Risk factors for neonatal infections in full-term babies in South Korea

PURPOSE: Since 1997, private postnatal care facilities (San-hu-jo-ri-won in Korean) have emerged to take the role of the family. As a result, neonates are now exposed to many people and are very vulnerable to infection. However, there has been no study on the influence of postnatal care facilities on neonatal infection. The aim of this study was to determine the risk factors of neonatal infection in full-term babies in Korea. MATERIALS AND METHODS: We followed up 556 pregnant women and their babies for 4 weeks after their births at 2 hospitals in Seoul and Daejeon from October 2004 to September 2005. Among 512 full-term babies, 58 had infectious diseases. To determine the risk factors for infection, 53 infected neonates at 4-28 days of life and 413 healthy neonates were compared. RESULTS: The incidence of neonatal infection at 4 to 28 days after birth was 10.5%. After adjusting the related factors, the number of siblings (OR = 2.05, 95% CI = 1.13-3.71 for 1 or more) and postnatal care facilities or home aides (OR = 1.91, 95% CI = 1.07-3.45) were significant risk factors. Formula or mixed feeding (OR = 1.66, 95% CI = 0.91-3.04) increased the risk of neonatal infection but it was not statistically significant. CONCLUSION: When the newborns had siblings, stayed at postnatal care facilities, or were cared for by home aides, the risk of neonatal infections significantly increased. Further research on the feeding effect on neonatal infection and evaluation of prevention efforts are needed.     

Temporal trends in Enterobacter species bloodstream infection: a population-based study from 1998–2007

Enterobacter species are the fourth most common cause of Gram-negative bloodstream infection (BSI). We examined temporal changes and seasonal variation in the incidence rate of Enterobacter spp. BSI, estimated 28-day and 1-year mortality, and determined in vitro antimicrobial resistance rates of Enterobacter spp. bloodstream isolates in Olmsted County, Minnesota, from 1 January 1998 to 31 December 2007. Multivariable Poisson regression was used to examine temporal changes and seasonal variation in incidence rate and Kaplan–Meier method was used to estimate 28-day and 1-year mortality. The median age of patients with Enterobacter spp. BSI was 58 years and 53% were female. The overall age- and gender-adjusted incidence rate of Enterobacter spp. BSI was 3.3 per 100 000 person-years (95% CI 2.3–4.4). There was a linear trend of increasing incidence rate from 0.8 (95% CI 0–1.9) to 6.2 (95% CI 3.0–9.3) per 100 000 person-years between 1998 and 2007 (p 0.002). There was no significant difference in the incidence rate of Enterobacter spp. BSI during the warmest 4 months compared to the remainder of the year (incidence rate ratio 1.06; 95% CI 0.47–2.01). The overall 28-day and 1-year mortality rates of Enterobacter spp. BSI were 21% (95% CI 8–34%) and 38% (95% CI 22–53%), respectively. Up to 13% of Enterobacter spp. bloodstream isolates were resistant to third-generation cephalosporins. To our knowledge, this is the first population-based study to describe the epidemiology and outcome of Enterobacter spp. BSI. The increase in incidence rate of Enterobacter spp. BSI over the past decade, coupled with its associated antimicrobial resistance, dictate the need for further investigation of this syndrome.     

Bloodstream infections and perinatal mortality.

Bloodstream infection is demonstrable at necropsy in 21.1% of perinatal death but is almost invariably a secondary event, often terminal, contributing to death as a secondary cause. In only 3.8% is infection recorded as the primary cause of death. Escherichia coli predominates, and postmortem and antemortem studies alike confirm the tendency of this and other microbes to involve the meninges in the course of bloodstream infection. Fatal viral and fungal infections are rare, and life-threatening disease is overwhelmingly of bacterial origin. A separate, prospective study of septicaemia in the newborn is reported, and the data are tabulated. The overall incidence in inborn and outborn populations, together with the incidence of specific infections, is stated, and the relationship to birthweight is analysed. The overall mortality for treated cases is 40.7% the mortality being inversely proportional to birthweight, and highest at 62.5% in those born weighting less than 1000 g. The advent of meningitis (1 in 5 cases of septicaemia) aggravates the mortality (83%). The potential hazard of nursing seriously infected babies is emphasised.     

