Risk factors and antibiotic resistance of pneumonia caused by multidrug resistant Acinetobacter baumannii in pediatric intensive care unit

BACKGROUND:

With beta-lactam drugs and immunosuppressants widely used, the infection caused by Acinetobacter baumannii (Ab) has become more and more serious with multidrug resistant Acinetobacter baumannii (MDRAb) emerging and worsening rapidly. Compared with other patients, the incidence and multidrug resistance of MDRAb are higher in children in pediatric intensive care unit (PICU) because of immune deficiency, severe basic diseases, prolonged hospitalization and invasive operations. Hence it is significant to study the epidemiology and changes of antibacterial susceptibility in order to reduce the incidence of MDRAb in children.

METHODS:

A total 115 patients with MDRAb pneumonia and 45 patients with negative MDRAb (NMDRAb) pneumonia who had been treated from January 2009 to August 2011 were studied retrospectively at the PICU of Wuhan Children’s Hospital. Clinical data were analyzed with univariate and multivariate Logistic regression.

RESULTS:

In 176 clinical strains of Acinetobacter baumannii isolated, there were 128 strains of MDRAb, accounting for 72.73%. Drug susceptibility tests showed that the resistance rates of β-lactam antibiotics were more than 70% except for cefoperazone sulbactam. The rates to carbapenems were higher than 90%. They were significantly higher than those of NMDRAb. Amikacin, levofloxacin, ciprofloxacin and minocycline had the lowest drug-resistance rates (<20%). Multivariate Logistic regression revealed that ICU stay, the time of mechanical ventilation, anemia, hypoproteinemia and the use of carbapenems were independent risk factors for MDRAb pneumonia.

CONCLUSIONS:

MDRAb is an important opportunistic pathogen to pneumonia in PICU, and its drug-resistance is severe. It increases significantly the mortality of patients. It is important to take the effective prevention measures for controlling it.KEY WORDS: Pediatric, Intensive Care Unit, Multidrug resistance, Acinetobacter baumannii, Pneumonia, Risk factor, Retrospective study     

Acinetobacter baumannii infection was decreased by the structural renovation of a medical intensive care unit

Purpose

The study aimed to determine whether improvements in intensive care unit (ICU) structural environment affect the incidence of ICU-acquired infections (IAIs), particularly those caused by multidrug-resistant pathogens.

Methods

The incidence of IAI and the number of infections caused by organisms during the 6 months immediately before ICU renovation and during the 6 months immediately after ICU renovation were compared. The observational duration was prolonged for an additional 1 year after recruiting the after-renovation data to observe if the found effect of ICU structural renovation is maintained. The relevant data were prospectively gathered.

Results

The overall IAI incidence and distribution of infection site showed no difference in both periods. In IAI-causing pathogens, no considerable difference was found between before and after renovation, except for Acinetobacter baumannii. In comparison of the major pathogens’ identification rate between the entire hospital and the renovated ICU during the study periods, only A baumannii cases in the renovated ICU significantly decreased. However, the reduction of the IAI cases by A baumannii was not sustained for more than 1 year.

Conclusions

These results suggest that structural ICU renovations only may not improve overall IAI incidence, except for transient decrease in IAI by A baumannii.     

Is vitamin D deficiency associated with development of Acinetobacter baumannii infections in critically ill patients?

Purpose

A growing number of evidence demonstrates deficiency of vitamin D in critically ill patients. We aimed to evaluate the vitamin D status of our critically ill patients and its relevance to infections in these patients.

Material and Methods

We conducted a prospective observational study in 201 critically ill patients admitted to the medical intensive care unit of Gazi University Hospital between October 2009 through March 2011.

Results

Sixty-nine percent of the patients were found to be vitamin D deficient. Infection rate was higher in the deficient group, though without statistical significance (P = .117). Infections with Acinetobacter baumannii was significantly more frequent in patients with Vitamin D deficiency (25% vs 10%, P = .012). The median level of 25-hydroxyvitamin D levels was 11.8 [6.3-17.2] ng/mL and 15.7 [8.1-28.9] ng/mL in patients with and without A baumannii infections respectively (P = .024). Logistic regression analysis demonstrated that vitamin D deficiency (P = .042) and invasive mechanical ventilation (P = .001) were the 2 independent risk factors in the development of A baumannii infections, in addition.

