Heart rate characteristics and clinical signs in neonatal sepsis

To test the hypothesis that heart rate characteristic (HRC) monitoring adds information to clinical signs of illness in diagnosing neonatal sepsis, we prospectively recorded clinical data and the HRC index in 76 episodes of proven sepsis and 80 episodes of clinical sepsis in 337 infants in the University of Virginia NICU more than 7 d old. We devised an illness severity score based on clinical findings and tests relevant to sepsis. Point scores were derived from coefficients of multivariable regression models, and we internally validated a total score. We determined relationships of the HRC index with individual clinical signs, laboratory tests, and the total score. We found highly significant correlations of the clinical score and individual clinical signs with the HRC index. The clinical score and HRC index added independent information in predicting sepsis, and were similar in clinical and proven sepsis. The clinical score and the HRC index rose before sepsis, and the HRC index rose first. We conclude that clinical signs of illness and HRC monitoring add independent information to one another in the diagnosis of neonatal sepsis.     

Abnormal heart rate characteristics are associated with neonatal mortality

Estimating the risk of in-hospital mortality in the newborn intensive care unit can provide important information for health-care providers, and illness severity scores have been devised to provide mortality risk estimates. Calculation of illness severity scores is time-consuming, and the information used to predict mortality is collected only for the first 12 to 24 h of life. A noninvasive continuous measure that uses information collected throughout the hospitalization and that requires no data entry could be less costly and more informative. We have previously shown that the abnormal heart rate characteristics (HRC) of reduced variability and transient decelerations accompany neonatal illness such as late-onset sepsis. We hypothesized that more frequent and severe abnormal HRC are associated with an increased risk of death. We tested this hypothesis in two ways. Using data on infants older than 7 d of age, we first determined the association of the HRC index with death in the next week. Second, we devised a cumulative HRC score and determined its association with in-hospital death. There were 37 deaths in the 685 patients. The major findings were 1) the HRC index showed highly significant association with death in the succeeding 7 d (receiver-operating characteristic area > 0.7, p < 0.001), and 2) the cumulative HRC was highly significantly associated with neonatal in-hospital mortality (receiver-operating characteristic area > 0.80, p < 0.001). In both analyses, HRC added information to birth weight, gestational age, and postnatal age (p < 0.01). The HRC index provides independent information about the risk of neonatal death in the upcoming 7 d, and the cumulative HRC is an estimate of the risk of in-hospital neonatal mortality.     

Low serum levels of mannose binding lectin are a risk factor for neonatal sepsis

Mannose binding lectin (MBL) is a soluble pattern recognition receptor of innate immunity that binds a wide range of pathogens and exerts opsonic effects. We investigated the association between serum MBL levels and development of sepsis in infants admitted to neonatal intensive care units (NICUs). Serum MBL levels on admission were measured by enzyme-linked immunosorbent assay (ELISA) in 206 neonates consecutively admitted to an NICU of whom 138 did not develop hospital-acquired sepsis and 68 did. Of these 68, 40 had confirmed sepsis with positive blood cultures, 19 clinically suspected sepsis, with negative blood cultures, and nine had clinically suspected sepsis with blood culture yielding coagulase-negative staphylococci (CoNS). Serum MBL levels on admission were significantly lower in infants with sepsis [0.45 microg/mL; interquartile range (IQR) 0.09-1.68], particularly in those with confirmed sepsis (0.17 microg/mL; IQR 0.05-0.96), compared with infants without sepsis (1.45 microg/mL; IQR 0.43-3.52), and infants with CoNS-positive blood culture (1.70 microg/mL: IQR 0.85-3.60). After adjusting for duration of exposure gestational age (GA) and birth weight (BW), the association of low MBL levels with development of sepsis was maintained [odds ratio (OR) = 0.52; 95% confidence interval (CI): 0.36-0.75]. The measurement of serum MBL levels on admission in NICU may help to identify neonates at higher risk of developing sepsis.     

