Overcrowding in a neonatal intermediate care unit: impact on the incidence of multidrug-resistant gram-negative organisms.

BACKGROUND: Overcrowding, reduced nurse to patient ratio, limited distance between incubators and absence of microbiological surveillance have been shown to promote spread of multidrug-resistant gram-negative organisms (MDRGN) in patients with birthweight < 1500 g. Patients > 1500 g treated on an intermediate care unit are unrepresented in recent literature. We therefore intended to present data obtained from a short-term overcrowded neonatal intermediate care unit (NIMCU) at a level III (international categorization) perinatal center at University Hospital Frankfurt, Germany. METHODS: During a 25 day overcrowding (OV) and 28 day post-overcrowding period (POST-OV) on NIMCU, epidemiological data obtained from continuously hold microbiological surveillance were investigated and compared to the last 12 months of ward-regular bed occupancy preceding OV (PRAE-OV). RESULTS: During OV, the number of patients simultaneously treated at the NIMCU increased from 18 to 22, resulting in a reduced bed-to-bed space. Nurse: patient ratio was 4:22 during OV compared to 3:18 during PRAE-OV. Cumulative incidence of MDRGN was 4.7% in OV and 2.4% POST-OV compared to 4.8% to PRAE-OV, respectively, without any significant variations. During OV and POST-OV, septic episodes due to MDRGN were not observed. In one case, potential nosocomial transmission of Enterobacter cloacae resistant to Piperacillin and 3rd/4th generation cephalosporins was observed. CONCLUSIONS: Prevention of nosocomial spread of MDRGN in an overcrowded NIMCU is based on staff's diligent training and adequate staffing. Concise microbiological surveillance should be guaranteed to escort through overcrowding periods. In our setting, impact of bed-to-bed distance on MDRGN transmission seemed to be less strong.

Analysis of Endothelial Adherence of Bartonella henselae and Acinetobacter baumannii Using a Dynamic Human Ex Vivo Infection Model.

Bacterial adherence determines the virulence of many human-pathogenic bacteria. Experimental approaches elucidating this early infection event in greater detail have been performed using mainly methods of cellular microbiology. However, in vitro infections of cell monolayers reflect the in vivo situation only partially, and animal infection models are not available for many human-pathogenic bacteria. Therefore, ex vivo infection of human organs might represent an attractive method to overcome these limitations. We infected whole human umbilical cords ex vivo with Bartonella henselae or Acinetobacter baumannii under dynamic flow conditions mimicking the in vivo infection situation of human endothelium. For this purpose, methods for quantifying endothelium-adherent wild-type and trimeric autotransporter adhesin (TAA)-deficient bacteria were set up. Data revealed that (i) A. baumannii binds in a TAA-dependent manner to endothelial cells, (ii) this organ infection model led to highly reproducible adherence rates, and furthermore, (iii) this model allowed to dissect the biological function of TAAs in the natural course of human infections. These findings indicate that infection models using ex vivo human tissue samples ("organ microbiology") might be a valuable tool in analyzing bacterial pathogenicity with the capacity to replace animal infection models at least partially.

Purpura fulminans after therapeutic hypothermia in an asphyxiated neonate with streptococcemia.

OBJECTIVE: Therapeutic hypothermia is an established therapeutic regimen in severely asphyxiated term neonates. The amount of cerebral injury is reduced resulting in an improved neurologic outcome. Therapeutic hypothermia-induced side effects mostly affect the circulatory system, kidney, and liver. However, asphyxia and hypothermia in itself reduce the hemostatic capacity of each individual organism. STUDY DESIGN: A case of a neonate with severe asphyxia and purpura fulminans after hypothermia is described. RESULTS AND CONCLUSION: Although purpura fulminans cannot be attributed to hypothermia solely, the influence of hypothermia on hemostasis may have promoted severe coagulopathy with a fatal outcome. Further studies are necessary to reveal therapeutic hypothermia as a trigger for severe coagulopathies in asphyxiated neonates, especially in those with sepsis and overt coagulopathy prior to therapeutic hypothermia.