Conclusions

Vitamin D deficiency is common in critically ill patients. Even though there was no statistical difference between vitamin D deficient and sufficient patients regarding development of infections in general, A baumannii infections were significantly more frequent in the deficient group. Vitamin D deficiency was found as one of the independent risk factors for A baumannii infections. Further multicenter studies with a larger sample size are required to validate our data.     

Emergence and characterization of nosocomial multidrug-resistant and extensively drug-resistant Acinetobacter baumannii isolates in Tehran,Iran

Rationale

Acinetobacter baumannii is one of the antibiotic-resistant superbugs that threatens hospitalized patients. Emergence and spread of the multidrug-resistant (MDR) and extensively drug-resistant (XDR) clones cause erratic outbreaks following environmental contamination of hospital settings.

Ultrasound-guided percutaneous catheter drainage in early treatment of severe acute pancreatitis

BACKGROUND:

Percutaneous catheter drainage (PCD) is a minimally invasive intervation for severe acute pancreatitis (SAP). This study was undertaken to compare the results of surgery and ultrasound-guided PCD in the treatment of 32 patients with SAP, and to direct clinicians to the most optimal approach for SAP.

METHODS:

In the 32 patients, 19 were proved to have deteriorated clinical signs or symptoms, extensive fluid exudation, and necrosis confirmed by computed tomography (CT) and they underwent operative debridement and drainage. For extensive fluid exudation or necrosis, complete liquefaction and safe catheter implantation, the other 13 patients were given PCD.

RESULTS:

The mortality rate of the surgery group was 26.3%, much higher than that of the PCD group (0%). There was a significant difference between the two groups (P=0.044). The mean time for recovery of the serum C-reactive protein (CRP) level was 43.8 days in the surgery group, which was significantly longer than that of the PCD group (23.8 days) (P=0.034).

CONCLUSION:

Early PCD guided by ultrasound could decrease the mortality of patients with severe acute pancreatitis, alleviate life-threatening inflammatory complications, and avoid unnecessary emergency operation.KEY WORDS: Percutaneous catheter drainage, Operation, Severe acute pancreatitis, Clinical efficacy     

Artificial liver support system in treatment of liver failure after acute poisoning

BACKGROUND:

Acute poisoning (AP) may cause failure of the liver and kidney, and even death. This study aimed to investigate the efficacy of artificial liver support system (ALSS) on the treatment of liver failure after acute poisoning.

METHODS:

A total of 31 patients with liver failure caused by AP were admitted to emergency ICU, central ICU, and Department of Gastroenterology from 2005 to 2009 in Zhongshan Hospital Affiliated to Xiamen University, China. Among them, 13 patients served as a treatment group, and used ALSS in addition to detoxification treatment and protective treatment of liver function, and the other 18 patients served as a control group receiving detoxification treatment and protective treatment of liver function.

RESULTS:

In the treatment group, 10 patients (76.9%) were cured or improved, 2 died, and 1 was discharged against advice. In the 18 patients in the control group, 7 (38.9%) were cured or improved, 3 died, and 8 were discharged against advice. There was a significant difference in the rates of improvement between the two groups (P<0.05).

CONCLUSION:

ALSS is a safe and effective clinical method for the treatment of acute toxic liver failure.KEY WORDS: Toxicity, Liver failure, Artificial liver support system     

Expeditious synthesis and preliminary antimicrobial activity of deflazacort and its precursors

The synthesis of deflazacort (DFZ) and a preliminary evaluation of its microbial activity against the human pathogens Acinetobacter baumannii and Staphylococcus aureus is herein reported. While DFZ is inactive, one of its synthetic precursors showed a strong antibacterial activity against both Gram-negative and -positive bacteria.

Synthesis of deflazacort: unexpected antibacterial activity of its epoxide synthetic precursor.     

High dose tigecycline in critically ill patients with severe infections due to multidrug-resistant bacteria

Introduction

The high incidence of multidrug-resistant (MDR) bacteria among patients admitted to ICUs has determined an increase of tigecycline (TGC) use for the treatment of severe infections. Many concerns have been raised about the efficacy of this molecule and increased dosages have been proposed. Our purpose is to investigate TGC safety and efficacy at higher than standard doses.