How to optimize the evaluation and use of antibiotics in neonates

Early and late-onset neonatal sepsis has specific pathogen distribution and infection rates in neonates with different gestational and postnatal ages. Despite the fact that early-onset sepsis is relatively rare (<1% of total deliveries), it is a major cause of mortality and morbidity. The known immunological immaturity of the neonate combined with non-specific clinical symptoms of infection has resulted in the frequent overuse of antibiotics in neonatal intensive care units (NICUs). In addition to this overuse there is a huge variability in the choice of antibacterial agents and dosing regimens used in NICUs across the world. Therefore, a more rational approach in the neonatal use of antibiotics is needed because of two major reasons: the emergence of multi-resistant bacteria in NICUs, and short- and long-term side effects of frequently used antibacterial agents in the neonatal population. This paper will focus on the optimal use of aminoglycosides (both used in early and late onset sepsis) and vancomycin (primarily used in late onset infections) in NICUs, and will underscore the need for specialists in neonatal medicine and pediatric pharmacology to work closely together to reach the most effective and safe way of using medicines in the NICU.     

Intercenter variability and time of onset: two crucial issues in the analysis of risk factors for nosocomial sepsis

BACKGROUND: Nosocomial sepsis is one of the most important causes of morbidity and mortality in neonatal intensive care units (NICUs). OBJECTIVE: To assess the impact of clinical conditions, exposure to invasive procedures and NICU characteristics on late (3 to 10 days) nosocomial sepsis (LNS) and very late (>10 days) nosocomial sepsis (VLNS) and to describe the variability among NICUs. METHODS: Multicenter prospective study in 21 NICUs including all newborns admitted in a 18-month period, weighing 相似文献   

Higher mortality rates among inborn infants admitted to neonatal intensive care units at night

OBJECTIVE: To examine circadian variation in deaths among infants < or =32 weeks' gestation admitted to Canadian neonatal intensive care units (NICU). STUDY DESIGN: We examined all infants (n=5192) between 24 and 32 weeks' gestation with complete data, who were admitted to 17 tertiary Canadian Neonatal Network NICUs from January 1996 to October 1997. Multivariable logistic regression was used to compare risk-adjusted early neonatal mortality rates (death within 7 days of NICU admission) of infants admitted during daytime (8 am to 5 pm) with infants admitted at night. RESULTS: Sixty percent (n=3131) of infants were admitted to the NICU at night. Patient risk factors significantly (P<.05) predictive of early neonatal death from multivariable logistic regression were male sex, outborn status, APGAR score <7 at 5 minutes, presence of congenital anomalies, low gestational age, and high admission Score for neonatal acute physiology, version II (SNAP-II). For inborn infants, in-house presence of a neonatal fellow or attending neonatologist at night (odds ratio, 0.6) and NICU admission at night (odds ratio, 1.6) were also predictive. CONCLUSIONS: Risk-adjusted early neonatal mortality odds was 60% higher among inborn infants < or =32 weeks' gestation admitted to NICUs at night compared with during daytime, equivalent to 29 excess deaths per 1000 infants.     

Significance of coagulase-negative staphylococci isolated from a single blood culture from neonates in intensive care

BACKGROUND: Coagulase-negative staphylococci (CoNS) are the most common pathogens of late-onset bacteraemia in neonatal intensive care units (NICUs). Discriminating true infection from contamination is difficult. METHODS: To evaluate the significance of a single blood culture yielding CoNS from only one blood culture obtained from NICU infants between July 1999 and November 2000, paired blood cultures were obtained simultaneously from two peripheral sites from infants hospitalised in two NICUs with clinically suspected late-onset sepsis, and a single blood culture was obtained peripherally from infants hospitalised in a third NICU. Demographic data, predisposing factors, clinical manifestations, laboratory data, management and outcome of infants with either paired or single blood cultures yielding CoNS were analysed and compared. RESULTS: Both blood cultures yielded CoNS during 26 episodes in 24 infants. A single blood culture which grew CoNS from one blood culture was identified during 24 episodes in 23 infants. Except for prior use of an umbilical venous catheter, there was no significant difference between the infants with CoNS isolated from a paired or a single blood culture in terms of demographic characteristics, predisposing factors, clinical manifestations, laboratory findings, management and outcome. CONCLUSION: There was no difference in the clinical features of CoNS infection between single and paired CoNS-positive blood cultures.     