Safety and Feasibility of Long-Distance Aeromedical Transport of Neonates and Children in Fixed-Wing Air Ambulance.

In cases of critical injury or illness abroad, fixed-wing air ambulance aircraft is employed to repatriate children to their home country. Air ambulance aircraft also transport children to foreign countries for treatment not locally available and newborns back home that have been born prematurely abroad. In this retrospective observational study, we investigated demographics, feasibility, and safety and outcomes of long-distance and international aeromedical transport of neonates and children. The study included 167 pediatric patients, 56 of those preterm neonates. A total of 41 patients were ventilated, 45 requiring oxygen prior to the transport, 57 transferred from an intensive care unit (ICU), and 48 to an ICU. Patients were transported by using Learjet 31A, Learjet 45, Learjet 55, and Bombardier Challenger 604, with a median transport distance of 1,008 nautical miles (NM), median transport time of 04:45 hours (median flight time = 03:00 hours), flight time ≥8 hours in 15 flights, and transport time ≥8 hours in 29 missions. All transports were accompanied by a pediatric physician/nurse team. An increase in FiO 2 during the transport was documented in 47/167 patients (28%). Therapy escalation (other than increased oxygen) was reported in 18 patients, and technical adverse events in 3 patients. No patient required CPR or died during the transport. Clinical transport outcome was rated by the accompanying physician as unchanged in 163 transports, improved in 4, and deteriorated in none. In summary, international, long-distance transport of neonatal and pediatric patients performed by experienced and well-equipped transport teams is feasible. Neither major adverse events nor physician-rated clinical deteriorations were observed in this group of patients.

The Use of Off-Label Medications in Newborn Infants Despite an Approved Alternative Being Available-Results of a National Survey.

Neonates continue to be treated with off-label or unlicensed drugs while in hospital. However, some medications that have previously been used in adults underwent clinical testing and licensure for use with a different indication in the neonatal and pediatric population. Almost always, the marketing of these newly approved substances in a niche indication is accompanied by a steep increase in the price of the compound. We investigated the use of the approved formulation or the cheaper off-label alternative of Ibuprofen (Pedea®), Propanolol (Hemangiol®) and Caffeine Citrate (Peyona®) in neonatal clinical practice by conducting a National Survey of 214 Perinatal Centers in Germany. We also assessed price differences between on- and off-label alternatives and the extend of the clinical development program of the on-label medication in the neonatal population. On-label medication was more frequently used than the off-label alternative in all indications (PDA: on-label to off-label ratio 1:0.26, Apnea: 1:0.56, Hemangioma 1:0.76). All sponsors did conduct placebo-controlled Phase III trials with efficacy and safety endpoints in the target population and the number of participants in the target population varied between 82 and 497. Costs for the three drugs in their approved and marketed formulations increased in median 405-fold compared with the corresponding off-label alternative. Overall, about one out of three neonatologists prescribed an off-label or non-approved drug to patients despite an alternative medication that is approved for the indication in the target population being available.

Disseminated intravascular coagulation in term and preterm neonates.

Among critically ill patients, the risk of developing disseminated intravascular coagulation (DIC) is probably highest in neonates. Low plasma reserves in pro- and anticoagulant coagulation factors, intravascular volume contraction after birth, and a high incidence of hypoxia and sepsis in critically ill newborns rapidly lead to a decompensation of the coagulation system in this population. Global coagulation tests and single-factor plasma levels have to be interpreted in the context of age-corrected normal ranges. Platelet consumption and reduced protein C plasma levels have diagnostic value; the latter also has prognostic potential in neonates with DIC and sepsis. Therapeutic success relies heavily on reversal of the underlying condition. Some coagulation-specific therapies have been explored in small studies and case series with varying success and sometimes conflicting results. Therefore, larger controlled trials in this common and serious condition are urgently needed.

Human protein C concentrate in the treatment of purpura fulminans: a retrospective analysis of safety and outcome in 94 pediatric patients.