Methods

We conducted a retrospective study of prospectively collected data in the ICU of a teaching hospital in Rome. Data from all patients treated with TGC for a microbiologically confirmed infection were analyzed. The safety profile and efficacy of high dosing regimen use were investigated.

Results

Over the study period, 54 patients (pts) received TGC at a standard dose (SD group: 50 mg every 12 hours) and 46 at a high dose (HD group: 100 mg every 12 hours). Carbapenem-resistant Acinetobacter.baumannii (bla_OXA-58 and bla_OXA-23 genes) and Klebsiella pneumoniae (bla_KPC-3 gene) were the main isolated pathogens (n = 79). There were no patients requiring TGC discontinuation or dose reduction because of adverse events. In the ventilation-associated pneumonia population (VAP) subgroup (63 patients: 30 received SD and 33 HD), the only independent predictor of clinical cure was the use of high tigecycline dose (odds ratio (OR) 6.25; 95% confidence interval (CI) 1.59 to 24.57; P = 0.009) whilst initial inadequate antimicrobial treatment (IIAT) (OR 0.18; 95% CI 0.05 to 0.68; P = 0.01) and higher Sequential Organ Failure Assessment (SOFA) score (OR 0.66; 95% CI 0.51 to 0.87; P = 0.003) were independently associated with clinical failure.

Conclusions

TGC was well tolerated at a higher than standard dose in a cohort of critically ill patients with severe infections. In the VAP subgroup the high-dose regimen was associated with better outcomes than conventional administration due to Gram-negative MDR bacteria.     

Peritoneal Dialysis-Related Peritonitis with Acinetobacter baumannii: A Review of Seven Cases

Peritonitis is still known as an important complication of continuous ambulatory peritoneal dialysis (CAPD). Multi-drug resistant (MDR) Acinetobacter baumannii is an increasing problem worldwide. Moreover, the increasing reports of carbapenem-resistant A. baumannii strains is common. Although peritoneal dialysis-related peritonitis with MDR A. baumannii is rarely reported, infection with this organism always results in serious peritonitis and increases the possibility of dropout or mortality. Here, we present 7 cases of peritonitis caused by A. baumannii species. Among those 7 cases, 2 involved MDR A. baumannii, and 1 involved a carbapenem-resistant strain. All the MDR bacterial infections failed treatment. We also review the literature about Acinetobacter peritonitis and current treatment protocols.Key words: Peritonitis, Acinetobacter baumannii, multi-drug resistance, peritonitis treatmentAcinetobacter baumannii, a gram-negative bacterium, has been identified as a significant cause of antibiotic-resistant infections and has emerged as one of the most troublesome pathogens for health care institutions (1). Multidrug resistant (MDR) A. baumannii is a growing problem worldwide, and reports of carbapenem-resistant A. baumannii strains are common. Some A. baumannii strains have been found to be resistant to all known antibiotics (2).Although MDR A. baumannii is rarely reported in association with peritonitis in peritoneal dialysis (PD) patients, when this organism is present, it results in serious infection and increases the possibility of dropout or mortality (3-5). Here, we present 7 cases of peritonitis caused by A. baumannii. Of those cases, 2 involved MDR A. baumannii, and 1 was caused by a carbapenem-resistant strain. Refractory peritonitis in 3 patients resulted in prolonged hospitalization, the need for catheter removal, and finally PD dropout and a switch to hemodialysis. The other 4 patients were cured and continued PD therapy. Acinetobacter peritonitis and its treatment process are particularly concerning.     

A continuous quality improvement project to reduce medication error in the emergency department

BACKGROUND:

Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED.

METHODS:

In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems.

RESULTS:

Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work.

CONCLUSION:

This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.KEY WORDS: Medication error, Medication safety, Continuous Quality Improvement (CQI)     

Perforin gene mutations in 77 Chinese patients with lymphomas

BACKGROUND:

Perforin gene (PRF1) mutations have been reported in patients with lymphoma, but the prevalence and characteristics of PRF1 mutation have not been identified in Chinese patients with lymphoma.

