Clostridial necrotizing enterocolitis

In a bacteriologic investigation of infants with necrotizing enterocolitis (NEC), 16 of 50 infants had clostridia in cultures of blood or of peritoneal fluid obtained by paracentesis. Twenty-eight of the 50 infants had enteric bacteria other than clostridia, and six infants had sterile cultures. Of the 16 infants with clostridia, nine had C. perfringens and seven had other species of clostridia. Compared to infants with nonclostridial NEC, those with clostridial NEC were larger and more mature, had more extensive pneumatosis intestinalis and gangrene and more rapid progression of NEC. The nine infants with C. perfringens had a fulminant form of NEC, analogous to gas-gangrene of the intestine. Mortality in this group was 78% (7/9). The seven infants with clostridial species other than C. perfringens had a mortality comparable to that of infants with nonclostridial NEC (32%). Improved survival from NEC associated with C. perfringens may be possible only by prevention, rather than earlier diagnosis and improved heroic treatment.     

Lessons to be learned from a complicated case of rhino-cerebral mucormycosis in a renal allograft recipient

Fungal infections still represent a serious complication after organ transplantation. Early diagnosis and aggressive treatment are crucial. Because of the many diagnostic problems involved, we present a case of mucormycosis -- primarily affecting the paranasal sinuses with later intracranial extension -- in a highly immunized recipient of a third renal transplant. Although fungal infection was suspected from various imaging techniques, only the detection of typical fungal hyphae in the infected tissue was diagnostic. Neither the blood tests and cerebrospinal fluid examinations performed nor cultures from maxillary sinus fluid were of any diagnostic help. Surgical debridement from a transnasal as well as an intracranial approach and systemic amphotericin B together with the discontinuation of immunosuppression after removal of the rejected graft were able to save the patient. This case stresses the importance of early diagnosis that can only be made from tissue biopsies and allows appropriate timely treatment.     

Lessons to be learned from a complicated case of rhino-cerebral mucormycosis in a renal allograft recipient

Fungal infections still represent a serious complication after organ transplantation. Early diagnosis and aggressive treatment are crucial. Because of the many diagnostic problems involved, we present a case of mucormycosis--primarily affecting the paranasal sinuses with later intracranial extension--in a highly immunized recipient of a third renal transplant. Although fungal infection was suspected from various imaging techniques, only the detection of typical fungal hyphae in the infected tissue was diagnostic. Neither the blood tests and cerebrospinal fluid examinations performed nor cultures from maxillary sinus fluid were of any diagnostic help. Surgical debridement from a transnasal as well as an intracranial approach and systemic amphotericin B together with the discontinuation of immunosuppression after removal of the rejected graft were able to save the patient. This case stresses the importance of early diagnosis that can only be made from tissue biopsies and allows appropriate timely treatment.     

Comparison of the efficacy of serum amyloid A, C-reactive protein, and procalcitonin in the diagnosis and follow-up of necrotizing enterocolitis in premature infants

Purpose

The aim of this study was to compare the efficacy of serum amyloid A (SAA) with that of C-reactive protein (CRP), and procalcitonin (PCT) in diagnosis and follow-up of necrotizing enterocolitis (NEC) in preterm infants.

Methods

A total of 152 infants were enrolled into this observational study. The infants were classified into 3 groups: group 1 (58 infants with NEC and sepsis), group 2 (54 infants with only sepsis), and group 3 (40 infants with neither sepsis nor NEC, or control group). The data including whole blood count, CRP, PCT, SAA, and cultures that were obtained at diagnosis (0 hour), at 24 and 48 hours, and at 7 and 10 days were evaluated.

Results

A total of 58 infants had a diagnosis of NEC. Mean CRP (7.4 ± 5.2 mg/dL) and SAA (46.2 ± 41.3 mg/dL) values of infants in group 1 at 0 hour were significantly higher than those in groups 2 and 3. Although the area under the curve of CRP was higher at 0 hour in infants with NEC, there were no significant differences between groups with respect to the areas under the curve of SAA, CRP, and PCT at all measurement times. Levels of SAA decreased earlier than CRP and PCT in the follow-up of NEC (mean SAA levels were 45.8 ± 45.2, 21.9 ± 16.6, 10.1 ± 8.3, and 7.9 ± 5.1 mg/dL at evaluation times, respectively). Levels of CRP and SAA of infants with NEC stages II and III were significantly higher than those with only sepsis and/or NEC stage I.