INTRODUCTION: Purpura fulminans (PF) is a devastating complication of uncontrolled systemic inflammation, associated with high incidence of amputations, skin grafts and death. In this study, we aimed to clarify the clinical profile of pediatric patients with PF who improved with protein C (PC) treatment, explore treatment effects and safety, and to refine the prognostic significance of protein C plasma levels. METHODS: In Germany, patients receiving protein C concentrate (Ceprotin, Baxter AG, Vienna, Austria) are registered. The database was used to locate all pediatric patients with PF treated with PC from 2002 to 2005 for this national, retrospective, multi-centered study. RESULTS: Complete datasets were acquired in 94 patients, treated in 46 centers with human, non-activated protein C concentrate for purpura fulminans. PC was given for 2 days (median, range 1-24 days) with a median daily dose of 100 IU/kg. Plasma protein C levels increased from a median of 27% to a median of 71% under treatment. 22.3% of patients died, 77.7% survived to discharge. Skin grafts were required in 9.6%, amputations in 5.3%. PF recovered or improved in 79.8%, remained unchanged in 13.8% and deteriorated in 6.4%. Four adverse events occurred in 3 patients, none classified as severe. Non-survivors had lower protein C plasma levels (P < 0.05) and higher prevalence of coagulopathy at admission (P < 0.01). Time between admission and start of PC substitution was longer in patients who died compared to survivors (P = 0.03). CONCLUSIONS: This retrospective dataset shows that, compared to historic controls, only few pediatric patients with PF under PC substitution needed dermatoplasty and/or amputations. Apart from epistaxis, no bleeding was observed. Although the data comes from a retrospective study, the evidence we present suggests that PC had a beneficial impact on the need for dermatoplasty and amputations, pointing to the potential value of carrying out a prospective randomised controlled trial.

Early Bacterial Colonization and Antibiotic Resistance Gene Acquisition in Newborns.

Several studies have recently identified the main factors contributing to the bacterial colonization of newborns and the dynamics of the infant microbiome development. However, most of these studies address large time periods of weeks or months after birth, thereby missing on important aspects of the early microbiome maturation, such as the acquisition of antibiotic resistance determinants during postpartum hospitalization. The pioneer bacterial colonization and the extent of its associated antibiotic resistance gene (ARG) dissemination during this early phase of life are largely unknown. Studies addressing resistant bacteria or ARGs in neonates often focus only on the presence of particular bacteria or genes from a specific group of antibiotics. In the present study, we investigated the gut-, the oral-, and the skin-microbiota of neonates within the first 72 h after birth using 16S rDNA sequencing approaches. In addition, we screened the neonates and their mothers for the presence of 20 different ARGs by directed TaqMan qPCR assays. The taxonomic analysis of the newborn samples revealed an important shift of the microbiota during the first 72 h after birth, showing a clear site-specific colonization pattern in this very early time frame. Moreover, we report a substantial acquisition of ARGs during postpartum hospitalization, with a very high incidence of macrolide resistance determinants and mecA detection across different body sites of the newborns. This study highlights the importance of antibiotic resistance determinant dissemination in neonates during hospitalization, and the need to investigate the implication of the mothers and the hospital environment as potential sources of ARGs.

Characterization of the pathoimmunology of necrotizing enterocolitis reveals novel therapeutic opportunities.

Necrotizing enterocolitis (NEC) is a severe, currently untreatable intestinal disease that predominantly affects preterm infants and is driven by poorly characterized inflammatory pathways. Here, human and murine NEC intestines exhibit an unexpected predominance of type 3/TH17 polarization. In murine NEC, pro-inflammatory type 3 NKp46-RORγt+Tbet+ innate lymphoid cells (ILC3) are 5-fold increased, whereas ILC1 and protective NKp46+RORγt+ ILC3 are obliterated. Both species exhibit dysregulation of intestinal TLR repertoires, with TLR4 and TLR8 increased, but TLR5-7 and TLR9-12 reduced. Transgenic IL-37 effectively protects mice from intestinal injury and mortality, whilst exogenous IL-37 is only modestly efficacious. Mechanistically, IL-37 favorably modulates immune homeostasis, TLR repertoires and microbial diversity. Moreover, IL-37 and its receptor IL-1R8 are reduced in human NEC epithelia, and IL-37 is lower in blood monocytes from infants with NEC and/or lower birthweight. Our results on NEC pathomechanisms thus implicate type 3 cytokines, TLRs and IL-37 as potential targets for novel NEC therapies.