METHODS:

Seventy-seven patients with lymphoma, including 6 patients with Hodgkin lymphoma and 71 patients with non-Hodgkin lymphoma, were recruited. DNA samples from peripheral blood were used for PRF1 mutation detection by the PCR-sequencing method.

RESULTS:

Eleven novel PRF1 mutations were found in 8 of the 77 patients with lymphoma. Biallelic or compound monoallelic missense mutations in 3 patients indicated the severe impairment of perforin function, monoallelic missense mutations in 3 patients possibly contributed a genetic predisposition to malignancies, and synonymous mutations in 2 patients showed unknown significance.

CONCLUSIONS:

The frequency of EBV infection was similar in lymphoma patients with PRF1 mutations and those without the mutations. The same PRF1 mutations were also found in DNA samples from nails or hair follicles from 4 patients with PRF1 mutations, suggesting that these mutations may be of germ-line origin.KEY WORDS: Perforin, Mutation, Lymphoma     

Discrepancy of blood pressure between the brachial artery and radial artery

BACKGROUND:

In this study, we attempted to find the relations between blood pressure (BP) measured on the brachial artery (bBP) and BP assessed on the radial artery (rBP) in the right arm.

METHODS:

Three hundred and fifteen patients were enrolled in this study. Those who had peripheral vascular disease, wounds of arm skin or subcutaneous tissue infection were excluded. After a 15-minute equilibration and stabilization period after inducation of anesthesia, three bBP and rBP records were obtained sequentially using an oscillometric device with an adult cuff and infant cuff, respectively. Order for each BP was randomized.

RESULTS:

The bBP was significantly lower than the rBP (P<0.05). The difference between the two values varied from 13 to 18 mmHg in systolic BP (SBP), diastolic BP (DBP) and mean blood pressure (MAP) respectively. And the rBP was positively correlated with the bBP (r=0.872, 0.754, 0.765; P<0.001, <0.001, <0.001; SBP, DBP, MAP, respectively).

CONCLUSION:

The bBP value can be evaluated by the noninvasive measurements of rBP using an appropriate cuff in clinical practice.KEY WORDS: Blood pressure, Brachial artery, Radial artery, Correlation, Linear regression     

Bispectral index in predicting the prognosis of patients with coma in intensive care unit

BACKGROUND:

The bispectral (BIS) index is a processed electroencephalogram (EEG) parameter with extensive validation and demonstrated clinical utility. The study aimed to investigate the correlation between the BIS index and the prognosis of patients with coma in the ICU.

METHODS:

A total of 208 patients with coma in the ICU were enrolled in this study. According to the BIS value, the patients were divided into four groups: group I, BIS value 0 to 20; group II, BIS value 21 to 40; group III, BIS value 41 to 60; and group IV, BIS value greater than 60. The difference in BIS values with the differences in prognosis of patients with coma was compared between the four groups, and the prognosis of patients with coma was stratified into consciousness, coma, vegetative state, and brain death. Subsequently, the best cut-off score of BIS values calculated for determining the correlation between BIS value and mental state was proposed.

RESULTS:

There are no significant differences in the age and APACHE II scores between the four groups (P>0.05). An inverse correlation was observed between BIS value and mental state (r= –0.749, P=0.00). According to the ROC curve, as BIS value was greater than 42.5, there were higher sensitivity and specificity in conscious-coma patients.

CONCLUSION:

BIS value is correlated with the prognosis of patients with coma in ICU, and BIS value can be a useful marker for estimating the prognosis of comatose patients.KEYWORDS: Bispectral index, Coma, Prognosis     

Streptomyces chiangmaiensis SSUT88A mediated green synthesis of silver nanoparticles: characterization and evaluation of antibacterial action against clinical drug-resistant strains

