Antibiotherapy at birth in very low birth weight infants before and after the use of interleukin 6 as an infectious biomarker in a tertiary level unit

BACKGROUND

Neonatal sepsis is a condition with high mortality and morbidity that contributes to high rates of antibiotic therapy at birth. In addition, very low birth weight newborns (VLBWN) are particularly vulnerable. Interleukin 6 (IL-6) seems to be an early and effective marker that could help a better selection of patients to be treated. This study aimed to evaluate the use of antibiotics in the first 72 hours of life in VLBW infants before and after using IL-6 as an infection marker. Also, we wanted to analyze the differences in morbidity and mortality during admission and other factors associated with the decision to start antibiotic treatment.

METHODS

We conducted a cohort retrospective study. We included VLBWN born in our hospital or admitted before 72 hours of life in two two-year periods (2007-2008 and 2011-2012).

RESULTS

Antibiotics use during the first 72 hours of life was analyzed as the primary variable, which was reduced by 20% on the second period (p = 0.002). Regarding the analysis of secondary variables, we found no significant differences in mortality during hospital admission and the incidence of nosocomial sepsis, enterocolitis, or invasive fungal infection. The multivariate analysis indicated extreme prematurity and the study group as the most strongly related factors to the start of antibiotic therapy.

CONCLUSIONS

IL-6 was a useful marker of infection to reduce the use of antibiotic therapy in VLBW infants without increasing mortality.

COVID-19 pandemic. What have we learned?

Since the COVID-19 pandemic was declared in March 2020, we have learned a lot about the SARS-CoV-2 coronavirus, and its role in pediatric pathology. Children are infected in a rate quite similar to adults, although in most cases they suffer mild or asymptomatic symptoms. Around 1% of those infected require hospitalization, less than 0.02% require intensive care, and mortality is very low and generally in children with comorbidities. The most common clinical diagnoses are upper or lower respiratory infections, gastrointestinal infection and, more seriously, multisystemic inflammatory syndrome (MIS-C). Most episodes do not require treatment, except for MIS-C. Remdesivir has been widely used as a compassionate treatment and its role has yet to be defined. The newborn can become infected, although vertical transmission is very low (<1%) and it has been shown that the baby can safely cohabit with its mother and be breastfed. In general, neonatal infections have been mild. Primary care has supported a very important part of the management of the pandemic in pediatrics. There has been numerous collateral damage derived from the difficulty of access to care and the isolation suffered by children. The mental health of the pediatric population has been seriously affected. Although it has been shown that schooling has not led to an increase in infections, but rather the opposite. It is essential to continue maintaining the security measures that make schools a safe place, so necessary not only for children's education, but for their health in general.

[COVID-19 pandemic. What have we learned?]

Since the COVID-19 pandemic was declared in March 2020, we have learned a lot about the SARS-CoV-2 coronavirus, and its role in pediatric pathology.Children are infected in a rate quite similar to adults, although in most cases they suffer mild or asymptomatic symptoms. Around 1% of those infected require hospitalization, less than 0.02% require intensive care, and mortality is very low and generally in children with comorbidities. The most common clinical diagnoses are upper or lower respiratory infections, gastrointestinal infection and, more seriously, multisystemic inflammatory syndrome (MIS-C). Most episodes do not require treatment, except for MIS-C. Remdesivir has been widely used as a compassionate treatment and its role has yet to be defined.The newborn can become infected, although vertical transmission is very low (<1%) and it has been shown that the baby can safely cohabit with its mother and be breastfed. In general, neonatal infections have been mild.Primary care has supported a very important part of the management of the pandemic in pediatrics. There has been numerous collateral damage derived from the difficulty of access to care and the isolation suffered by children. The mental health of the pediatric population has been seriously affected. Although it has been shown that schooling has not led to an increase in infections, but rather the opposite. It is essential to continue maintaining the security measures that make schools a safe place, so necessary not only for children's education, but for their health in general.