Cobedding in the NICU: a new adventure

With advances in neonatal and obstetric care over the past few years, the number of premature, multiple-birth neonates entering NICUs has increased. As we have started to recognize the special bond that twins and higher multiples share, cobedding has emerged as an NICU practice. As with any change, the introduction of cobedding presents challenges in the NICU. Both the theoretical benefits anti the potential concerns are many. Although nursing staff and parents may be excited about the prospect of placing these infants in the same crib, careful investigation and planning are necessary for any new procedure. This article discusses the cobedding of multiples as implemented at the University of Michigan. As a new practice, cobedding warrants further research, especially regarding its proposed benefits and implementation in the NICU.     

Neonatal bacterial sepsis in a neonatal intensive care unit: A 5 year analysis

Objective : To study the pattern of neonatal sepsis in a neonatal intensive care unit (NICU) during a 5 year period and assess the relationship between maternal risk factors and early onset sepsis (EOS).
Methodology : The study reported here was a retrospective analysis of 209 episodes of septicaemia and 5 episodes of bacterial meningitis in 198 newborn infants, 22 of whom died. Eighty-one infants had EOS (≤72h) and 117 infants had late onset sepsis (LOS >72 h). All infants had clinical evidence of sepsis, a computerized haematological score for sepsis of 4 or greater, and either treatment with antibiotics for 7 days or more or had earlier death due to sepsis. The organisms causing neonatal sepsis were analyzed according to the day of onset, gestational age, birthweight and year of infection.
Results : Sepsis occurred in 5.6 per 1000 live births and 3.8% of NICU admissions. There were 81 episodes of EOS and 128 of LOS. Coagulase negative staphylococci (CONS) 38.8%, group B Streptococcus (GBS) 20.1% and Gram-negative bacilli (GNB) 20.1% were the common causes of sepsis; and GBS (50.6%) and CONS (60.9%) were the most common organisms in EOS and LOS, respectively. The mean gestational age and birthweight were heigher in babies with EOS than compared with LOS. The higher likelihood of probable rather than definite infection in infants with EOS was related to more mothers in the EOS group receiving intrapartum antibiotics. GNB infection was more common in their babies.
Conclusions : GBS and CONS were the most common causes of EOS and LOS, respectively. The use of maternal intrapartum antibiotics interferes with neonatal blood culture results. Because blood cultures are not always positive in neonatal septicaemia, a combination of clinical, haematological and other microbiological evidence should be used when diagnosing neonatal septicaemia.     

Breaking down barriers: enabling care-by-parent in neonatal intensive care units in China

Background:Denying parents access to their infant in the Neonatal Intensive Care Unit (NICU) is a standard practice in most hospitals across China.Visitation is not usually permitted or may be strictly limited,and NICU care for most neonates is provided by health-care professionals with little participation of the parents.An exception to this rule is the level 2 "Room-In" ward in Qilu Children's Hospital,Shandong University,where parents have 24-hour access to their infants and participate in providing care.Methods:This retrospective cohort study compared the outcomes of infants who were admitted to the NICU and remained there throughout their stay (NICU-NICU group,n=428),admitted to the NICU and then transferred to the Room-In ward (NICU-RIn group,n=1018),or admitted straight to the Room-In ward (RIn only group,n=629).Results:There were no significant differences in the rates of nosocomial infection,bronchopulmonary dysplasia,intraventricular hemorrhage,and retinopathy of prematurity between the NICU-NICU and NICURIn groups.The rate of necrotizing enterocolitis was significantly lower in the NICU-RIn group (P=0.04),while weight gain and duration of hospital stay were significantly higher (both P＜0.001).Rates of adverse outcomes were lower in RIn-only infants due to their low severity of illness on admission.Conclusions:Allowing parents access to their infant in the NICU is feasible and safe in China,and may result in improvements in infant outcomes.Further studies are required to generate stronger evidence that can inform changes to neonatal care in China.     

