linsell L, Bell JL, Tremlett C, Muthukumar P, Pattnayak S, Partlett C, King A, Juszczak E, Heath PT. 2% chlorhexidine gluconate aqueous versus 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin disinfection prior to percutaneous central venous catheterisation: the ARCTIC randomised controlled feasibility trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:202-210. [PMID: 37907266 PMCID: PMC10894828 DOI: 10.1136/archdischild-2023-325871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/08/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE Catheter-related sepsis (CRS) is a major complication with significant morbidity and mortality. Evidence is lacking regarding the most appropriate antiseptic for skin disinfection before percutaneous central venous catheter (PCVC) insertion in preterm neonates. To inform the feasibility and design of a definitive randomised controlled trial (RCT) of two antiseptic formulations, we conducted the Antiseptic Randomised Controlled Trial for Insertion of Catheters (ARCTIC) feasibility study to assess catheter colonisation, sepsis, and skin morbidity. DESIGN Feasibility RCT. SETTING Two UK tertiary-level neonatal intensive care units. PATIENTS Preterm infants born <34 weeks' gestation scheduled to undergo PCVC insertion. INTERVENTIONS Skin disinfection with either 2% chlorhexidine gluconate (CHG)-aqueous or 2% CHG-70% isopropyl alcohol (IPA) before PCVC insertion and at removal. PRIMARY OUTCOME Proportion in the 2% CHG-70% IPA arm with a colonised catheter at removal. MAIN FEASIBILITY OUTCOMES Rates of: (1) CRS, catheter-associated sepsis (CAS), and CRS/CAS per 1,000 PCVC days; (2) recruitment and retention; (3) data completeness. SAFETY OUTCOMES Daily skin morbidity scores recorded from catheter insertion until 48 hours post-removal. RESULTS 116 babies were randomised. Primary outcome incidence was 4.1% (95% confidence interval: 0.9% to 11.5%). Overall catheter colonisation rate was 5.2% (5/97); CRS 2.3/1000 catheter days; CAS 14.8/1000 catheter days. Recruitment, retention and data completeness were good. No major antiseptic-related skin injury was reported. CONCLUSIONS A definitive comparative efficacy trial is feasible, but the very low catheter colonisation rate would make a large-scale RCT challenging due to the very large sample size required. ARCTIC provides preliminary reassurance supporting potential safe use of 2% CHG-70% IPA and 2% CHG-aqueous in preterm neonates. TRIAL REGISTRATION NUMBER ISRCTN82571474.
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Affiliation(s)
- Paul Clarke
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Aung Soe
- Neonatal Intensive Care Unit, Medway Maritime Hospital, Gillingham, Kent, UK
| | - Amy Nichols
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Helen Harizaj
- Neonatal Intensive Care Unit, Medway Maritime Hospital, Gillingham, Kent, UK
| | - Mark A Webber
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
- Quadram Institute Bioscience, Norwich, Norfolk, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Catherine Tremlett
- Department of Microbiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Priyadarsini Muthukumar
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Santosh Pattnayak
- Neonatal Intensive Care Unit, Medway Maritime Hospital, Gillingham, Kent, UK
| | - Christopher Partlett
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew King
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ed Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul T Heath
- Centre for Neonatal and Paediatric Infection, Infection and Immunity, Saint George's University of London, London, UK
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Lally PJ, Montaldo P, Oliveira V, Soe A, Swamy R, Bassett P, Mendoza J, Atreja G, Kariholu U, Pattnayak S, Sashikumar P, Harizaj H, Mitchell M, Ganesh V, Harigopal S, Dixon J, English P, Clarke P, Muthukumar P, Satodia P, Wayte S, Abernethy LJ, Yajamanyam K, Bainbridge A, Price D, Huertas A, Sharp DJ, Kalra V, Chawla S, Shankaran S, Thayyil S. Magnetic resonance spectroscopy assessment of brain injury after moderate hypothermia in neonatal encephalopathy: a prospective multicentre cohort study. Lancet Neurol 2018; 18:35-45. [PMID: 30447969 PMCID: PMC6291458 DOI: 10.1016/s1474-4422(18)30325-9] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/21/2018] [Accepted: 08/26/2018] [Indexed: 12/31/2022]
Abstract