This study involved the characterization of AgNPs synthesized from soil isolate Streptomyces sp. SSUT88A and their antimicrobial activities. The strain SSUT88A revealed 98.8% similarity of the 16s rRNA gene to Streptomyces chiangmaiensis TA4-1^T. The AgNPs were synthesized by mixing either intracellular or extracellular cell-free supernatant of strain SSUT88A with AgNO₃. The synthesized AgNPs from intracellular cell-free supernatant and extracellular cell-free supernatant were designated as IS-AgNPs and ES-AgNPs, respectively. The IS-AgNPs showed maximum absorbance of UV-vis spectra at 418 nm, while ES-AgNPs revealed maximum absorbance at 422 nm. The TEM observation of synthesized AgNPs revealed a spherical shape with an average diameter of 13.57 nm for IS-AgNPs and 30.47 nm for ES-AgNPs. The XRD and XANES spectrum profile of both synthesized AgNPs exhibited similar spectrum energy, which corresponded to AgNPs. The IS-AgNPs revealed antimicrobial activity against clinical isolate drug-resistant bacteria (Acinetobacter baumannii, Escherichia coli 8465, Klebsiella pneumoniae 1617, and Pseudomonas aeruginosa N90PS), while ES-AgNPs had no antimicrobial activity. When compared to commercial AgNPs, IS-AgNPs exhibited antibacterial efficacy against all clinical isolate bacteria including A. baumannii, one of the most threatening multi-drug resistant strains, while commercial AgNPs did not. Thus, IS-AgNPs has potential to be further developed as an antimicrobial agent against drug-resistant bacteria.

The first synthesis of AgNPs by Streptomyces chiangmaiensis which had superior antibacterial action against serious drug-resistant pathogens than commercial AgNPs.     

Characterization of pABVA01, a Plasmid Encoding the OXA-24 Carbapenemase from Italian Isolates of Acinetobacter baumannii

Two epidemiologically unrelated carbapenem-resistant Acinetobacter baumannii isolates were investigated as representatives of the first Italian isolates producing the OXA-24 carbapenemase. Both isolates were of European clonal lineage II and carried an identical OXA-24-encoding plasmid, named pABVA01. Comparative analysis revealed that in pABVA01, bla_OXA-24 was part of a DNA module flanked by conserved inverted repeats homologous to XerC/XerD binding sites, which in other Acinetobacter plasmids flank different DNA modules, suggesting mobilization by a novel site-specific recombination mechanism.Acinetobacter baumannii is an opportunistic nosocomial pathogen of increasing clinical relevance (3, 4, 22). The species is naturally resistant to several antimicrobial agents and exhibits a remarkable propensity to acquire new resistances (4, 14, 22). Carbapenems are elective agents for treatment of A. baumannii infections, and the emergence of carbapenem-resistant strains is a matter of increasing clinical concern (22, 24). Acquired class D carbapenemases of the OXA-23, OXA-24 (also named OXA-40), and OXA-58 lineages are playing a major role as determinants of acquired carbapenem resistance in A. baumannii (24).In Italy, production of OXA-58 is the dominant carbapenem resistance mechanism in A. baumannii, and several outbreaks caused by OXA-58-producing strains related to European clonal lineage II have been documented (11, 15, 17), while strains producing OXA-23 and OXA-24 have not been reported. Here we report the characterization of the first Italian isolates of carbapenem-resistant A. baumannii producing the OXA-24 carbapenemase.(Part of this study was presented at the 18th European Congress of Clinical Microbiology and Infectious diseases, Barcelona, Spain, 2008. [M. M. D''Andrea, T. Giani, F. Luzzaro, and G. M. Rossolini, oral communication O300].)     

Sudden cardiac death following blunt chest trauma: commotio cordis

BACKGROUND:

There have been numerous reports of sudden cardiac death attributable to the condition of commotio cordis. Primarily, these are reports from the USA. Although three Australian cases have been mentioned in the published literature, the present case appears to be the first described Australian case.

METHODS:

A man was brought to the Emergency Department after sudden collapse while playing cricket. His medical history was suggestive of hitting by a cricket ball while batting.

RESULTS:

The epidemiology and mechanism of arrhythmia induction in commotio cordis are discussed. The emergency management of commotio cordis is outlined.

CONCLUSIONS:

Commotio cordis is rare in sports (and Emergency Medicine). However it has a high mortality rate, and rapid recognition of the condition allows early defibrillation, generally with a good outcome. The improvement of participant care is recommended at community and other sport events.KEY WORDS: Arrhythmia, Sudden cardiac death, Commotio cordis, Cricket     

Meningitis secondary to Cryptococcus gattii,an emerging pathogen affecting immunocompetent hosts

BACKGROUND:

Meningitis continues to be one of the most important infections diagnosed and treated by emergency physicians. Despite the advent of anti-infective therapy, meningitis carries a mortality rate of 20%–40%. In this study, we describe the first reported emergency medicine case of meningitis associated with Cryptococcus gattii to alert providers of this insidious, emerging global pathogen infecting immunocompetent individuals.