Neonatal sepsis in Egypt associated with bacterial contamination of glucose-containing intravenous fluids

BACKGROUND: Rates of sepsis exceeding 50% in a neonatal intensive care unit (NICU) in Cairo, Egypt, were not controlled by routine antimicrobial therapy. We investigated these conditions in September 2001. METHODS: Case series and retrospective cohort studies were conducted on 2 groups of NICU infants admitted to an academic medical center between February 12 and July 31, 2001. Observation of clinical practices led us to culture in-use intravenous (i.v.) fluids and medications. We monitored rates of i.v. fluid contamination, clinical sepsis and mortality after interventions to establish new procedures for handling and disposal of i.v. fluids, infection control training and improved clinical laboratory capacity. RESULTS: Among infants in the retrospective cohort group, 88 (77%) of 115 had clinical sepsis, and 59 (51%) died. In the case series group, we documented the time of initial positive blood culture; 21 (64%) of 33 were septic <24 hours after birth. Klebsiella pneumoniae accounted for 24 (73%) of 33 isolates; 14 (58%) of 24 were extended spectrum beta-lactamase-producing and aminoglycoside-resistant. On admission, all neonates received glucose-containing i.v. fluids; i.v. bottles (500 mL) were divided among multiple infants. The i.v. fluids were prepared at the bedside; poor hand hygiene and poor adherence to aseptic techniques were observed. K. pneumoniae was isolated from 13 (65%) of 20 in-use glucose-containing i.v. fluids. Fluid contamination, sepsis and mortality rates declined significantly after intervention. CONCLUSION: Extrinsically contaminated i.v. fluids resulted in sepsis and deaths. Standard infection control precautions significantly improve mortality and sepsis rates and are prerequisites for safe NICU care.     

Impact of staffing on bloodstream infections in the neonatal intensive care unit

OBJECTIVE: To examine the association between registered nurse staffing and healthcare-associated bloodstream infections in infants in the neonatal intensive care unit (NICU). DESIGN: Prospective cohort study. SETTING: Two level III-IV NICUs in New York, NY, from March 1, 2001, through January 31, 2003. PARTICIPANTS: A total of 2675 infants admitted to the NICUs for more than 48 hours and all registered nurses who worked in the same NICUs during the study period.Intervention Hours of care provided by registered nurses.Main Outcome Measure Time to first episode of healthcare-associated bloodstream infection. RESULTS: A total of 224 infants had an infection that met the study definition of healthcare-associated bloodstream infection. In a multivariate analysis, after controlling for infants' intrinsic and extrinsic risk factors, a greater number of hours of care provided by registered nurses in NICU 2 was associated with a decreased risk of bloodstream infection in these infants (hazard ratio, 0.21; 95% confidence interval, 0.06-0.79). CONCLUSION: Our findings suggest that registered nurse staffing is associated with the risk of bloodstream infection in infants in the NICU.     