Risk factors for community-onset bloodstream infection with extended-spectrum β-lactamase-producing Enterobacteriaceae: national population-based case–control study

ObjectivesThe aim was to investigate risk factors for community-onset bloodstream infections with extended-spectrum β-lactamase-producing Enterobacteriaceae (EPE BSI).MethodsIt is mandatory to report EPE BSI to a national register at the Public Health Agency of Sweden. Using this register, we performed a population-based case–control study from 2007 to 2012 of 945 cases and 9390 controls. Exposure data on comorbidity, hospitalization, in- and outpatient antibiotic consumption and socio-economic status were collected from hospital and health registers.ResultsThe overall incidence of EPE BSI was 1.7 per 100 000 person-years. The 30-day mortality was 11.3%. Urological disorders inferred the highest EPE BSI risk, adjusted odds ratio (aOR) 4.32 (95% Confidence Interval (CI) 3.41–5.47), followed by immunological disorders, aOR 3.54 (CI 2.01–6.23), haematological malignancy, aOR 2.77 (CI 1.57–4.87), solid tumours, aOR 2.28 (1.76–2.94) and diabetes, aOR 2.03 (1.58–2.61). Consumption of fluoroquinolones or mostly non-EPE-active antibiotics with selective Gram-negative spectrum of activity within the previous 3 months was associated with EPE BSI, aORs 5.52 (CI 2.8–11.0) and 3.8, CI 1.9–7.7) respectively. There was a dose–response relationship in EPE BSI risk with increasing number of consecutive regimens. Antibiotic consumption >3 months before EPE BSI was not associated with increased risk. Higher age, malignancies and education ≤12 years (aORs >2) were associated with increased 30-day mortality.ConclusionsTargeted interventions should be directed towards improving care for patients with immunosuppression, urological disorders and subjects with lower socio-economic status. Antibiotic stewardship should focus on reduction of fluoroquinolones.     

The effect of migration on the incidence and mortality of bloodstream infection: a Danish register-based cohort study

ObjectivesTo investigate bloodstream infection (BSI) related to migrant status by comparing the incidence and mortality in migrants with that in non-migrants.MethodsIn this register-based cohort study we linked a cohort of migrants and non-migrants with a bacteraemia database covering two regions in Denmark. We included first-time BSI between January 2000 and December 2015 in individuals ≥18 years. Migrants were categorized according to status: refugees or family-reunified migrants. Incidence rate ratio and mortality rate ratio were analysed using Poisson regression.ResultsWe identified 493 080 non-migrants, of which 3405 had BSI, and 80 740 migrants with 576 cases; of the latter, 40 222 were family-reunified migrants with 226 cases and 40 518 were refugees with 350 cases. Refugees had a higher risk of BSI than non-migrants (adjusted IRR 1.19, 95%CI 1.01–1.40). Family-reunified migrants and refugees had a higher risk of Gram-negative BSIs (adjusted IRR 1.23, 95%CI 1.00–1.51 and 1.57, 95%CI 1.32–1.86), respectively, and a lower risk of Gram-positive BSIs (adjusted IRR 0.65, 95%CI 0.51–0.83 and 0.77, 95%CI 0.63–0.95), respectively, compared to non-migrants. Originating from Southeast Asia and the Pacific was associated with an increased risk of BSI compared to non-migrants (adjusted IRR 1.26, 95%CI 1.07–1.49). We found no differences in the adjusted 30-day or 90-day mortality according to migrant status.ConclusionsVulnerability towards BSI differs according to migrant status. Refugees had a higher risk of BSI overall. Both refugees and family-reunified migrants had a higher incidence of Gram-negative BSI than non-migrants. Similarly, migrants from Southeast Asia and the Pacific had a higher risk of BSI than non-migrants.     

