Six year trend of neonatal septicaemia in a large Malaysian maternity hospital

Abstract A study carried out in the Maternity Hospital, Kuala Lumpur over a 6 year period from 1986 to 1991, showed that the annual rates of septicaeia ranged from 5.2 to 10.2/100 admissions. Septicaemia accounted for between 11.0 to 30.4% of all neonatal deaths. The case fatality ratios ranged from 23.0 to 52.2%, being highest in 1989 when basic facilities were compromised. Low birthweight neonates accounted for 55.5% of those with septicaemia. The most common causative organisms were Staphylococcus epidermidis and Staphylococcus aureus in 1986 and 1987, but from 1988 Klebsiella species became the most common. More than 50% of neonatal septicaemia occurred after the age of 2 days. The results of the study demonstrated the dynamism of infection control: when control measures introduced earlier were not sustained, outbreaks of nosocomial infection recurred or worsened.     

Increase of staphylococci in neonatal septicaemia: a fourteen-year study

All cases of neonatal septicaemia during 1981-94 were studied at Örebro Medical Centre Hospital, Sweden. One hundred and thirty-two children fulfilled laboratory and clinical criteria for neonatal septicaemia and were included. Staphylococcus aureus ( n = 41), Group B streptococcus (GBS) ( n = 32) and coagulase-negative staphylococci (CoNS) ( n = 27) were the dominating aetiologies. The annual incidence of septicaemia increased significantly, from 2.3 cases during the first 7-year period to 3.3 per 1000 live births during 1988-94. This increase was caused by S. aureus and CoNS, which mainly affected premature children and had an onset more than 48 h after delivery. GBS, on the other hand, slightly decreased and affected full-term children within 48 h. The overall mortality was 11%. CoNS isolated during the latter 7-year period were more resistant to antibiotics than those isolated during 1981-87; resistance to methicillin increased from 14 to 45% and to gentamicin from 0 to 20%. These changes in aetiology and antibiotic susceptibility should be considered when selecting antibiotic treatment in neonatal septicaemia.     

产时抗菌药物预防治疗B族链球菌感染对早发型新生儿败血症发生率及病原菌分布的影响

目的 了解产时抗菌药物预防（intrapartum antibiotic prophylaxis,IAP）治疗B族链球菌（Group B streptococcus,GBS）感染对早发型新生儿败血症（early-onset neonatal sepsis,EONS）发生率及病原菌分布的影响。 方法 回顾性分析GBS筛查阳性的494例孕产妇及其所分娩的526例新生儿的临床资料。根据孕产妇是否接受IAP治疗将新生儿分为IAP组（304例）和对照组（222例）,比较两组间的各项临床指标、EONS发生率、血培养病原菌分布情况。 结果 IAP组出现异常临床表现的患儿比例显著低于对照组（P<0.001）。IAP组EONS发生率显著低于对照组（P=0.022）。IAP组和对照组EONS患儿血培养检测病原菌种类最多分别为大肠埃希菌（2.3%）和GBS（3.2%）。IAP组氨苄青霉素耐药性大肠埃希菌的检出率显著高于对照组（P=0.029）。 结论 IAP治疗虽可降低GBS阳性孕产妇所娩新生儿的EONS发生率,但IAP治疗后氨苄青霉素耐药性大肠埃希菌感染率升高,提示应强化对EONS患儿血培养结果的监测,根据药敏试验结果及时调整诊疗计划。     

Changing pattern of neonatal septicaemia in an African city

The pattern of neonatal septicaemia in a large cosmopolitan African city is presented. Comparison of microorganisms isolated in the present study when compared with the results of previous reports from the same institution, show an increase in the incidence of klebsiella and pseudomonas septicaemia. In contrast, Escherichia coli infection has decreased appreciably from an incidence of 56.8% to 14.3%. Staphylococcus aureus has remained the dominant Gram-positive pathogen over the last decade while group B streptococcal (GBS) disease was rarely encountered. A significant finding was the emergence of gentamicin-resistant strains of E. coli and proteus species during the past 5 years. The overall incidence of neonatal septicaemia was 5.6/1000 livebirths and the mortality rate was 30.6%.     

Quantification of neonatal amplitude-integrated EEG patterns

Background

Amplitude-integrated EEG (aEEG) is increasingly used in research with premature infants; however, comprehensive interpretation is limited by the lack of simple approaches for reliably quantifying and summarizing the data.

Aim

Explore operational measures for quantifying continuity and discontinuity, measured by aEEG as components of infant brain function.