新生儿急性肾损伤的早期诊断临床分析

目的 探讨新生儿重症监护病房（NICU）中新生儿急性肾损伤（AKI）发生率和病死率, 比较不同的AKI早期诊断标准评估新生儿AKI的发生率和病死率的差异, 探讨新生儿AKI早期诊断标准的重要性。 方法　采用前瞻性队列研究, 将2012年6月至2012年8月就诊于复旦大学附属儿科医院NICU的新生儿作为研究对象, 分别收集并记录每小时尿量以及入院当天、 48 h内的血肌酐等临床、 实验室指标及治疗等情况, 依照AKIN 2005年儿童AKI和AKIN 2012年新生儿AKI早期诊断标准进行分组, 比较新生儿AKI的发病情况、 病死率及临床特点。结果　按照AKIN 2005年儿童AKI的早期诊断标准共确诊AKI患儿20例,发生率为14.71%;在AKI组中,死亡9例,病死率为45%。按照AKIN 2012年新生儿早期诊断标准共确诊AKI患儿35例,发生率为25.73%;其中AKI新生儿死亡18例,病死率为51.43%;2012年AKIN早期诊断标准对新生儿AKI诊出率明显高于2005年的标准,两种早期诊断标准所致的新生儿AKI发生率差异存在统计学意义（P＝0.024）,但两种诊断标准所致的病死率差异无统计学意义（P＝0.646）。结论 新生儿AKI在NICU中发生率、病死率高,诊断困难,AKIN 2012年新生儿AKI早期诊断标准较AKIN 2005年儿童AKI早期诊断标准有助于新生儿AKI的早期诊断。     

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??Objective??To investigate the morbidity and mortality of neonatal AKI in NICU??evaluate the the performance of the different AKI diagnosis criteria of the Acute Kidney Injury Network ??AKIN?? and to study the importance of early diagnosis criteria for neonatal AKI. Methods??This is a prospective cohort study performed in NICU??Children Hospital of Fudan University. We prospectively followed the neonates??less than 28 days?? admitted from June1st??2012 to August 31??2012??until their discharge or death. For all the neonates we collected the clinical data at admission. Results??AKI was diagnosed in 35 neonates??the incidence of neonatal AKI was 25.73% according to the diagnosis criteria of AKIN in 2012. The mortality of neonatal AKI group was 51.43%??18/35??. Meanwhile??AKI was diagnosed only in 20 neonates??incidence of AKI being 14.71% in the same study with the other diagnosis criteria of AKIN in 2005 and the mortality of neonatal AKI group was 45%??9/20??. Conclusion??AKI is a common and severe clinical problem in NICU with high morbidity and mortality in NICU and is hard to diagnose. The criteria of AKIN in 2012 can improve the early diagnosis of newborn AKI in PICU.     

新生儿抗生素合理使用研究进展

抗生素是新生儿重症监护病房（NICU）的常用药物。然而,在生后早期,不必要地或长时间地暴露于抗生素,可增加新生儿发生不良预后的风险。NICU中的抗生素治疗大多始于经验性治疗。新生儿经验性抗生素治疗的启动标准及治疗疗程尚不统一。针对细菌培养阴性且临床表现稳定的新生儿,及时终止经验性抗生素治疗已成为共识。目前NICU中抗生素的使用存在较大差异。采取针对性的抗生素管理措施,是优化NICU抗生素使用方案的有效途径。     

Clinical and epidemiologic characteristics of viral infections in a neonatal intensive care unit during a 12-year period

BACKGROUND: The incidence of viral infections in patients treated in the neonatal intensive care unit (NICU) is not well-known. We summarized the data of all patients with laboratory-confirmed viral infections admitted at the NICU of our hospital during the period of 1992-2003. OBJECTIVES: To determine the incidence of viral infections among infants hospitalized in a NICU, the associated clinical manifestations and their outcome. METHODS: Retrospective analysis of epidemiologic, virologic and clinical data from infants with proven viral infection. The diagnosis viral infection was confirmed by positive viral culture and/or polymerase chain reaction from clinical samples. RESULTS: Viral infection was confirmed in 51 of 5396 infants (1%) admitted to the NICU; 20 (39%) had an enterovirus and parechovirus (EV/PEV) infection, 15 (29%) a respiratory syncytial virus (RSV) infection, 5 (10%) a rotavirus infection, 3 (6%) a cytomegalovirus (CMV) infection, 2 (4%) an adenovirus infection, 2 (4%) a parainfluenza virus infection, 2 (4%) a herpes simplex virus infection, 1 (2%) a rhinovirus infection and 1 (2%) a rubella virus infection. Three of the infants presented at birth with symptomatic rubella virus, CMV or herpes simplex virus infection. RSV infection developed mostly in hospitalized infants (60%), and 93% of infections occurred during the winter (November-March). The clinical presentations of EV/PEV disease were sepsis-like illness, prolonged seizures in term infants and gastrointestinal disease in preterm infants. RSV, parainfluenza virus, rhinovirus and CMV caused respiratory disease, predominantly in preterm infants. Gastrointestinal disease was seen only in preterm infants with adenovirus, rotavirus or EV/PEV infection. Mortality and serious sequelae were high in patients infected with EV/PEV (10 and 15%, respectively). CONCLUSIONS: The incidence of viral infection in the NICU was 1%. Enteroviral infections were the most frequently diagnosed infections, occurred often in term infants born at home and presented with sepsis-like illness or seizures. Preterm infants hospitalized from birth mainly developed gastrointestinal disease caused by rotavirus and adenovirus infection or respiratory disease caused by RSV, parainfluenza and CMV infection. Enteroviruses were responsible for the highest mortality and development of serious sequelae.     