The Incidence,Aetiology and Antimicrobial Susceptibility of Central Line-Associated Bloodstream Infections in Intensive Care Unit Patients at a Private Tertiary Care Hospital in Mumbai,India

Background: There is a need to generate accurate data on temporal trends in incidence rates, aetiology and antimicrobial susceptibility of central line-associated bloodstream infections (CLABSIs) in the Indian setting. Aim: To study the incidence, aetiology and antimicrobial susceptibility of CLABSI in adult, paediatric and neonatal intensive care units (NICUs) in a tertiary care private hospital in Mumbai, India. Materials and Methods:This is a prospective observational study conducted at the adult, paediatric and NICUs of tertiary care private hospital from 2011 to 2018. CLABSI was defined as per the Centers for Disease Control criteria. Surveillance of CLABSI in the intensive care units (ICUs) was conducted using a form adapted from the International Nosocomial Infection Control Consortium surveillance system. The incidence rates of CLABSI (per 1000 central line days), crude mortality, aetiology and antimicrobial susceptibility were calculated and reported. Results: Six hundred and eighty-six episodes of CLABSI were recorded, and the overall incidence of CLABSI was 5/1000 catheter days, 4.1 in the adult ICU, 5 in the paediatric ICU and 9 in the newborn ICU. Crude mortality in patients with CLABSI in the adult, paediatric and NICUs was 45%, 30% and 7%, respectively. Of the 752 isolates, 80% were Gram negative, 10% Gram positive and 10% yeast. The prevalence of extended-spectrum beta-lactamase producers was 80%, and rates of carbapenem resistance were on an average 50%. Conclusions: The CLABSI rates at a well-equipped tertiary care hospital are still significantly higher than the USA benchmarks. Alarming rates of drug resistance in Gram-negative pathogens were seen.     

Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes

OBJECTIVE: The purpose of this study was to examine if depressive symptomatology in pregnancy is associated with adverse obstetric and neonatal outcomes. METHOD: In a prospective observational study, 959 women were followed up longitudinally from early pregnancy to postpartum. The level of depression was measured at baseline (first antepartum visit) and in late pregnancy using the Beck Depression Inventory (BDI). Adverse obstetric and neonatal outcomes were recorded at delivery. RESULTS: Depression in late pregnancy was associated with increased risk of epidural analgesia (33% vs. 19%, p =.01, adjusted RR = 2.56, 95% CI 1.24-5.30), operative deliveries (caesarean sections and instrumental vaginal deliveries) (39% vs. 27%, p =.02, adjusted RR = 2.28, 95% CI 1.15-4.53), and admission to neonatal care unit (24% vs. 19%, p =.03, adjusted RR = 2.18, 95% CI 1.02-4.66). These effects remained significant even when controlled for potential confounders, such as antepartum complications. CONCLUSION: Previous studies have shown that antepartum anxiety or stress was associated with growth retardation, premature delivery, and epidural analgesia. Our findings add to this body of evidence, which together suggest an adverse impact of antepartum psychological morbidity on maternal and neonatal well-being.     

Seasonal variation in Escherichia coli bloodstream infection: a population-based study

Seasonal variation in the rates of infection with certain Gram-negative organisms has been previously examined in tertiary-care centres. We performed a population-based investigation to evaluate the seasonal variation in Escherichia coli bloodstream infection (BSI). We identified 461 unique patients in Olmsted County, Minnesota, from 1 January 1998 to 31 December 2007, with E. coli BSI. Incidence rates (IR) and IR ratios were calculated using Rochester Epidemiology Project tools. Multivariable Poisson regression was used to examine the association between the IR of E. coli BSI and average temperature. The age- and gender-adjusted IR of E. coli BSI per 100 000 person-years was 50.2 (95% CI 42.9–57.5) during the warmest 4 months (June through September) compared with 37.1 (95% CI 32.7–41.5) during the remainder of the year, resulting in a 35% (95% CI 12–66%) increase in IR during the warmest 4 months. The average temperature was predictive of increasing IR of E. coli BSI (p 0.004); there was a 7% (95% CI 2–12%) increase in the IR for each 10-degree Fahrenheit ( c. 5.5°C) increase in average temperature. To our knowledge, this is the first study to demonstrate seasonal variation in E. coli BSI, with a higher IR during the warmest 4 months than during the remainder of the year.     