Background In neonatal encephalopathy, the clinical manifestations of injury can only be reliably assessed several years after an intervention, complicating early prognostication and rendering trials of promising neuroprotectants slow and expensive. We aimed to determine the accuracy of thalamic proton magnetic resonance (MR) spectroscopy (MRS) biomarkers as early predictors of the neurodevelopmental abnormalities observed years after neonatal encephalopathy. Methods We did a prospective multicentre cohort study across eight neonatal intensive care units in the UK and USA, recruiting term and near-term neonates who received therapeutic hypothermia for neonatal encephalopathy. We excluded infants with life-threatening congenital malformations, syndromic disorders, neurometabolic diseases, or any alternative diagnoses for encephalopathy that were apparent within 6 h of birth. We obtained T1-weighted, T2-weighted, and diffusion-weighted MRI and thalamic proton MRS 4–14 days after birth. Clinical neurodevelopmental tests were done 18–24 months later. The primary outcome was the association between MR biomarkers and an adverse neurodevelopmental outcome, defined as death or moderate or severe disability, measured using a multivariable prognostic model. We used receiver operating characteristic (ROC) curves to examine the prognostic accuracy of the individual biomarkers. This trial is registered with ClinicalTrials.gov, number NCT01309711. Findings Between Jan 29, 2013, and June 25, 2016, we recruited 223 infants who all underwent MRI and MRS at a median age of 7 days (IQR 5–10), with 190 (85%) followed up for neurological examination at a median age of 23 months (20–25). Of those followed up, 31 (16%) had moderate or severe disability, including one death. Multiple logistic regression analysis could not be done because thalamic N-acetylaspartate (NAA) concentration alone accurately predicted an adverse neurodevelopmental outcome (area under the curve [AUC] of 0·99 [95% CI 0·94–1·00]; sensitivity 100% [74–100]; specificity 97% [90–100]; n=82); the models would not converge when any additional variable was examined. The AUC (95% CI) of clinical examination at 6 h (n=190) and at discharge (n=167) were 0·72 (0·65–0·78) and 0·60 (0·53–0·68), respectively, and the AUC of abnormal amplitude integrated EEG at 6 h (n=169) was 0·73 (0·65–0·79). On conventional MRI (n=190), cortical injury had an AUC of 0·67 (0·60–0·73), basal ganglia or thalamic injury had an AUC of 0·81 (0·75–0·87), and abnormal signal in the posterior limb of internal capsule (PLIC) had an AUC of 0·82 (0·76–0·87). Fractional anisotropy of PLIC (n=65) had an AUC of 0·82 (0·76–0·87). MRS metabolite peak-area ratios (n=160) of NAA–creatine (<1·29) had an AUC of 0·79 (0·72–0·85), of NAA–choline had an AUC of 0·74 (0·66–0·80), and of lactate–NAA (>0·22) had an AUC of 0·94 (0·89–0·97). Interpretation Thalamic proton MRS measures acquired soon after birth in neonatal encephalopathy had the highest accuracy to predict neurdevelopment 2 years later. These methods could be applied to increase the power of neuroprotection trials while reducing their duration. Funding National Institute for Health Research UK.
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Affiliation(s)
- Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Aung Soe
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Gaurav Atreja
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Ujwal Kariholu
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Helen Harizaj
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | - Martin Mitchell
- Oliver Fisher Neonatal Unit, Medway NHS Foundation Trust, Kent, UK
| | | | | | | | | | - Paul Clarke
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Priya Muthukumar
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Prakash Satodia
- Neonatal Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Sarah Wayte
- Neonatal Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Kiran Yajamanyam
- Neonatal Unit, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Alan Bainbridge
- Neonatal Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Price
- Neonatal Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Angela Huertas
- Neonatal Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - David J Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, London, UK
| | - Vaneet Kalra
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Sanjay Chawla
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.
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