Sepsis in neonatal intensive care in the late 1990s

AIM: To determine the incidence and clinical characteristics of sepsis in ventilated infants from an Australian neonatal intensive care unit (NICU) in the late 1990s. METHODS: Demographic data was collected from babies requiring assisted ventilation (AV) over the 6-month period from 1 July to 31 December 1998. Sepsis was divided into early onset sepsis (EOS; " 72 h of age) and late onset sepsis (LOS; >72 h of age), including both definite (culture-proven + abnormal markers) and probable (culture negative + abnormal markers) episodes. RESULTS: Two hundred and eleven babies required AV over this period. Of these, 64 (30.3%) had at least one infection, with 85 episodes of sepsis (40.3 episodes per 100 admissions requiring AV). There were 22 babies with 22 episodes of EOS, and 45 with 63 episodes of LOS. Three babies had both EOS and LOS. The rate of EOS was 10.4 infected infants (10.4 infections per 100 admissions requiring AV). The rate of LOS was 21.3 infected infants (29.9 infections per 100 admissions requiring AV). The rates of both EOS and LOS were higher than previously reported by Australian studies in the early 1990s. In both EOS and LOS, risk factors for infection were common. Group B streptococcus was the commonest cause of definite EOS. The mortality rate from sepsis in the EOS group was 14% (3/22). Coagulase-negative staphylococci were the commonest cause of LOS. The mortality rate from sepsis in the LOS group was 11% (5/45). CONCLUSIONS: EOS and LOS are significant problems in ventilated NICU infants in the late 1990s.     

Management of outbreaks in neonatal intensive care units

Outbreaks in neonatal intensive care units (NICUs) have disastrous consequences for neonates and raise enormous concerns in staff, altering usual practice patterns of the NICU. Our objective was to perform a systematic analysis for gaining insights into the control and prevention of NICUs outbreaks. Epidemiology, risk factors and outcomes are reviewed.     

Sepsisartige Erkrankungen durch humane Parechoviren Typ 3

Background

Human parechovirus (HPeV) has only recently been described as a causative agent for sepsis-like illness in neonates and young infants. In rare cases, meningoencephalitis and long-term neurological sequelae can occur. HpeV and enterovirus (EV) are important causative agents in neonatal sepsis-like illness.

Materials and methods

In this retrospective case–control study, clinical signs and laboratory data of young infants with HPeV (n?=?20) and EV (n?=?20) infection were compared.

Results

HPeV infections in young infants are associated with sepsis-like symptoms such as increased body temperature (100?%), poor feeding (90?%), mottled complexion/reduced acral perfusion (100?%) and irritability (60?%). The general condition of HPeV-infected infants is often worse than that of children with EV infections. White blood cell (WBC), C-reactive protein (CRP) and cerebrospinal (CSF) parameters usually remain normal. Even where HPeV is detected in CSF, the WBC count in CSF is normal.