Predictive scoring model of mortality in Gram-negative bloodstream infection

Mortality is a well-recognized complication of Gram-negative bloodstream infection (BSI). The aim of this study was to develop a model to predict mortality in patients with Gram-negative BSI by using the Pitt bacteraemia score (PBS) and other clinical and laboratory variables. A cohort of 683 unique adult patients who were followed for at least 28 days after admission to Mayo Clinic Hospitals with Gram-negative BSI from 1 January 2001 to 31 October 2006 and who received clinically predefined appropriate empirical antimicrobial therapy was retrospectively identified. Multivariable logistic regression was used to identify independent risk factors for 28-day all-cause mortality. Regression coefficients from a multivariable model were used to develop a risk score to predict mortality following Gram-negative BSI. Malignancy (OR 3.48, 95% CI 1.94–6.22), liver cirrhosis (OR 5.42, 95% CI 2.52–11.65), source of BSI other than urinary tract or central venous catheter infection (OR 5.54, 95% CI 2.42–12.69), and PBS (OR 1.98, 95% CI 0.92–4.25 for PBS of 2–3 and OR 6.42, 95% CI 3.11–13.24 for PBS ≥ 4) were identified as independent risk factors for 28-day mortality in patients with Gram-negative BSI. A risk-score model was created by adding points for each independent risk factor, and had a c-statistic of 0.84. Patients with risk scores of 0, 4, 8, 12 and 16 had estimated 28-day mortality rates of approximately 0%, 3%, 14%, 45%, and 81%, respectively. The Gram-negative BSI risk score described herein estimated mortality risk with high discrimination in patients with Gram-negative BSI who received clinically adequate empirical antimicrobial therapy.     

Effect of antiseptic bathing with chlorhexidine or octenidine on central line–associated bloodstream infections in intensive care patients: a cluster-randomized controlled trial

ObjectivesOur study aimed to compare the effect of daily bathing with chlorhexidine, octenidine, or water and soap (routine care = control) on central line (CL)–associated bloodstream infection (CLABSI) rates in intensive care units (ICUs).MethodsA multicentre cluster-randomized controlled trial was done with a 12-month intervention period from February 1, 2017 to January 31, 2018 (octenidine and routine care group) or from June 1, 2017 to May 31, 2018 (chlorhexidine group). Wards were randomly assigned to one of two decolonization regimes or routine care (control). Intervention included daily bathing with 2% chlorhexidine-impregnated cloths or 0.08% octenidine wash mitts for 12 months, whereas the control group used water and soap (routine care). The primary outcome was incidence density of CLABSI per 1000 CL days. Poisson regression and generalized estimating equation models were applied.ResultsA total of 72 ICUs with 76 815 patients (22 897 patients in the chlorhexidine group, 25 127 in the octenidine group, and 28 791 in the routine care group) were included. Incidence densities were 0.90 CLABSI per 1000 CL days (95% CI 0.67–1.19) in the chlorhexidine group, 1.47 (95% CI 1.17–1.81) in the octenidine group, and 1.17 (95% CI 0.93–1.45) in the routine care group. Adjusted incidence rate ratios of CLABSI were 0.69 (95% CI 0.37–1.22, p = 0.28) in the chlorhexidine group and 1.22 (95% CI 0.54–2.75, p = 0.65) in the octenidine group (compared with routine care).DiscussionAntiseptic bathing with 2% chlorhexidine-impregnated cloths and 0.08% octenidine wash mitts lacks a significant preventive effect on CLABSI rates in ICUs. However, our trial has a high likelihood of being underpowered because CLABSI rates in the routine care group were approximately 40% lower than initially assumed.     

Infection control interventions affected by resource shortages: impact on the incidence of bacteremias caused by carbapenem-resistant pathogens

We evaluated an infection control (IC) program influenced by personnel and material resource shortages on the incidence of bloodstream infections (BSI) due to carbapenem-resistant Klebsiella pneumoniae (CRKP), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPA) in an endemic region. Between January 2010 and December 2015, all BSI episodes caused by CRKP, CRAB, and CRPA were recorded. An IC bundle was implemented in January 2012. We evaluated the effect of the interventions on BSI rates between the pre-intervention (2010–2011) and intervention (2012–2013) periods, using an interrupted time-series model. From 2014, when interventions were still applied, BSI incidence was gradually increased. For this reason, we evaluated with a linear mixed effects model several factors possibly contributing to this increase for the years 2012–2015, which was considered as the intervention/follow-up period. During the study period, 351 patients with BSI were recorded, with a total of 538 episodes; the majority (83.6%) occurred in the intensive care unit (ICU). The BSI incidence rate per year during 2010–2015 for ICU patients was 21.03/19.63/17.32/14.45/22.85/25.02 per 1000 patient-days, respectively, with the reduction in BSI levels after the start of intervention marginal (p = 0.054). During the follow-up period (2014–2015), the most influential factors for the increased BSI incidence were the reduced participation in educational courses and compliance with hand hygiene. The implementation of IC interventions reduced the BSI incidence rates, particularly for ICU patients. However, factors possibly related to the restrictions of human and material resources apparently contributed to the observed expansion of BSI in our endemic setting.     