Conclusions

Serum amyloid A, CRP, and PCT all are accurate and reliable markers in diagnosis of NEC, in addition to clinical and radiographic findings. Higher CRP and SAA levels might indicate advanced stage of NEC. Serial measurements of SAA, CRP, and PCT, either alone or in combination, can be used safely in the diagnosis and follow-up of NEC.     

Management of candida septicaemia in a regional burn unit

Sepsis due to candida infection is a major cause of mortality and morbidity on our unit. Over a period of 3 years and 4 months, 29 cases of candida septicaemia, diagnosed by blood cultures, were encountered at the burn unit at Augusta Regional Medical Center.

Factors known to predispose to fungal sepsis were present in all cases. All patients had large burns (14–98 per cent total body surface (TBSA) with a mean of 48.3 per cent). All but one patient had at least one central venous line. Respiratory problems requiring ventilator support were present in 24 patients.

Sixteen patients had Candida albicans sepsis, two in association with another fungal sepsis. Candida parapsilosis was encountered in nine patients, one in combination with another species. Four patients had Candida tropicalis.

Amphotericin B was prescribed therapeutically in 25 patients, in seven together with fluconazole. Two patients received fluconazole only and two received no antifungal therapy.

There were eight deaths all attributed to sepsis and all of whom had multiple organ failure. Five of those who died had completed a course of amphotericin B therapy, two were receiving treatment at the time of death, and one patient died before culture data became available. Early and aggressive therapy is advised and amphotericin B appears to be the drug of choice.     

原位肝移植术后真菌感染的诊治

目的 探讨原位肝移植术后真菌感染的诊断和治疗。方法 58例肝移植患者术后怀疑真菌感染时，行体液（痰、血、尿、胆汁、引流液等）或导管真菌培养，结合胸腹部CT影像学检查、活组织检查及诊断性治疗结果综合判断，一旦诊断确定，即给予氟康唑治疗，无效者改用伊曲康唑和两性霉素B，同时调整免疫抑制治疗方案。结果 58例患者中，16例术后并发真菌感染21例次（5例患者发生两次以上、不同部位或不同菌株的感染），感染发生率为27．6％（16／58），感染发生在术后4～38d，感染好发部位依次为肺（28．6％）、肠道（19．0％）、泌尿系统（14．3％）、腹腔（14．3％）、切口（9．5％）、血液（4．8％）、胆管（4．8％）及肝脏（4．8％）。在21例次真菌感染中，念珠菌感染占85．7％，曲霉菌感染占14．3％。氟康唑治疗有效者占66．7％，伊曲康唑治疗有效者占14．3％，两性霉素B治疗有效者占14．3％，1例（4．7％）各种抗真菌药物治疗均无效，治疗总有效率为95．2％。结论 肝移植术后真菌感染的发生率较高，依据影像学检查、病原学检查及活组织检查综合判断真菌感染，及时选用氟康唑、伊曲康唑及两性霉素B治疗。     

Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging.

A method of clinical staging for infants with necrotizing enterocolitis (NEC) is proposed. On the basis of assigned stage at the time of diagnosis, 48 infants were treated with graded intervention. For Stage I infants, vigorous diagnostic and supportive measures are appropriate. Stage II infants are treated medically, including parenteral and gavage aminoglycoside antibiotic, and Stage III patients require operation. All Stage I patients survived, and 32 of 38 Stage II and III patients (85%) survived the acute episode of NEC. Bacteriologic evaluation of the gastrointestinal microflora in these neonates has revealed a wide range of enteric organisms including anaerobes. Enteric organisms were cultured from the blood of four infants dying of NEC. Sequential cultures of enteric organisms reveal an alteration of flora during gavage antibiotic therapy. These studies support the use of combination antimicrobial therapy in the treatment of infants with NEC.     

