Containment of a Methicillin-resistant Staphylococcus aureus (MRSA) Outbreak in a Neonatal Intensive Care Unit.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a challenging nosocomial pathogen in the last 50 years. OBJECTIVES: To describe an investigation and containment of an MRSA outbreak in a neonatal intensive care unit (NICU). METHODS: Our NICU is a 25-bed level III unit. Almost 540 neonates are admitted yearly. The index case was an 8 day old term baby. MRSA was isolated from his conjunctiva. Immediate infection control measures were instituted, including separation of MRSA+ carriers, strict isolation, separate nursing teams, and screening of all infants for MRSA. Healthcare workers and parents of positive cases were screened and re-educated in infection control measures. New admissions were accepted to a clean room and visiting was restricted. MRSA isolates were collected for molecular testing. RESULTS: MRSA was isolated from five infants by nasal and rectal swabs, including the index case. Screening of healthcare workers and families was negative. Two MRSA+ patients already known in the pediatric intensive care unit (PICU) located near the NICU were suspected of being the source. All NICU isolates were identical by pulsed-field gel electrophoresis but were different from the two PICU isolates. The NICU and one of the PICU isolates were defined as ST-5 strain by multilocus sequence typing. One PICU isolate was ST-627. All NICU isolates were Panton-Valentine leukocidin negative and SCCmec type IV. No further cases were detected, and no active infections occurred. CONCLUSIONS: A strict infection control policy and active screening are essential in aborting outbreaks of MRSA in the NICU.

Performing red reflex eye examinations increases the rate of neonatal conjunctivitis.

AIM: Red reflex eye examinations often require opening the eyelids, risking infection. We evaluated links between this procedure and neonatal conjunctivitis. METHODS: We divided 18 872 neonates of more than 35 weeks of gestation into two birth periods, 2008-2009 and 2010-2011, before and after red reflex examinations were carried out by our facility. The rates of clinical conjunctivitis, bacterial conjunctivitis and bacterial growth percentage were compared between the two periods. RESULTS: The 2010-2011 period included more Caesarean deliveries and longer lengths of stay (LOS) than the 2008-2009 period. The clinical conjunctivitis rate increased significantly during 2010-2011 (p = 0.029), but the bacterial conjunctivitis and bacterial growth percentages did not differ between the two periods. Variables that were independently and significantly associated with clinical conjunctivitis included being born in 2010-2011, with an odds ratio (OR) of 1.22, male gender (OR 1.31) and LOS (OR 1.19). Bacterial conjunctivitis was associated with vaginal delivery (OR 3.65), males delivered by Caesarean (OR 2.68) and LOS (OR 1.37). CONCLUSION: Clinical conjunctivitis was significantly associated with the later study period, male gender and LOS. Conjunctival swab sampling increased significantly following the implementation of red reflex examinations, but without changes in the bacterial conjunctivitis rate and the bacterial growth percentage.

[The effect of maternal medications, hypertension/pre-eclamptic toxemia and diabetes mellitus on neonatal hearing screening].

BACKGROUND: The effects of maternal medications and disease on neonatal hearing screening have scarcely been investigated. OBJECTIVE: To verify the effect of maternal medications and disease during gestation on the results of the first otoacoustic emissions (OAE) test. METHODS: We recorded perinatal and hearing screening data, medications during pregnancy and Labor (119 kinds of medication), hypertension/pre-eclamptic toxemia (HTN/PET) and diabetes mellitus (DM). RESULTS: Of the 2306 infants studied, 214 (9.3%) failed the first OAE test. Vaginal delivery (VD) and cesarean delivery (CD) infants were analyzed separately. Multivariate logistic regression analysis showed: Independently significant variables associated with failed first OAE in VD infants included: Birth weight (BW) >4000g [OR 2.2 (1.1-4.3) p=0.026]; decreasing age at first OAE [OR 0.31 (0.17-0.6) p<0.001] and maternal DM [OR 2.2 (1.0-4.84) p=0.049]. The findings for CD infants were: male gender [OR 1.91 (1.24-2.96) p=0.004); decreasing age at first OAE [OR 0.34 (0.21-0.55) p<0.001]; maternal HTN/PET [OR 2.3 (1.22-4.3) p=0.01 and small-for-gestational-age (SGA) status [OR 2.9 (1.1-7.56) p=0.03]. CONCLUSION: Increased failure on first OAE occurs in VD infants with BW >4,000g, early first OAE and DM; and in CD infants with male gender, early first OAE, HTN/PET and SGA status. It is yet to be determined whether postponing of first OAE beyond 48 hours of age will allow the reduction of false positive results on first OAE.