Study design

An exploratory naturalistic study of neonates while in the Neonatal Intensive Care Unit (NICU). One single channel aEEG recording per infant was obtained without disruption of nursing care practices.

Subjects

24 infants with mean postmenstrual age (PMA) of 33.11 weeks (SD 3.49), average age of 2.62 weeks (SD 1.35) and mean birth weights of 1.39 kg (SD 0.73).

Outcome measures

Quantification of continuity and discontinuity included bandwidth and lower border of aEEG, calculated proportion of time with signal amplitude below 10 μV, and peak counts. Variance of bandwidth and lower border denoted cycling.

Results

Group mean bandwidth was 52.98 μV (SD 27.62). Median peak count in 60 second epochs averaged 3.63 (SD 1.74), while median proportion < 10 μV was 22% (SD 0.20). The group mean of lower border within-subject aggregated medians was 6.20 μV (SD 2.13). Group mean lower border standard deviation was 3.96 μV. Proportion < 10 μV showed a strong negative correlation with the natural log of the lower border median (r = − 0.906, p < .0001) after controlling for PMA.

Conclusions

This study introduces a novel quantification process by counting peaks and proportion of time < 10 μV. Expanded definitions and analytic techniques will serve to strengthen the application of existing scoring systems for use in naturalistic research settings and clinical practice.     

Neonatal candidemia

Fifty five clinically diagnosed cases of neonatal septicaemia of the nursery ward, Medical College Hospital Calcutta were subjected to blood culture on two consecutive days in all cases. Bacterial isolates were found in 34 (61.8%) cases as pure growth and candida species from 9(16.4%) as pure culture. Remaining 12 samples did not yield any growth. Species distribution of candida showed C.albicans 6, C.parapsilosis 2, and C.guillermondii 1. Asphyxia neonatorum was the common feature in all cases of candidaemia. All neonates with candidal infection were low-birth-weight and premature. C. albicans, the predominant species (66.6%) recovered, was responsible for a localised outbreak of infection in the nursery.     

Recrudescence and relapse of meningococcal meningitis and septicaemia

Three cases of recrudescence and relapse of Neisseria meningitidis group B meningitis and septicaemia are reported. The recrudescence and relapses could not be explained by infectious foci, increased bacterial penicillin resistance or immunological defects. As a supplement to antibiotic treatment, all three patients received corticosteroids for the initial 2 days of treatment, and this may have contributed to the unusual course of the disease in our patient.     

Massive subdural haematoma: An unusual complication of septicaemia in preterm very low birthweight infants

Non-traumatic massive subdural haematoma is a rare condition in newborn infants and is usually associated with hereditary coagulation disorders or congential vascular malformation. Its occurrence in preterm very low birthweight infants secondary to systemic bacterial infection has not been reported. We describe two extremely preterm neonates who developed massive subdural haematoma as a result of Gram-negative septicaemia and disseminated intravascular coagulation. Both infants suffered severe parenchymal cerebral injury and hydrocephalus. Clinicians should be aware of this unusual and catastrophic complication if a very low birthweight infant with severe sepsis and disseminated intravascular coagulation suddenly deteriorates despite successful treatment with antibiotics. Radiological imaging by cranial ultrasound or computed tomography scanning should be routinely considered in all such infants for the detection of intracranial bleeding.     

Haemophilus influenzae septicaemia in the neonate: Report of two cases and review of the English literature

Two neonates with early onset respiratory illness were found to have Haemophilus influenzae septicaemia. One of them died. A review of the English literature showed that Haemophilus influenzae septicaemia is increasing in incidence. Almost all cases presented with respiratory distress in the first 2 days. Other associated features included meningitis, arthritis, conjunctivitis and cellulitis. The mortality, which averaged 52%, was high, especially in premature babies. The septicaemia was caused by ascending infection from the colonized maternal birth canal, and most cases were caused by nontypable strains of Haemophilus influenzae. Because of the occurrence of ampicillin or chloramphenicol resistance, a third generation cephalosporin is the treatment of choice for known cases of serious infection.     