原位肝移植术后真菌感染43例次诊治体会

目的 探讨原位肝移植术后真菌感染的诊断、治疗及预防。方法 回顾总结为175位患者所施行的180次原位肝移植的临床资料，并对可能导致真菌感染的危险因素进行统计学分析。结果 全组29例患者出现43例次真菌感染，感染率为16．6％(29／175)。其中念珠菌占98％(42／43)，曲霉菌2％(1／43)。发病中位时间为术后26d(3～96d)。常见感染部位依次是肺部37％(16／43)，肠管19％(8／43)和血液16％(7／43)。26例患者接受氟康唑治疗，感染严重的8例患者改用脂质体两性霉素B治疗。病死率45％(13／29)，直接与真菌感染有关的病死率为4．0％(7／175)。全胃肠外营养时间较长、抗生素治疗超过3周或出现肝动脉并发症的患者真菌感染的发生率显著增加。结论 真菌感染是影响肝移植生存率的重要原因之一。最常见的感染部位和病原菌分别是肺部和念珠菌。减少各种危险因素将有助于降低真菌感染的发生率。早期诊断和及时治疗是治愈的关键，严重的真菌感染应及时给予两性霉素B或其脂质体治疗。     

Primary Laparotomy is Effective and Safe in the Treatment of Necrotizing Enterocolitis

Introduction

There is ongoing controversy regarding the surgical treatment of necrotizing enterocolitis (NEC) in infants with extremely low birth weight (ELBW). We hypothesize that primary laparotomy is a safe and effective treatment for all infants with surgical NEC.

Methods

We retrospectively compared a group of ELBW infants (<1,000 g, group A, n = 39) with preterm infants (≥1,000 g, group B, n = 18) with surgical NEC during a 4-year period (10/2008–09/2012). Indications for emergency operation were Bell stages IIIa or IIIb. The main outcome measure was survival. Data were analyzed using Chi squared test and Spearman’s rank correlation coefficient.

Results

Fifty-seven patients were included with a gestational age from 24 to 30 weeks in group A and 27–38 weeks in group B. There were no significant differences in Bell stage (IIIa; IIIb) and NEC type (focal; segmental; pannecrosis). The operative techniques were not significantly different between the groups and included resection and stoma formation in 44 of 57 (77 %) patients; resection and anastomosis in 6 of 57 (11 %); and inspection only, followed by withdrawal of care, in 7 of 57 (12 %). Overall mortality was 10 of 57 (17 %) with no significant difference between the groups. The only significant correlation was observed between the length of necrotic bowel and mortality. In total, 7 of 57 infants required repeated surgery after initial treatment. We observed stoma complications in 36 % of the patients in group A and 21 % in group B without the need of stoma revision. All stomas were successfully closed at the time of the study. One of 44 patients with stoma closure required a relaparotomy due to bowel obstruction.

Conclusions

Early primary laparotomy is safe and effective for the management of surgical NEC in ELBW infants. Outcome of affected infants is not influenced by age or weight at surgery but by the length of necrotic bowel.     

Fungal sepsis in surgical patients

Records of 65 surgical patients with positive fungal blood cultures were reviewed to address risk, overall mortality, and treatment. Negative urine cultures did not rule out sepsis. Staphylococcus epidermidis sepsis was present in 27 (42%) of the patients. In 70% of whom it occurred before or during fungemia. Increased mortality correlated with the use of multiple antibiotics, antibiotic use for prolonged periods, and with associated bacterial sepsis. Stopping antibiotic therapy did not reduce mortality. Amphotericin B reduced mortality in patients with dissemination, indicating that it is the treatment of choice for disseminated fungemia and that antibiotic therapy should not be discontinued when concomitant bacterial sepsis is present.     

Abdominal candidiasis in surgical patients

Although abdominal candidiasis in critically ill surgical patients is becoming increasingly common, optimal management has not been defined. We treated 16 patients with abdominal candidiasis over a 36 month period. Violation of the gastrointestinal tract mucosa was the most common precipitating event (13 patients). Predisposing factors included: CVP catheters, broad spectrum antibiotics, and parenteral hyperalimentation in all patients, H2-blockers/antacids in 14 patients, as well as malnutrition (7 patients), DM (3 patients), alcoholism (3 patients), and steroids/chemotherapy (3 patients). Candida was isolated from an abscess in seven patients, peritoneal fluid in six patients and both in three patients. In four patients abdominal candidiasis was preceded by positive cultures from blood or two peripheral sites which had not been treated. All patients were treated with amphotericin B (146-4000 mg) without any major adverse effects. Fungal infection was eradicated in ten patients; three patients succumbed to candidiasis. Patients treated within seven days required less Amphotericin B and appeared to have a better outcome than those having delayed treatment. The authors conclude that abdominal candidiasis is a potentially lethal infection in critically ill surgical patients that should be aggressively treated. Amphotericin B can be safely administered and concurrent antibiotics need not be stopped.     