Delayed first otoacoustic emissions test decreases failure on neonatal hearing screening after caesarean delivery.

AIM: Caesarean delivery (CD) was associated with a 3.2-fold higher failure on 1st otoacoustic emissions (OAE) hearing test. We aimed to verify whether postponing 1st OAE beyond 48 h in CD infants decreases hearing screening failure. METHODS: We compared two groups of CD infants as to failure on 1st OAE test: early-1st OAE (n = 560): 1st OAE at 12- to 48-h-olds and late-1st OAE (n = 566): 1st OAE at 48- to 132-h-olds. RESULTS: Compared with early-1st OAE group, the failure rate among late-1st OAE infants was significantly sixfold lower (20.5% vs. 3.4%), with sixfold lower need for repeated tests: 205 vs. 34 tests/1000 CD neonates (p < 0.001). The failure rate decreased with increasing age in both groups (p < 0.001). Univariate analysis: timing of 1st OAE (late vs. early) was significantly associated with failure on 1st OAE. Multivariable analysis: late (48-132 h) 1st OAE test was associated with a 7.7-fold lower risk for failure of 1st OAE, OR (95% CI): 0.13 (0.08-0.21). CONCLUSION: Among CD infants, the risk for failure in late-1st OAE group (>48 h) was 7.7-fold lower, with a sixfold lower need for repeated hearing tests. Delaying 1st OAE in CD infants beyond 48 h of age (preferably between 48 and 132 h) decreases neonatal OAE screening failure.

Fetal reduction in triplet gestations: twins still fare better.

BACKGROUND: Reduction of fetal number has been offered in high order multiple gestations but is still controversial in triplets. Since recent advances in neonatal and obstetric care have greatly improved outcome, the benefits of multifetal pregnancy reduction (MFPR) may no longer exist in triplet gestations. OBJECTIVES: To evaluate if fetal reduction of triplets to twins improves outcome. METHODS: We analyzed the outcome of 80 triplet gestations cared for at Rambam Health Care Campus in the last decade; 34 families decided to continue the pregnancy as triplets and 46 opted for MFPR to twins. RESULTS: The mean gestational age at delivery was 32.3 weeks for triplets and 35.6 weeks for twins after MFPR. Severe prematurity (delivery before 32 gestational weeks) occurred in 37.5% and 7% of twins. Consequently, the rate of severe neonatal morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage) and of neonatal death was significantly higher in unreduced triplets, as was the length of hospitalization in the neonatal intensive care unit (31.4 vs. 15.7, respectively). Overall, the likelihood of a family with triplets to take home all three neonates was 80%; the likelihood to take home three healthy babies was 71.5%. CONCLUSIONS: MFPR reduces the risk of severe prematurity and the neonatal morbidity of triplets. A secondary benefit is the reduction of cost of care per survivor. Our results indicate that MFPR should be offered in triplet gestations.

Heart rate dynamics during acute pain in newborns.

Autonomic nervous system modulation of heart rate is significantly altered during painful procedures in newborns. Most studies investigating pain employed only linear-based analysis methods, thus ignoring the complex, non-linear nature of heart rate control mechanisms. The emergences of dynamic, nonlinear analysis methods enable us to uncover information embedded in the fluctuations of heart rate not otherwise noticeable. Our objective was to examine how cardiac dynamics change in newborns who undergo heel lancing by analyzing linear and nonlinear characteristics of heart rate fluctuations. We used dynamic nonlinear analyses methods to reveal heart rate variability and complexity alterations during painful stimulus in newborns. Poincaré plots were applied to examine the dynamics of the system, sample entropy to investigate the complexity of the system, and detrended fluctuation analysis, to reveal the fractal properties of the system. Heart rate significantly increased (165 vs.123 beats per minute, p < 0.001) while variability decreased. Sample entropy and the quantitative measures of the Poincaré plots (SD1 and SD2) significantly decreased during heel lancing (0.75 vs. 1.0, p < 0.01; 6.4 vs. 12.8, p < 0.001; and 30.4 vs. 50.5, p < 0.01, respectively). Detrended fluctuation analysis showed a significant decrease in the short-term scaling exponent α1 (1.06 vs. 1.3, p < 0.001), and an increase in the long-term scaling exponent α2 (1.5 vs. 1.1, p < 0.001). Our results indicate altered complexity of heart rate variability during painful stimulus in newborns and disruption of the mechanisms that regularly control it. Such alterations resemble certain pathological conditions and may represent stress reaction.