Neonates Born to Mothers With COVID-19: Data From the Spanish Society of Neonatology Registry

OBJECTIVES

To describe neonatal and maternal characteristics of the largest prospective cohort of newborns from mothers with coronavirus disease 2019 (COVID-19), the data of which were prospectively collected from the nationwide registry of the Spanish Society of Neonatology.

METHODS

Between March 8, 2020, and May 26, 2020, the data of 503 neonates born to 497 mothers diagnosed with COVID-19 during pregnancy or at the time of delivery were collected by 79 hospitals throughout Spain.

RESULTS

Maternal symptoms were similar to that of the general population, with 5% of severe forms. In 45.8% of asymptomatic women at the time of delivery, severe acute respiratory syndrome coronavirus 2 infection was detected because of recommendations established in Spain to perform COVID-19 screening in all women admitted to the hospital for labor. The rate of preterm deliveries was 15.7% and of cesarean deliveries, 33%. The most common diagnostic test was detection of viral RNA by polymerase chain reaction of nasopharyngeal swabs at a median age of 3 hours after delivery (1-12 hours). Almost one-half of neonates were left skin-to-skin after delivery, and delayed clamping of umbilical cords was performed in 43% of neonates. Also, 62.3% of asymptomatic neonates were managed with rooming-in. Maternal milk was received by 76.5% of neonates, 204 of them as exclusive breastfeeding.

CONCLUSIONS

The current study indicates that there is no need for separation of mothers from neonates, allowing delayed cord clamping and skin-to-skin contact along with maintenance of breastfeeding in a high percentage of newborns from mothers with COVID-19.

[Psychomotor development in late premature newborns at five years. Comparison with term newborns using the ASQ3®]

INTRODUCTION

Late prematures (LP) belong to a subgroup of many premature babies with a risk of delayed psychomotor development (PMD). Many subtle changes pass unnoticed if adequate assessment tools are not used. The Ages & Stages Questionnaires 3® (ASQ3®) for parents appears simple and useful for the detection of risk of impairment of PMD, and is recommended by scientific societies that study LP.

OBJECTIVES

To evaluate the risk of impaired PMD in LP at 5years-old, and compare them with term newborns (TNB) using the ASQ3.

PATIENTS AND METHODS

Data were collected on the LP born in a third level hospital in 2010, as well as 2TNB of the same gender for each LP. The prenatal and postnatal morbidity variables were compared. At 5years, their families (excluding those with other neurological risks) were asked to complete the ASQ3. The cut-off point was determined for the total score of the ASQ3 that would discriminate the risk of PMD impairment using ROC analysis. The cut-off point to determine a change in each domain was obtained according to the ASQ3 manual.

RESULTS

The ASQ3 was completed for 88 (47%) and 131 (35%) TNB. All the overall mean scores and those for domains were lower in LP, with no significant differences found between the two groups. A risk of PMD impairment (≤253 points) was observed in 7LP compared to 4TNB, with no significant difference. More maternal, foetal, and neonatal illnesses were observed in 195LP than in the 390TNB. In the univariate analysis, male gender and restricted uterine growth (RUG) were factors associated with a risk of PMD impairment and only RUG in the multivariate analysis.

CONCLUSION

The risk of PMD impairment between LP and TNB at 5years appears not to be shown, with no significant differences between both, and with the values obtained in the ASQ3 being slightly lower in the LP. Male gender and RUG negatively influence this risk.