Fungal hepatic abscesses: characterization and management

Hepatic abscesses are being recognized with increasing frequency in immunocompromised patients and those with malignant diseases. Risk factors and treatment for patients with pure fungal abscesses and mixed fungal and pyogenic abscesses have not been well described. A retrospective review of patients with hepatic abscesses was undertaken at The Johns Hopkins Hospital from 1973 through 1993. Eight patients with pure fungal hepatic abscesses and 34 patients with mixed fungal/pyogenic abscesses were identified. Clinical presentation, diagnosis, management, and outcome were analyzed. In the group with pure fungal abscesses, fungemia was predictive of death; four patients in this group died, whereas the remaining four patients who received amphotericin B treatment before the onset of fungemia all survived. In the group with mixed fungal/pyogenic abscesses, 11 patients received amphotericin B, whereas 23 did not. Ten (43%) of these 23 patients died. However, only one of five patients who received more than 1000 mg of amphotericin B died. In patients with hematologic malignancies, who are known to be at risk for fungal infections, amphotericin B treatment should be instituted early. In patients with mixed fungal/pyogenic hepatic abscesses who fail to improve after drainage and broad-spectrum antibiotics, antimycotic therapy should be considered early, before the onset of fungemia.     

A randomized prospective trial of amphotericin B lipid emulsion versus dextrose colloidal solution in critically ill patients.

BACKGROUND: Amphotericin B is the agent of choice for most invasive fungal infections in critically ill patients. It is associated with at least a 50% incidence of nephrotoxicity, despite prophylactic measures such as sodium loading. Newer formulations of amphotericin B are available but are costly and have unknown bioavailability in critically ill patients. Previous trials in neutropenic and critically ill patients have demonstrated that mixing amphotericin B with 20% lipid solution (Intralipid; Clintec Nutrition, Deerfield, III) may decrease nephrotoxicity. METHODS: In this randomized, prospective clinical trial, patients with positive fungal blood cultures, tracheal/sputum cultures or peritoneal cavity cultures were randomized to receive either 0.5 mg/kg per day of amphotericin B dextrose or 1.0 mg/kg per day of amphotericin B lipid emulsion. Duration of therapy was determined by the primary care team. Weekly 24-hour creatinine clearance was measured until 2 weeks after amphotericin B therapy was completed. RESULTS: The two groups were similar based on age, white blood cell count, serum creatinine, and creatinine clearance at the beginning of therapy. The group receiving amphotericin B lipid emulsion had significantly less decrease in creatinine clearance compared with controls, despite receiving significantly more amphotericin B. CONCLUSION: Amphotericin B lipid emulsion can be given at a higher total cumulative dose than amphotericin B dextrose with less nephrotoxicity.     

Portal vein ultrasonography in the early diagnosis of necrotizing enterocolitis

The nonoperative diagnosis of necrotizing enterocolitis (NEC) is dependent upon the radiographic finding of pneumatosis intestinalis. A significant number of neonates develop clinical signs compatible with NEC but nondiagnostic radiographs. This can result in delayed, inappropriate, or unnecessary therapy. This paper presents experience with portal vein (PV) ultrasonography in the diagnosis of NEC. Since January 1984, 15 newborns with suspected NEC have undergone PV ultrasonography (mean gestation 33 weeks, mean weight 1,705 g). Each had developed abdominal distention with evidence of sepsis. Stool was positive for occult blood in 11. Abdominal radiographs were interpreted as abnormal but nonspecific in 10 neonates, definite pneumatosis in 3, and normal in 2. No infant had portal vein air on plain abdominal radiograph. Occult PV air was detected by ultrasonography in five infants. These included all infants with obvious pneumatosis, a newborn with a nonspecific radiograph and a neonate with a "normal" x-ray. Of the ten infants without PV air on ultrasound, clinical symptoms resolved without specific therapy in seven. Two infants were proven to have nonenteric sepsis, and the remaining newborn developed intestinal necrosis secondary to aortic thrombus. In the five infants with occult PV air on ultrasound, two subsequently required intestinal resection. The remaining three were treated medically for ten days without sequelae. PV ultrasonography has proven to be a helpful adjunct in the early diagnosis of NEC. This diagnostic maneuver, when applied appropriately, may enable early therapy of the infant with NEC and avoid inappropriate or unnecessary therapy in the suspected case.     