Severe skin loss after meningococcal septicaemia: complications in treatment

Meningococcal septicaemia can lead to purpura fulminans with subsequent full thickness skin loss and deep muscle damage. The case reports on two infants who recovered from such a severe episode are used to describe post-septicaemic procedures and complications encountered in nursing care, psychological support and rehabilitation, with the main focus on surgery. Skin grafting is complicated by contaminated and contracting wound areas. Extensive tissue necrosis required leg amputations. Cultured keratinocytes in one of the patients were found to be too vulnerable. It has still to be proven whether more radical early-stage fasciotomies can limit skin and muscle necrosis. Patients with meningococcal septicaemia are subject to a high number of complications that are optimally treated in a burns unit. These patients require up-to-date knowledge of constantly evolving treatment possibilities and a high-level collaboration of all medical fields involved.     

Polymorphonuclear leucocyte transfusion in neonatal septicaemia

In one neonatal intensive care unit during a 15 month period 6 infants developed septicaemia which was resistant to antibiotic treatment. The infants' mean gestational age and birthweight were 32.7 weeks and 1519 g respectively. Intravenous infusions of polymorphonuclear leucocytes were given. Three infants died and the remainder survived without complications. No side effects of the treatment were identified.     

Necrotizing bowel lesions complicated byPseudomonas septicaemia in previously healthy infants

Two previously healthy infants withPseudomonas septicaemia presented with necrotizing bowel lesions. Necrotizing bowel lesions should be suspected when infants presenting with a history of diarrhoea, develop abdominal distension and toxic signs.Pseudomonas aeruginosa should be regarded as one of the important aetiologies in such disorders, especially if there is associated neutropenia and ecthyma gangrenosum-like lesions. Antibiotics must be able to cover this pathogen to avert a catastrophic outcome.Conclusion The intestine should be considered a possible site of involvement inPseudomonas sepsis and special attention should be paid to examination of the abdomen.     

Serum TNF levels in neonatal sepsis and septic shock

Tumor necrosis factor (TNF-alpha) has been implicated as a principal mediator in the pathogenesis of septic shock. TNF-alpha was measured by immunoradiometric assay in serum samples from 23 full-term infants with sepsis (15 with severe infection and 8 with septic shock) and in 20 healthy full-term newborns. Serum TNF-alpha levels were significantly higher in the group with sepsis, at the time of admission to the neonatal intensive care unit, than in the healthy neonates. The highest TNF levels were found in those newborns with septic shock, particularly in those who died. Although the method is far too slow for any clinical routine work, our results suggest that the presence of elevated serum TNF-alpha levels could be considered a sensitive and specific test for predicting septic shock and its clinical outcome.     

Predictive value of C-reactive protein in neonatal septicaemia

The following non-specific indices of infection were studied in septicaemic and non-septicaemic babies: haemoglobin, total white blood cell count, differential white count, ESR, platelet count, C-reactive protein (CRP), serum immunoglobulins, plasma C3 and haptoglobin. Forty-three low-birthweight (LBW) infants with clinical features suggesting septicaemia were investigated; blood cultures were positive in 19 and negative in 24. The mortality was 53% in the culture-positive and 13% in the culture negative group. Comparisons between the two groups of babies showed that the CRP titre (measured by Latex agglutination) was the only reliable non-specific indicator of infection. The titre was elevated more often in culture positive (16/19) than culture negative (7/17) babies (P less than 0.001). The CRP titre (Mean +/- 2 S.D.) was 15.75 +/- 12 in blood culture positive and 6.13 +/- 11.72 in culture negative neonates respectively (P less than 0.0004). Positive CRP titres were found in 5 of 20 healthy controls (4 +/- 8.4). Sequential CRP titres showed a gradual decline with clinical improvement in both groups of patients. The IgM was unhelpful as it was raised (greater than or equal to 40 mg%) in 37 of the patients.     

Prognostic value of direct bilirubin in neonatal hyperbilirubinemia

Objective To determine the prognostic value of indirect and direct hyperbilirubinemia in neonates with jaundice. Methods A cohort of 92 consecutive neonates reporting with hyperbilirubinemia to a tertiary care center were followed up till well and discharged, or, till death to assess risk and rate of mortality. Results The baseline median values of total, direct and indirect bilirubin in the cohort of 21.8, 1.6 and 18.6 mg/dl, respectively, were used as cut-offs for high and low levels. Using survival analyses i.e. Kaplan-Meier plots, logrank tests and multivariate Cox proportional hazards regression models to adjust for other strong predictors such as receipt of breastfeeding, being small for gestational age (SGA) and exchange transfusion, high direct bilirubin (≥ median value of 1.6 mg/dl) was independently associated with a higher and faster mortality. Conclusion This study showed that direct bilirubin has independent and additive prognostic value and due attention should be given to newborns with raised levels.     