Neonatal Infection Due to SARS-CoV-2: An Epidemiological Study in Spain

Objective: Coronavirus disease 2019 (COVID-19) cases caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to increase worldwide. Although some data from pediatric series are available, more evidence is required, especially in neonates, a group with specific characteristics that deserve special attention. This study aimed to describe general and clinical characteristics, management, and treatment of postnatal-acquired (community and nosocomial/hospital-acquired) COVID-19 neonatal cases in Spain. Methods: This was a national prospective epidemiological study that included cases from a National Registry supported by the Spanish Society of Neonatology. Neonates with postnatal SARS-CoV-2 infection were included in this study. General data and infection-related information (mode and source of transmission, age at diagnosis, clinical manifestations, need for hospitalization, admission unit, treatment administered, and complementary studies performed, hospital stay associated with the infection) were collected. Results: A total of 40 cases, 26 community-acquired and 14 nosocomial were registered. Ten were preterm newborns (2 community-acquired and 8 nosocomial COVID-19 cases). Mothers (in both groups) and healthcare workers (in nosocomial cases) were the main source of infection. Hospital admission was required in 22 community-acquired cases [18 admitted to the neonatal intermediate care unit (NIMCU) and 4 to the neonatal intensive care unit (NICU)]. Among nosocomial COVID-19 cases (n = 14), previously admitted for other reasons, 4 were admitted to the NIMCU and 10 to the NICU. Ten asymptomatic patients were registered (5 in each group). In the remaining cases, clinical manifestations were generally mild in both groups, including upper respiratory airways infection, febrile syndrome or acute gastroenteritis with good overall health. In both groups, most severe cases occurred in preterm neonates or neonates with concomitant pathologies. Most of the cases did not require respiratory support. Hydroxychloroquine was administered to 4 patients in the community-acquired group and to 2 patients in the nosocomial group. Follow-up after hospital discharge was performed in most patients. Conclusions: This is the largest series of COVID-19 neonatal cases in Spain published to date. Although clinical manifestations were generally mild, prevention, treatment, and management in this group are essential.

Prognostic factors of mortality in very low-birth-weight infants with neonatal sepsis of nosocomial origin

OBJECTIVE

To identify the variables associated with sepsis-associated mortality, as well as to develop a severity risk score to predict death in very low-birth-weight (VLBW) neonates affected by nosocomial sepsis.

STUDY DESIGN

Retrospective cohort study. Infants weighing ≤ 1500 g with neonatal sepsis of nosocomial origin were included. Epidemiological, clinical, and laboratory variables were recorded at onset (0 hours), at 12 hours, and at 24 hours. Bivariate and multivariate analyses were performed.

RESULT

The study population included 95 VLBW infants who presented 129 episodes of nosocomial sepsis. In the bivariate analysis, gram-negative bacilli as the etiology of sepsis, seizures, age, postconceptional age, weight, serum procalcitonin (24 hours), platelet count (24 hours), blood urea nitrogen (0 and 24 hours), creatinine (24 hours), diuresis (12 and 24 hours), mean blood pressure (12 and 24 hours), pH, base excess (0, 12, and 24 hours), and SpO(2) (pulse oximetric saturation):F(IO(2)) (fraction of inspired oxygen) ratio (12 and 24 hours) were significantly associated with mortality. In the multivariate analysis, weight at the onset of sepsis, base excess (0 hours), and SpO(2):F(IO(2)) ratio (12 hours) were independent predictors of mortality.

CONCLUSION

A lower weight at the onset of sepsis, base excess, and SpO(2):F(IO(2)) ratio are useful to predict nosocomial sepsis-associated mortality in VLBW infants.

Psychometric properties of the d2 selective attention test in a sample of premature and born-at-term babies

The psychometric properties of the d2 Selective Attention Test are analyzed in two samples of premature ( n = 63) and born-at-term ( n = 78) children. The reliability coefficients (internal consistency) reached values of around .90. Principal components analysis revealed a three-factor structure, which accounts for 58% of the variance, and thus coincides with the number of factors presented in the manual of the Spanish adaptation of the test but not with their composition. Results suggest that the d2 test has adequate psychometric properties both for the global sample and for each sub-sample.