Surgical treatment for fungal infections in the central nervous system

The hospital records of 78 patients who underwent surgical therapy for fungal infections of the central nervous system (CNS) between 1964 and 1984 are summarized. Nine different fungal types were identified, but Coccidioides immitis and Cryptococcus neoformans accounted for most (67.1%) of the infections. A variety of clinical syndromes were seen, including chronic basal meningitis (45 patients), intracranial mass lesions (12 patients), and communicating hydrocephalus (six patients). Thirteen patients had rhinocerebral forms of fungal infection, and two presented with spinal involvement. Delays in diagnosis were frequent and ranged from 2 months to 11 years. In 31 patients the CNS lesion was the first indication of a fungal infection, and lesion biopsy or cerebrospinal fluid (CSF) examination confirmed the diagnosis. A total of 144 surgical procedures were carried out, including lesion biopsy or excision in 13 patients, primary CSF shunting in 22, and placement of an Ommaya reservoir for administration of intraventricular or intracisternal antifungal agents in 48. All patients received parenteral and, in some cases, intrathecal or oral antifungal chemotherapy in addition to surgical therapy. Overall mortality was 43.6% (34 deaths). With prompt diagnosis and treatment, the mortality rate was 39% whereas, when appropriate treatment was delayed, the mortality rate was 64%. An additional 14 surviving patients (17.9%) exhibited permanent morbidity due to neurological deficits, seizure disorders, or renal toxicity following treatment with amphotericin B. The combined mortality and morbidity rate was 62.8%. Clinical symptoms were resolved completely in 29 patients, although in 10 evidence of disease persisted and chemotherapy was continued. Fungal infections of the CNS are being recognized with increased frequency. It is suggested that a high index of suspicion, aggressive attempts to obtain a diagnosis, and early and vigorous therapy may reduce the unfortunate outcome seen in a relatively high proportion of patients with CNS fungal infections.     

2016至2018年某医院真菌血流感染者流行病学特征及耐药性分析

目的分析真菌性血流感染的病原菌分布以及耐药特征，为真菌血流感染的早期合理用药提供理论依据。 方法回顾性分析武汉大学人民医院2016年1月至2018年12月收治的真菌性血流感染者的菌群、科室分布以及耐药性。 结果入组192例真菌血流感染者的血培养样本中共分离192株真菌，其中白色念珠菌检出率为31.77%（61/192），其次热带念珠菌检出率为18.75%（36/192）；重症医学科检出率最高为33.85%（65/192）。所有菌株均对两性霉素B敏感，对其他抗菌药物耐药率分别为5-氟胞嘧啶4.49%（9/192）、伊曲康唑5.73%（11/192）、氟康唑10.94%（21/192）和伏立康唑11.46%（22/192）；除两性霉素B外，2016至2018年真菌对其他抗菌药物的耐药率均逐年上升，其中2018年所分离192株光滑念珠菌对伊曲康唑耐药菌率达46.7%。 结论真菌血流感染病原菌以念珠菌属为主，对目前抗真菌药物具有较高敏感性，但耐药率逐年上升，加强监测血培养病原菌变化及耐药趋势对指导临床用药至关重要。     

Fungal peritonitis during continuous ambulatory peritoneal dialysis: a report of 17 cases

Seventeen cases of fungal peritonitis and one case of Nocardia asteroides peritonitis were observed in 141 patients during the first 5 years of our continuous ambulatory peritoneal dialysis program (CAPD). Fungal peritonitis accounted for 7% of the episodes of peritonitis observed in this interval. There were eight deaths associated with fungal peritonitis. In only three instances could factors predisposing to fungal peritonitis be identified. We were unable to predict who would develop fungal peritonitis by analysis of nutritional, demographic, or technical factors associated with the dialysis procedure. The diagnosis of fungal peritonitis was easily established using routine blood agar culture techniques. Successful management of these patients included prompt removal of the Tenckhoff catheter and intravenous (IV) administration of amphotericin.     