Factors associated with iatrogenesis in neonatal intensive care units: an observational multicenter study.

The objective of our study was to assess factors associated with iatrogenic events in Neonatal Intensive Care Units (NICUs). This was a retrospective analysis based on a cohort of patients who participated in our previous prospective study (Pediatrics 122:550-555, 2008), conducted in four tertiary university-affiliated NICUs in Israel, that included all consecutive infants (n = 615) hospitalized during the study period. Ongoing monitoring of iatrogenic events was performed by designated "iatrogenesis advocates." The main outcome measures were the association of individual infant characteristics and NICUs' environmental characteristics with iatrogenic events assessed by univariate and multiple logistic regression analysis. We found that four infant characteristics were significantly (p < 0.001) associated with iatrogenic events in a univariate analysis: gestational age, birth weight, severity of initial illness as assessed by the Score for Neonatal Acute Physiology and Perinatal Extension (SNAPPE II), and length of stay (LOS). All four factors demonstrated a significant (p < 0.001) dose-response relationship with iatrogenic events. Univariate analysis for environmental characteristics showed that type of shift, but not nursing workload, was significantly associated with iatrogenic events (p < 0.001). In a multiple logistic regression analysis, only LOS (adjusted OR 1.02 [95 % CI, 1.01-1.03]) and type of shift, morning vs. evening (adjusted OR 3.44 [95 % CI, 2.33-5.08]) and morning vs. night (adjusted OR 6.07 [95 % CI, 3.86-9.56]), remained independently associated with iatrogenic events (p < 0.001). Prolonged LOS and morning shifts were found to be significantly associated with iatrogenic events. Further prospective research is warranted to identify the specific causes for iatrogenic events in order to target active interventions to prevent them.

Transient abnormal fetal cardiac flow patterns at 13 to 17 gestational weeks.

OBJECTIVE: To report the outcome of transient abnormal cardiac flow patterns (ABCFP) at 13 to 17 weeks' gestation. METHODS AND RESULTS: Observational single operator study of transvaginal sonography scans of 13,183 fetuses. Of the 22 fetuses with ABCFP (1:600) high pulmonary valvular velocity was detected in 11 (8 of them transient), an abnormal blood flow in the coronary region in 6, mitral regurgitation in 3, and high aortic valvular velocity in 2 cases. In over 90%, these findings were transient. At birth, there were two cases of mild pulmonary stenosis, one meconium ileus, and two cases of asymptomatic bicuspid aortic valve without stenosis. All the remaining neonates were healthy. CONCLUSIONS: The transient sonographic findings at 13 to 17 weeks' gestation of mitral regurgitation, pulmonary or aortic high valvular flow, and coronary sinus flow have a good prognosis, and in most cases are not associated with persistent cardiac anomalies. The etiology, incidence, and the prognosis of fetuses with transient ABCFP at 13 to 17 weeks' gestation are different from what is observed when the same occurs later in gestation.

Fetal Ebstein's anomaly: early and late appearance.

OBJECTIVE: To present sonographic findings in early and late appearance of fetal Ebstein's anomaly. METHODS: Fetal sonography was performed in 53,447 consecutive pregnant women at 14 to 16 weeks' gestation. RESULTS: Ebstein's anomaly was detected in eight fetuses, in four of them additional anomalies were observed. All eight pregnancies were terminated. In an additional fetus, a normal four-chamber view without valvular regurgitation was visualized at 15 weeks' gestation. At 24 weeks, a normal four-chamber view was depicted. No Doppler examination was performed at that time. The newborn was found to have Ebstein's anomaly with pulmonary stenosis. A balloon pulmonary valvuloplasty was performed with a good outcome at three months of age. CONCLUSION: Fetal Ebstein's anomaly may be detected in early pregnancy. The incidence is higher than what is reported in newborns. Depiction of a normal fetal heart in early and midpregnancy does not exclude the possibility of subsequent development of Ebstein's anomaly.

Fetal transient clitoromegaly and transient hypertrophy of the labia minora in early and mid pregnancy.