Urinary tract infection in the newborn: clinical and radio imaging studies

The objective of this study was to assess clinical characteristics and results of radio imaging studies and compare community-acquired urinary tract infection (UTI) with nosocomial UTI in 301 neonates with UTI consecutively admitted to 28 neonatal units in Spain over 3 years (community-acquired UTI, n = 250; nosocomial UTI, n = 51). UTI was diagnosed in the presence of symptoms of infection together with any colony growth for a single pathogen from urine obtained by suprapubic aspiration, or >or=10(4) CFU/ml for a single pathogen from urine obtained by urethral catheterization. Abnormal renal ultrasound was present in 37.1% of cases (34% in community-acquired UTI and 54.5% in nosocomial UTI, P < 0.01). The voiding cystourethrography (VCUG) showed vesicoureteral reflux (VUR) in 27% of cases (23.8% in community-acquired UTI and 48.6% in nosocomial UTI, P < 0.01). In patients with abnormal renal ultrasound and VUR, renal scan with dimercaptosuccinic acid (DMSA) performed early after UTI revealed cortical defects in 69.5% of cases. However, in patients with abnormal renal ultrasound and normal VCUG, DMSA also revealed cortical defects in 39% of cases. The absence of VUR in neonates with UTI and abnormal renal ultrasound does not exclude the presence of cortical defects suggestive of pyelonephritis.

Evaluation of procalcitonin for diagnosis of neonatal sepsis of vertical transmission

Background

The results of recent studies suggest the usefulness of PCT for early diagnosis of neonatal sepsis, with varying results. The aim of this prospective multicenter study was to determine the behavior of serum PCT concentrations in both uninfected and infected neonates, and to assess the value of this marker for diagnosis of neonatal sepsis of vertical transmission.

Methods

PCT was measured in 827 blood samples collected prospectively from 317 neonates admitted to 13 acute-care teaching hospitals in Spain over one year. Serum PCT concentrations were determined by a specific immunoluminometric assay. The diagnostic efficacy of PCT at birth and within 12–24 h and 36–48 h of life was evaluated calculating the sensitivity, specificity, and likelihood ratio of positive and negative results.

Results

169 asymptomatic newborns and 148 symptomatic newborns (confirmed vertical sepsis: 31, vertical clinical sepsis: 38, non-infectious diseases: 79) were studied. In asymptomatic neonates, PCT values at 12–24 h were significantly higher than at birth and at 36–48 h of life. Resuscitation at birth and chorioamnionitis were independently associated to PCT values. Neonates with confirmed vertical sepsis showed significantly higher PCT values than those with clinical sepsis. PCT thresholds for the diagnosis of sepsis were 0.55 ng/mL at birth (sensitivity 75.4%, specificity 72.3%); 4.7 ng/mL within 12–24 h of life (sensitivity 73.8%, specificity 80.8%); and 1.7 ng/mL within 36–48 h of life (sensitivity 77.6%, specificity 79.2%).

Conclusion

Serum PCT was moderately useful for the detection of sepsis of vertical transmission, and its reliability as a maker of bacterial infection requires specific cutoff values for each evaluation point over the first 48 h of life.

Neonatal invasive candidiasis: a prospective multicenter study of 118 cases

A prospective multicenter study was conducted to assess the epidemiology of neonatal invasive candidiasis in Spain. In a total of 20,565 admissions to the 27 participating neonatal units over an 18-month period, systemic candidiasis was diagnosed in 118 (0.57%) neonates. Candida species were isolated from the blood in 79 infants, from the urine in 33, and from the cerebrospinal fluid in 4; in 2 cases, histologic evidence of deep tissue candidiasis was found at autopsy. Very-low-birth-weight (VLBW) infants (< or = 1500 g) showed a significantly higher incidence of systemic candidiasis (4.8%) than infants weighing > 1500 g (0.2%) ( p < 0.001). Candida albicans was the most frequent species (52.5%) followed by C. parapsilosis (23.7%), and C. tropicalis (7.6%). Only seven infants were treated with amphotericin B (initial dose 0.18 +/- 0.3 mg/kg, maximal daily dose 1.7 +/- 0.9 mg/kg) but treatment was stopped in three of them (43%) due to nephrotoxicity. Liposomal amphotericin B was given to 81 neonates and amphotericin B lipid complex to 29. There were no differences in mortality rate and in the incidence of adverse effects in relation to treatment with liposomal amphotericin B or amphotericin B lipid complex. The mortality rate was 10.2% and all deaths occurred in the VLBW cohort with candidemia.