Necrotizing enterocolitis: incidence, operative care, and outcome

At Jefferson Davis Hospital, the incidence of necrotizing enterocolitis (NEC) was three per 1,000 live births, and 30 per 1,000 low birth weight births. The occurrence of NEC was sporadic and no epidemics occurred. NEC occurred most frequently in infants weighing between 750 and 1,500 g, and the smaller infant with NEC was more likely to require surgical intervention. As the survival of small birth weight infants improved over the 4 years of the study, the patient population developing NEC became smaller. The age at operation also increased in the period between 1982 and 1984. Those infants who developed NEC after 30 days of age typically had more extensive disease and a less favorable prognosis. In this series, 31% of infants with acute NEC required surgical intervention. An additional 11% of those infants treated nonoperatively eventually required surgical intervention for late sequelae of NEC. The overall survival of infants with NEC was 75%. While the survival of all infants operated for NEC was 68%, the survival for those with the acute syndrome was 63% and those operated on for late sequelae was 87%. Primary anastomosis in selected patients did not adversely affect mortality and simplified the postoperative care of these infants with severe complications. Indeed, enterostomy closure in an infant who had previously had NEC was an extensive procedure that carried significant risk. Our results indicated that the trained pediatric surgeon could predict at the operating table which infants could safely undergo resection and anastomosis and that, with experience, the percent undergoing primary anastomosis increased to approximately 50%.     

Effect of prophylaxis on fungal infection and costs for high-risk liver transplant recipients.

We sought to determine whether the prophylactic use of amphotericin B products (conventional amphotericin B and liposomal amphotericin B) reduces the incidence of fungal infections in high-risk liver transplant recipients, and if so, whether this lowers the cost of care. The study sample comprised 232 adult orthotopic liver transplants performed from 1994 to 2005 at a single center for patients classified as being at high risk for fungal infections. High-risk patients who received transplants with a prophylaxis regimen of amphotericin B (n=58 transplants) were compared with high-risk patients who received no prophylaxis (n=174 transplants). Fungal infections occurred in 3 transplants (5.17%) of those who received amphotericin B and 28 transplants (16.09%) in those without prophylaxis (P=0.0432). Regression models were used to analyze fungal infection and costs for the 232 high-risk transplants. Failure to offer prophylaxis conferred a 4-fold greater risk of fungal infection (P=0.046) compared with those who received amphotericin B. A fungal infection in a high-risk recipient increased mean costs by 46.48%. The indirect effect of prophylaxis (operating through infection reduction) is estimated to reduce overall costs in high-risk patients by 8.73%.     

Outcome of perforated necrotizing enterocolitis in the very low-birth weight neonate may be independent of the type of surgical treatment

Perforated necrotizing enterocolitis (NEC) in the low-birth weight infant is now one of the most common surgical problems encountered in contemporary neonatal intensive care units. However, morbidity and mortality from NEC remain high, and the optimal surgical management of these infants remains controversial. Currently few data exist comparing the factors influencing outcome in very low-birth weight infants with perforated NEC treated by either local drainage or exploration. We hypothesize that survival of very low-birth weight neonates with perforated NEC may be more dependent on clinical status than on treatment modality. We present our experience treating a large cohort of infants weighing less than 1000 g with perforated NEC. A retrospective cohort study describes our experience with perforated NEC in very low-birth weight infants in a Level III neonatal intensive care unit. Between January 1991 and May 1998 a total of 70 newbo infants weighing less than 1000 g were evaluated and managed for perforated NEC. Comorbid factors were identified and calculated for each infant. Primary treatment was either local drainage or laparotomy. Statistical analysis was performed by Student's t test and multiple logistic regression. A multiple logistic regression model examined factors (comorbidities, number of comorbidities, and mode intervention) influencing outcome. A Kaplan-Meier survival analysis comparing survival versus number of comorbidities was performed. Twenty-two infants with an average weight of 679 g were treated by local drainage. Forty-eight infants with an average weight of 756 g were treated with exploratory laparotomy. Infants treated by local drainage had a higher cumulative number of comorbid factors (5.2+/-0.50 vs 3.7+/-0.29; P < 0.05) than those managed by operative exploration. Fourteen infants (63%) initially undergoing local drainage for perforated NEC survived. Of the 48 infants 36 operated on survived (75%). No single factor or combination of any comorbid factors was predictive of outcome. The total number of comorbidities for each neonate did reach statistical significance (P < 0.05). A greater likelihood of death was associated with a higher number of comorbidities. Survival with four or fewer comorbidities was 84 per cent, whereas survival with greater than six comorbidities was 30 per cent. The mean number of comorbidities was greater for drainage than for surgery, and for the same number of comorbidities the probability of survival tended to be greater for those treated with drainage than for those undergoing surgery. Multiple logistic regression analysis identified the total number of comorbidities as affecting outcome rather than treatment choice. This suggests therefore that selection of therapeutic options for the patient requires evaluating all factors that may impact survival rather than applying a single treatment strategy for all patients.