Risk factors for carbapenem-resistant Klebsiella pneumoniae bloodstream infection among rectal carriers: a prospective observational multicentre study

Knowledge of carbapenem-resistant Klebsiella pneumoniae (CR-KP) colonization is important to prevent nosocomial spread but also to start prompt adequate antibiotic therapy in patients with suspicion of infection. However, few studies have examined the incidence and risk factors for CR-KP bloodstream infection (BSI) among rectal carriers. To identify risk factors for CR-KP BSI among carriers, we performed a multicentre prospective matched case–control study of all adult CR-KP rectal carriers hospitalized in five tertiary teaching hospitals in Italy over a 2-year period. Carriers who developed CR-KP BSI were compared with those who did not develop subsequent BSI. Overall, 143 CR-KP BSIs were compared with 572 controls without a documented infection during their hospitalization. Multivariate analysis revealed that admission to the Intensive Care Unit (ICU) (OR, 1.65; 95% CI, 1.05–2.59; p 0.03), abdominal invasive procedure (OR, 1.87; 95% CI, 1.16–3.04; p 0.01), chemotherapy/radiation therapy (OR, 3.07; 95% CI, 1.78–5.29; p <0.0001), and number of additional colonization sites (OR, 3.37 per site; 95% CI, 2.56–4.43; p <0.0001) were independent risk factors for CR-KP BSI development among CR-KP rectal carriers. A CR-KP BSI risk score ranging from 0 to 28 was developed based on these four independent variables. At a cut-off of ≥2 the model exhibited a sensitivity, specificity, positive predictive value and negative predictive value of 93%, 42%, 29% and 93%, respectively. Colonization at multiple sites with CR-KP was the strongest predictor of BSI development in our large cohort of CR-KP rectal carriers.     

Blood stream infection is associated with cerebrovascular accident in patients with left ventricular assist device: a systematic review and meta-analysis

Cerebrovascular accident (CVA) is one of the major complications and a leading cause of death in patients with a left ventricular assist device (LVAD). Multiple studies of have shown that patients with blood stream infection (BSI) are more likely to develop CVA compared to patients without BSI. However, there is no meta-analysis to confirm this association. Studies were systematically acquired from MEDLINE and EMBASE electronic databases. Included studies assessed patients with heart failure requiring LVAD and reported the number of patients who had BSI post LVAD, incidence of ischemic CVA, hemorrhagic CVA, or any CVA. Pooled effect size was calculated with a random-effect model, weighted for the inverse of variance. Heterogeneity was assessed with I². Six studies were analyzed. Participants with LVAD who developed BSI were more likely to have a CVA compared to participants without BSI (RR 3.43, 95% CI 2.49–4.72, I²?=?0). In four studies, there was an association between BSI and increased incidence of hemorrhagic CVA post LVAD (RR 5.28, 95% CI 2.65–10.53) with minimal heterogeneity (I²?=?30%). In three studies, participants with BSI were more likely to develop ischemic CVA (RR 2.18, 95% CI 1.23–3.84) compared to patients without BSI. This meta-analysis suggested that there maybe an association between blood stream infection and cerebrovascular accident in patients with LVAD.     

Predictors of multidrug-resistant Pseudomonas aeruginosa in neutropenic patients with bloodstream infection