OBJECTIVE: The purpose of this study was to describe a series of cases of transient changes in the female fetal external genitalia. METHODS: In our practice area, most pregnant women usually undergo a detailed sonographic survey of all fetal organs, including the external genitalia in early and mid pregnancy. RESULTS: During the study period (1987-2010), 62,145 consecutive pregnant women were scanned. We detected 4 fetuses with an isolated finding of clitoromegaly at 15 to 16 weeks' gestation, which disappeared at 22 to 26 weeks. Maternal hormonal study results were normal. There was 1 case of clitoromegaly and a cloacal anomaly at 15 weeks' gestation, in which the clitoris retuned to a normal size at 22 weeks. In addition, there were 3 cases of hypertrophy of the labia minora in early pregnancy, which disappeared at 26 to 32 weeks. All fetuses in these series had a normal XX karyotype and normal external genitalia at birth. CONCLUSIONS: Transient changes in the appearance of the fetal external genitalia may occur in chromosomally normal female fetuses.

Doppler middle cerebral artery peak systolic velocity for diagnosis of neonatal anemia.

OBJECTIVES: The peak systolic velocity (PSV) of the middle cerebral artery was found to be predictive of fetal anemia and is routinely applied in the treatment of such fetuses. Our objective was to determine whether a correlation exists between the PSV in the neonatal middle cerebral artery and hemoglobin levels for possible future implementation in clinical practice. METHODS: A prospective study on 151 neonates was conducted, examining their middle cerebral artery PSV concomitantly with their hemoglobin level during the first 36 hours after delivery. The study population included 122 normocythemic, 24 anemic, and 5 polycythemic neonates. An analysis of variance between normocythemic, anemic, and polycythemic neonates was performed, and a regression analysis of the PSV versus hemoglobin levels was conducted. RESULTS: The normocythemic neonates had a mean middle cerebral artery PSV ± SD of 41.3 ± 11.4 cm/s, whereas the anemic neonates had a significantly higher PSV (63.8 ± 28.5 cm/s), and the polycythemic neonates had a significantly lower PSV (26.8 ± 7.4 cm/s; P < .001). A statistically significant correlation was found between hemoglobin levels and the middle cerebral artery PSV (P < .01). CONCLUSIONS: Neonatal anemia and polycythemia can be rapidly diagnosed at the bedside by examining the middle cerebral artery PSV. This technique can be used as an ancillary measure to promptly diagnose acute neonatal blood volume changes for an immediate intervention.

Optimizing outcome of twins by routine cesarean section beyond 37 weeks.

The appropriate time and the optimal mode of delivery of twins are still controversial. We assessed the effect of gestational age and the mode of elective delivery of twins on the occurrence of neonatal respiratory morbidity (NRM) and of maternal morbidity. This study included twins born beyond 35 weeks' gestation. NRM was defined as respiratory distress syndrome (RDS) and transient tachypnea of the newborn (TTN). Additionally, maternal complications related to the different modes of delivery were taken into account. Of 711 twin pregnancies (1422 liveborn neonates) included, 74 (5.2%) experienced NRM. Maternal age > 25 years, delivery at an earlier gestational age, and delivery by emergency cesarean section maintained statistical significance with NRM. From the maternal point of view, increased length of hospitalization ( P = 0.045) and the need for postoperative antibiotics ( P = 0.0065) were significantly higher following an emergency cesarean section than after an elective cesarean birth. The risk of NRM in twins born beyond 37 weeks' gestation is rather low. We suggest considering elective cesarean delivery at completion of 37 weeks. This can be performed safely in regard to NRM, the trade-off being reduced maternal morbidity associated with elective cesarean delivery.

Fetal thickened nuchal soft tissues may first appear in the second trimester in Down syndrome.

PURPOSE: To describe a series of cases of late-onset fetal nuchal translucency in Down syndrome. METHOD: In our practice area, most pregnant women usually undergo 3 different sonographic examinations: a fetal nuchal translucency examination in the 1st trimester and 2 detailed surveys of all fetal organs in the early 2nd trimester and in midpregnancy. RESULT: During the study period (2003-2008), we detected 11 fetuses with new appearance of severe thickened nuchal soft tissues (>or=6 mm) at 14-16 weeks' gestation after a normal nuchal screening in the 1st trimester. All of these fetuses had trisomy 21. Associated structural anomalies were observed in 10/11 of the cases. In addition, there were 12 fetuses with new appearance of thickened nuchal soft tissues (<4 mm); all these fetuses had a normal karyotype and were normal at delivery. CONCLUSION: Obstetricians should be aware that a nuchal abnormality may first appear only at 14-16 weeks' gestation. Fetal karyotyping is advocated in these cases because of the high probability of Down syndrome.