Incidence and clinical outcome of cytomegalovirus transmission via breast milk in preterm infants

AIM: To evaluate incidence, timing and clinical relevance of acquired human cytomegalovirus (HCMV) infection in preterm infants. METHODS: The prospective longitudinal study included preterm infants

Activated protein C downregulates p38 mitogen-activated protein kinase and improves clinical parameters in an in-vivo model of septic shock.

Despite the success of the anti-coagulant protease protein C (PC) in treating septic shock in humans, the signaling pathways used are still unclear. To explore the effects of treatment with PC zymogen and its activated form aPC in a setting of sepsis, we employed a piglet model of endotoxic shock. In the aPC group, we observed a 65%-90% reduction in plasma TNF-alpha levels and a concomitant clinical improvement. Unexpectedly, administration of aPC also resulted in stabilization of the plasma pH above 7.2. Moreover, phosphorylated p38 mitogen-activated protein kinase (p38MAPK) was virtually absent in the livers of those piglets receiving aPC. In cultured human umbilical vein endothelial cells, we observed that nanomolar concentrations of PC and aPC inhibited the phosphorylation of p38MAPK. Furthermore, we showed that the regulation of the pro-apoptotic cell cycle regulator p53 by PC and aPC is dependent on the reduction of p38MAPK activation. The transduction of these effects involves all three receptors associated with protein C signaling, namely endothelial protein C receptor, protease-activated receptor 1, and sphingosine 1-phosphate receptor 1. Ultimately, this study elucidates novel signaling pathways regulated by protein C and emphasises the pivotal importance of its multiple modes of action beyond anticoagulation. APC's clinical success may, in part, be due to p38MAPK inhibition.

A prospective pilot study of prophylactic treatment of preterm neonates with recombinant activated factor VII during the first 72 hours of life.

OBJECTIVE: Intraventricular hemorrhage (IVH) in the preterm infant is a devastating complication, causing marked mortality and morbidity. A general hemostatic agent such as recombinant activated factor VII (rFVIIa) might have the potential to reduce the extent of severe IVH. DESIGN: Prospective, single-arm pilot study. SETTING: Level III neonatal intensive care unit. PATIENTS: Ten preterm infants between 23 and 28 wks of gestation. INTERVENTION: Administration of a 100-microg/kg rFVIIa bolus injection within the first 2 hrs of life, followed by 100 microg/kg rFVIIa every 4 hrs, for the first 72 hrs of life. MEASUREMENTS AND MAIN RESULTS: Cranial ultrasonography and flow studies of the major arteries and the venae cava, aorta, vena portae, and venae renales, was performed at study enrollment and at 12 hrs, 24 hrs, 48 hrs, and 72 hrs. Blood cell counts and coagulation studies were performed. End points of the study were occurrences of adverse events, with an emphasis on thrombotic events or disseminated intravascular coagulation (DIC). Ten preterm infants with a gestational age of 23 wks 1 day to 28 wks 3 days were included. None had venous thrombosis or cerebral infarction during or after the treatment. Neither platelet consumption nor DIC was observed. Two infants with an umbilical artery catheter had a thrombus at the catheter tip (one during infusion of the study drug), which was successfully treated with heparin. One had grade III IVH and died on day 6 of life; in another, grade II IVH progressed to grade III after termination of the drug. CONCLUSION: One hundred microg/kg rFVIIa does not accumulate if administered prophylactically to preterm infants of <28 wks of gestation every 4 hrs in the first 72 hrs of life. In this population, rFVIIa does not cause DIC. Thrombus formation was observed in two infants with umbilical artery catheters but in none of the infants with venous catheters. Embolic events were not observed. In this pilot study, which did not provide the sample size to assess any effect of rFVIIa on the incidence of IVH, 20% of the neonates went on to have grade III or IV IVH, which is similar to the rate in studies in which rFVIIa was not given.