ObjectivesTo assess risk factors for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) infection in neutropenic patients.MethodsSingle-centre retrospective analysis of consecutive bloodstream infection (BSI) episodes (2004–2017, Barcelona). Two multivariate regression models were used at BSI diagnosis and P. aeruginosa detection. Significant predictors were used to establish rules for stratifying patients according to MDR-PA BSI risk.ResultsOf 661 Gram-negative BSI episodes, 190 (28.7%) were caused by P. aeruginosa (70 MDR-PA). Independent factors associated with MDR-PA among Gram-negative organisms were haematological malignancy (OR 3.30; 95% CI 1.15–9.50), pulmonary source of infection (OR 7.85; 95% CI 3.32–18.56), nosocomial-acquired BSI (OR 3.52; 95% CI 1.74–7.09), previous antipseudomonal cephalosporin (OR 13.66; 95% CI 6.64–28.10) and piperacillin/tazobactam (OR 2.42; 95% CI 1.04–5.63), and BSI occurring during ceftriaxone (OR 4.27; 95% CI 1.15–15.83). Once P. aeruginosa was identified as the BSI aetiological pathogen, nosocomial acquisition (OR 7.13; 95% CI 2.87–17.67), haematological malignancy (OR 3.44; 95% CI 1.07–10.98), previous antipseudomonal cephalosporin (OR 3.82; 95% CI 1.42–10.22) and quinolones (OR 3.97; 95% CI 1.37–11.48), corticosteroids (OR 2.92; 95% CI 1.15–7.40), and BSI occurring during quinolone (OR 4.88; 95% CI 1.58–15.05) and β-lactam other than ertapenem (OR 4.51; 95% CI 1.45–14.04) were independently associated with MDR-PA. Per regression coefficients, 1 point was assigned to each parameter, except for nosocomial-acquired BSI (3 points). In the second analysis, a score >3 points identified 60 (86.3%) out of 70 individuals with MDR-PA BSI and discarded 100 (84.2%) out of 120 with non-MDR-PA BSI.ConclusionsA simple score based on demographic and clinical factors allows stratification of individuals with bacteraemia according to their risk of MDR-PA BSI, and may help facilitate the use of rapid MDR-detection tools and improve early antibiotic appropriateness.     

Incidence of bronchopulmonary dysplasia in Korea

A nationwide survey was conducted to determine the incidence of bronchopulmonary dysplasia (BPD) in Korea and the intercenter differences in survival and BPD rates among preterm infants. Questionnaires were sent to all registered neonatal intensive care units (NICUs). The questionnaires inquired about the survival and BPD rates of very low birth weight (VLBW, < 1,500 g) infants who had been admitted to each NICU from 2007 to 2008. BPD was defined as requiring oxygen at 36 weeks' postmenstrual age. Almost all level III NICUs replied. During the study period, 3,841 VLBW infants were born in the NICUs that responded to the survey. The survival rate was 81% and the BPD rate was 18%. Combined outcome of BPD or death rate was 37%. The BPD rate and combined outcome of BPD or death rate varied considerably from 5% to 50% and 11% to 73%, respectively across the centers. There was no significant correlation between the survival rate and the BPD rate across the centers. In conclusion, the incidence of BPD among VLBW infants in Korea during the study period was 18%, and a considerable intercenter difference in BPD rates was noted.     

Single motherhood and neonatal survival of twins among blacks and whites

OBJECTIVE: We investigated whether an association existed between single motherhood and neonatal mortality among twins and whether such a linkage varied by race. STUDY DESIGN: Retrospective cohort analysis on 446,570 twin live births (between 24-44 gestational weeks inclusive) in the United States from 1995 through 1998. Neonatal survival was compared between twins of single and those of married mothers for blacks and whites separately using Cox proportional hazards regression that adjusted for the confounding effects of education, parity, adequacy of prenatal care and maternal smoking during pregnancy. The Robust Sandwich Estimator was employed to adjust for intracluster correlation. RESULTS: The rates for neonatal mortality among blacks were 34.9 per 1,000 among married and 43.4 per 1,000 among single mothers. Among whites, the rates were 20.6 per 1,000 for married and 28.9 per 1,000 for unmarried mothers. Neonatal mortality was significantly elevated among white twins of single mothers (Hazard Ratio (HR) = 1.23; 95% Confidence Interval (CI) = 1.14-1.31) and among black twins of single mothers (HR = 1.12; 95% CI = 1.01-1.25). However, when gestational age was adjusted for, the association between single motherhood and neonatal mortality disappeared. CONCLUSION: Single motherhood was a risk factor for neonatal mortality among twins, and the disparity in survival was more accentuated among whites. The association between single motherhood and neonatal mortality was explained by the preponderance of preterm births among twins of unmarried gravidas. Our findings reinforce the importance of future research to develop and test interventions that will decrease the incidence of preterm birth.     