METHODS:

We provided a case report and accompanying review of the literature. A MEDLINE search for the term Cryptoccocus gattii was performed to obtain background information on Cryptococcus gattii.

RESULTS:

After two months of hospitalization, the patient was eventually discharged neurologically intact except for a continued mild bilateral hearing deficit.

CONCLUSION:

Cryptococcus gattii is an emerging world pathogen, which affects otherwise healthy, immunocompetent patients and requires timely identification and treatment in order to prevent severe neurological sequelae.KEY WORDS: Meningitis, Cryptococcus gattii     

Role of corticotrophin releasing hormone in cerebral infarction-related gastrointestinal barrier dysfunction

BACKGROUND:

Corticotrophin releasing hormone (CRH) is believed to mediate stress-induced behaviors, implying a broader, integrative role for the hormone in the psychological stress response, and studies on CRH in physical stress are few. This study was undertaken to investigate whether CRH plays an important role in cerebral infarction-related gastrointestinal barrier dysfunction.

METHODS:

Thirty male Wistar rats were randomly divided into a pseudo-operation group (group C, n=10), a cerebral infarction group (group I, n=10), and a cerebral infarction + ic α-helical-CRH (9-41) group (group Aic, n=10). Urine samples were collected to determine the levels of epinephrine, norepinephrine, cortisol, and sucrose. At 24 hours after establishment of the models, blood samples were taken to determine the activity of diamine oxidase (DAO) and the concentration of D-lactic acid (D-lac). The stomach was taken to determine gastric Guth score, and the hypothalamus was also taken to determine tissue CRH protein expression using Western blotting.

RESULTS:

The hypothalamus CRH protein, the indicators of stress, the plasma DAO activity and plasma D-lac, urine sucrose exertion and gastric Guth score in group I were higher than those in groups Aic and C.

CONCLUSIONS:

After cerebral infarction, CRH in the hypothalamus was increased, the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system were activated, gastrointestinal permeability was increased, and gastrointestinal barrier function was destroyed. CRH receptor antagonist alleviated the gastrointestinal barrier function.KEY WORDS: Corticotrophin releasing hormone, Cerebral infarction, Gastrointestinal barrier, Stress     

Hydrocolloid dressing in preventing nasal trauma secondary to nasal continuous positive airway pressure in preterm infants

BACKGROUND:

Continuous positive airway pressure (CPAP) with nasal devices (nCPAP) is widely used in the respiratory management of newborns. The present study aimed to compare the incidence of nasal trauma secondary to nasal continuous positive airway pressure (nCPAP) protected with or without hydrocolloid dressing in preterm infants.

METHODS:

This prospective controlled study was performed in the neonatal intensive care unit (NICU) of the Children’s Hospital of Hunan Province from March 1, 2010 to June 31, 2010. A total of 65 infants, 46 males and 19 females, were recruited in this study. Their average gestational age was 32.6 weeks (range 28–37 weeks). The infants were randomly divided into clinical trial group (group A, n=33) and control group (group B, n=32). Paraffin oil was smeared around the nostrils before inserting prongs in group B; the infants in group A were covered on the infant’s nostrils surface with hydrocolloid dressing (hydrocolloid dressing, 1.8 mm thick, 90029T, 3M Company, Minnesota, USA) with a size of 2–3 cm cutting two holes adapted to the nose and nostrils. The nostrils of those infants were inspected daily during nCPAP support until they were weaned off nCPAP.

RESULTS:

Nine infants (2 in group A and 7 in group B) developed nasal injury during nCPAP support. The Chi-square test revealed that there was a statistically significant difference (P=0.01) in the incidence of nasal injury between groups A and B.

CONCLUSION:

The study demonstrated that hydrocolloid dressing significantly decreased the incidence and the severity of nasal injury.KEY WORDS: Continuous positive airway pressure, Nasal injury, Hydrocolloid dressing, Preterm infants, Nasal prongs