The cephalosporin compounds in severe neonatal infection

The new cephalosporin compounds have increased in vitro activity against gram-negative enteric bacilli and penetrate well into cerobrospinal fluid. Moreover, their pharmacokinetic properties are favorable and their safety seems adequate, although insufficiently evaluated to date. Interest has been focused on them as therapeutic agents for neonatal sepsis and meningitis caused by Enterobacteriaceae. In this review the third generation cephalosporins are evaluated for their possible use in the neonates; opinions are based on currently available data. It is concluded that moxalactam and cefotaxime and probably also ceftriaxone and ceftazidime represent valuable alternatives to aminoglycosides for therapy of severe neonatal infection. Curriculum vitae. Urs B. Schaad was born 1945 in Switzerland. He graduated 1971 from the Medical Faculty of the Bernese University and his postgraduate training included 1 year General Surgery (Lugano), 11/2 years Internal Medicine (Langenthal) and 41/2 years Pediatrics (Berne). From 1978 to 1980 he completed a Research Fellowship in Pediatric Infectious Diseases at the University of Texas at Dallas, USA (Directors of Program: Prof. George H. McCracken, Jr., and Prof. John D. Nelson). Since 1981 he is back at the Department of Pediatrics, University of Berne (Head: Prof. E. Rossi), conducting clinical, research and teaching activities in Pediatric Infectious Diseases. In June 1983 he was promoted to Privatdozent and received the Venia Docendi in Pediatrics with special regard to Infectious Diseases. Main topics of research have been experimental meningitis and studies on pharmacokinetics and efficacy of different antimicrobial agents in pediatric patients. Previous reviews included recrudescence and relapse in bacterial meningitis, atypical myobacterial lymphadenitis, melioidosis, pyogenic sacroiliitis, arthritis in meningococcal disease, infantile chlamydial pneumonia, Campylobacter-reactive arthritis, prophylaxis against pneumococcal, meningococcal and H. influenzae type b infections in childhood, neonatal sepsis and meningitis, and infectious diarrhea in the pediatric age group.     

How clinicians in neonatal care see the introduction of neonatal nurse practitioners

The aim of this study was to investigate the views of UK clinicians in neonatal care who were working with nurses trained as neonatal nurse practitioners (NNPs). A questionnaire survey was used with a total sample of senior clinicians in the 66 neonatal units with one or more qualified NNPs. The main outcome measures were type and frequency of response, and similar data from NNPs were used to make comparisons. Data were returned from 57 of the 66 clinicians contacted (86%). NNP clinical practice as perceived by them was largely similar to that recorded by NNPs, though the clinicians expected more NNP involvement in some procedures (inserting central venous lines, umbilical arterial catheters, chest drains and peripheral arterial cannulae) than was actually found. Perceptions of the NNP role were similar, though the clinicians were significantly less likely to see taking a case-load, conducting a ward round, accepting outside referrals and taking charge of emergency transfers as integral elements. Reflections on the utilization of NNPs in neonatal care and the impact on junior medical staff education referred to NNPs filling gaps, a reduction in the intensity of work, improvements in training and in the quality of care.

Conclusion : The introduction of NNPs is seen positively from the perspective of clinicians working alongside them in neonatal care. The development of similar models of care in countries where the introduction of NNPs is being considered is likely to be similarly supported.     

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.     

Cardiomegaly in neonatal hypoglycemia

Chest. X-rays of 24 hypoglycemic newborns were compared with those of a matched control group of newborns with normal blood glucose levels. In the hypoglycemic group heart size was found to be significantly greater than in the control group.No correlation could be established between the degree of cardiomegaly and the severity of hypoglycemia. 19 of the 24 hypoglycemic children were prematures or small for dates and it is postulated that the low glycogen stores in these infants do not meet the metabolic demands of the myocardium during its postpartum circulatory adaptation.     

Infection scoring in early neonatal infection

This study reports the usefulness of infection scoring system, comprising of maternal and neonatal high risk factors for infection. The score was applied on 947 neonates at birth who were followed up for superficial and deep infections in postnatal wards or neonatal nursery. Total score consisted of 10 points. A high association was observed between increasing score and total and deep infections. Incidence of infections was 0, 5.0, 10.5, 20.9, 61.8 and 95.4 percent respectively with infection scores of 0, 1, 2, 3, 4 and 5 and above respectively. For term infants, cut off point for infection was at score 3, while for low birth ones this was lower at 2. This study, therefore, shows the utility of this practical scoring system in prediction of early neonatal infections.