Introducing new data on gestation-specific infant mortality among babies born in 2005 in England and Wales

Gestational age is highly correlated with birth outcomes including birthweight and infant mortality. Since gestational age is not recorded at the registration of live births in England and Wales, it has not been possible to produce routine statistics on gestation-specific infant mortality rates. A new system, introduced in 2002, for allocating NHS numbers at birth (NN4B) provided the opportunity to obtain gestational age information. NN4B records have been linked with birth registration data for all births occurring in 2005, and further linked with registration records for deaths in the first year of life. Thus, for the first time, we produce gestation-specific infant mortality rates for England and Wales as a whole, including in relation to birthweight, multiplicity, age of mother, marital status/registration type, and the National Statistics Socio-Economic Classification.     

Colonization and persistence of antibiotic-resistant Enterobacteriaceae strains in infants nursed in two neonatal intensive care units in East London, United Kingdom

Stool samples were collected from infants nursed in two neonatal intensive care units (NICUs) in East London, United Kingdom. The aim of the study was to determine the incidence of and risk factors for the carriage of multiresistant Enterobacteriaceae strains (MRE; resistant to three or more classes of antibiotic) and the extent of the persistence of resistant strains following discharge. Sixty-two (50%) of 124 infants had acquired MRE by 2 weeks of postnatal age, and 69 (56%) infants had acquired MRE by discharge. The proportions of infants at 2 weeks carrying strains that were resistant to antibiotics were the following: tetracycline, 79%; amoxicillin, 78%; cephalosporins, 31%; trimethoprim, 20%; piperacillin-tazobactam, 11%; chloramphenicol, 9%; and aminoglycoside, 4%. A gestational age of less than 26 weeks was a risk factor for colonization with MRE at discharge, but not at 2 weeks. Analysis within a NICU showed that exposure of an infant to a specific antibiotic in the NICU was not a risk factor for the carriage of a strain resistant to that antibiotic. Estimates of persistence from discharge to 6 months were the following: for tetracycline, 57% (95% confidence intervals [CI], 0.35 to 0.87); chloramphenicol, 49% (95% CI, 0.20 to 0.83); trimethoprim, 45% (95% CI, 0.22 to 0.74); piperacillin-tazobactam, 42% (95% CI, 0.20 to 0.71); and augmentin, 34% (95% CI, 0.11 to 0.66). Strains resistant to cephalosporins or aminoglycosides showed lower levels of persistence. Nine of 34 infants (26.5%) with Escherichia coli and 4 (7.1%) of 56 infants with Klebsiella spp. at discharge carried strains indistinguishable by randomly amplified polymorphic DNA and antibiotic susceptibility patterns at 6 months. MRE were found at high frequency in the infants during their stay in the NICU and persisted in a proportion of infants.     

Effect of telemedicine on health outcomes in 87 infants requiring neonatal intensive care.

OBJECTIVE: This is an evaluation of a telemedicine system for the rapid interpretation of neonatal echocardiograms from a regional, level III neonatal intensive care unit (NICU). The use of telemedicine to support the cardiology needs of NICUs is increasing. However, there is very little published objective information regarding health outcomes or costs resulting from such telemedicine systems. The primary hypothesis tested was that the utilization of a telemedicine system for the interpretation of neonatal echocardiograms reduces the intensive care length of stay of low birthweight (LBW) infants. STUDY DESIGN: All infants who were admitted to neonatal intensive care at New Hanover Regional Medical Center during the first six months of the system were studied by the use of echocardiograms. They were compared with infants who were born in the same period of the previous year. The outcome measures were the intensive care length of stay, rate of transfer to academic medical centers, and mortality rate. RESULTS: A statistically non-significant reduction of 5.4 days in the intensive care length of stay (LOS) of low birthweight infants was observed (p = 0.37). The cost per echocardiogram transmitted was calculated at $33 compared to previous method of sending videotapes via overnight courier. CONCLUSIONS: While the sample size was inadequate to demonstrate improvements in health outcomes, the magnitude of the change and the low costs of the system suggest that this intervention is practical for obtaining rapid diagnostic and treatment support. Larger studies are warranted to confirm these findings and determine whether faster diagnosis and earlier initiation of treatment improve health outcomes of newborn infants.