The Maimonides Model for a Regimen of Health: A Comparison with the Contemporary Scenario.

Rabbi Moses Ben Maimon, known as Maimonides, or The "Rambam" (a Hebrew acronym for his name), was one of the greatest arbiters of all times on matters of Jewish law, one of the greatest philosophers of the Middle Ages, a scientist, and a researcher. In addition, he was a court physician to the Egyptian Sultan. In addition to his monumental work on Jewish law and ethics, his writings on medicine have been considered classics over the generations. The aim of this paper is to assess Maimonides' health regimen and to compare his dietary recommendations with contemporary dietary regimens. To this end, Maimonides' recommendations were compared to the modern guidelines of the United States, the Netherlands, and the World Health Organization (WHO), as well as to the Mediterranean diet, which is popular worldwide. Both marked similarities and contrasts were noted between Maimonides' and modern recommendations. Most of Maimonides' medical recommendations remain relevant more than 800 years later.

Medical care for terrorists--to treat or not to treat?

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities.

Early-onset group B Streptococcus sepsis in high risk neonates born after prolonged rupture of membranes.

BACKGROUND: According to the U.S. Centers for Disease Control guidelines, prolonged rupture of membranes mandates intrapartum antimicrobial prophylaxis for group B Streptococcus whenever maternal GBS status is unknown. OBJECTIVES: To evaluate the local incidence, early detection and outcome of early-onset GBS sepsis in neonates born at 35-42 weeks gestation after PROM to women with unknown GBS status who were not given intrapartum antimicrobial prophylaxis. METHODS: During a 1 year period we studied all neonates born beyond 35 weeks gestation with maternal PROM > or =18 hours, unknown maternal GBS status and without prior administration of IAP. Complete blood count, C-reactive protein, blood culture and polymerase chain reaction amplification of bacterial 16S rRNA gene were performed in blood samples collected immediately after birth. Unfavorable outcome was defined by one or more of the following: GBS bacteremia, clinical signs of sepsis, or positive PCR. RESULTS: Of the 3616 liveborns 212 (5.9%) met the inclusion criteria. Only 12 (5.7%) of these neonates presented signs suggestive of sepsis. PCR was negative in all cases. Fifty-eight neonates (27.4%) had CRP > 1.0 mg/dl and/or complete blood count abnormalities, but these were not significantly associated with unfavorable outcome. Early-onset GBS sepsis occurred in one neonate in this high risk group (1/212 = 0.47%, 95% CI 0.012-2.6). CONCLUSIONS: In this single-institution study, the incidence of early-onset GBS sepsis in neonates born after PROM of 18 hours, unknown maternal GBS status and no intrapartum antimicrobial prophylaxis was 0.47%.

Approach to term neonates born after maternal intrapartum fever and unknown maternal group B Streptococcus status: value of serum C-reactive protein and 16S rRNA gene PCR amplification.

Thirty-six term neonates born after maternal intrapartum fever, with premature rupture of membranes <18 hours and unknown maternal group B Streptococcus status had blood samples for complete blood count, C-reactive protein, culture, and 16S rRNA gene polymerase chain reaction amplification. Only 2 neonates were symptomatic and none had leukopenia, C-reactive protein >1.0 mg/dL, bacteremia, or positive polymerase chain reaction.

Early and late onset fetal microphthalmia.

OBJECTIVE: The purpose of this study was to present sonographic and pathologic findings in early and late onset fetal microphthalmia. STUDY DESIGN: Fetal sonography was prospectively performed in 30,989 consecutive pregnancies at 14 to 24 weeks' gestation. In addition, we retrospectively reevaluated US recordings of 4 fetuses from other hospitals, in which normal eyes were observed in early and midgestation and microphthalmia was diagnosed only in the third trimester of pregnancy or after birth. RESULTS: Microphthalmia was detected in 13 fetuses in the prospective group. Twelve of 13 had additional structural and chromosomal anomalies. Termination of pregnancy was performed in 12 cases. In the retrospective group of late onset microphthalmia we confirmed the normal eye measurements performed in the early and midpregnancy. Severe vision impairment or blindness was noted in 3 of these children, while the fourth pregnancy was terminated. CONCLUSION: Normal measurements of the fetal eyes in early and midpregnancy do not exclude the possibility of subsequent development of microphthalmia.