Outcome of preterm and term neonates of mothers with malignant diseases diagnosed during pregnancy.

OBJECTIVE: To investigate the outcome of preterm and term neonates born to mothers with malignant diseases diagnosed during pregnancy. METHODS: A retrospective analysis with a matched-paired control group in a third level obstetric department and third level neonatal department of the University Hospital Frankfurt. Patients were preterm and term neonates from mothers with oncologic diseases diagnosed during pregnancy and matched-paired preterm and term neonates from healthy mothers. MEASUREMENTS AND RESULTS: Nineteen preterm and three term (1 x twins) neonates from 21 mothers with oncologic diseases and matched-paired neonates from 21 healthy mothers were included. With the exception of one case, pregnancy was terminated because of the necessity for maternal oncological treatment. Children from mothers with malignant diseases had a significantly lower birth weight and a tendency towards a higher incidence of high-grade respiratory distress syndrome. No significant differences concerning Apgar scores, red blood cell (RBC), white blood cell (WBC), and platelet (PLT) counts postpartum, and duration of hospital days between the two groups of neonates were observed. CONCLUSION: Direct perinatal outcome of preterm or term neonates from mothers with malignant diseases diagnosed during ongoing intact pregnancy does not differ from the outcome of a comparable group of neonates from healthy mothers. This might be in contrast to the long-term outcome of this special patient group. In our study we could find no elevated mortality in neonates where pregnancy was terminated because of the need for maternal chemotherapeutic therapy.

Group B streptococcus infections in neonates admitted to a German NICU: Emphasis on screening and adherence to pre-analytical recommendations.

BACKGROUND: Infections by group B streptococci (GBS), e.g. Streptococcus agalactiae, presenting as early-onset disease (EOD) or late-onset disease (LOD), are leading causes of severe infections in newborn and premature patients. Although screening and intra partum antibiotic prophylaxis are frequently performed, vertically transmitted GBS remain a challenge for pediatrics. AIMS: In order to prevent or reduce potential life-threatening events, this study retrospectively investigated epidemiological, microbiological and clinical aspects of infants admitted to the Division of Neonatology at the Department of Pediatrics at the University Hospital Frankfurt, Germany (UHF). STUDY DESIGN AND SUBJECTS: Between January 2010 and January 2016, perinatal GBS screening status, clinical presentation of EOD or LOD and therapeutic management of neonates admitted to UHF were retrospective analysed. Infants tested positive for GBS within their first three months of life were included; patient data were obtained from the chart report. Severity of neonatal disease was analysed by using the NEOMOD and CRIB score. RESULTS: 108 GBS infected infants born to 105 mothers were observed. N=101 of them (93.5%) presented with EOD, whereof n=9 (10%) primarily presented with pneumonia or pneumothorax. In 82 (78%) mothers of infected infants GBS status was unknown prior to hospitalization of the neonate. 3/108 (2.8%) infants died from GBS septicemia. CONCLUSION: Avoidance of GBS transmission sub partu is the key issue in preventing neonatal GBS infection and should be the focus of preventive strategies. Our results highlight the impact of perinatal screening.

Immune cell subsets at birth may help to predict risk of late-onset sepsis and necrotizing enterocolitis in preterm infants.

BACKGROUND: Parameters predicting late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) in preterm infants would be valuable. Ten-color flow-cytometry enables the estimation of cellular immune status requiring only small sample volumes. AIMS: Identifying predictive parameters for LOS and NEC in the cellular immune status of preterm infants. STUDY DESIGN AND SUBJECTS: In this prospective study in 40 preterm infants (week 26+0 to 30+6) and 10 healthy full-term newborn infants (control group, week 37+0 to 40+6), flow cytometric analyses of lymphocyte subpopulations were performed between the 2nd and the 6th day of life, with a follow-up until the preterm infant reached the calculated gestational age of week 40. Patients' episodes of infections and NEC were analyzed according to the NEO-KISS criteria of the German National Reference Center. RESULTS: Ten preterm infants showed events within the first week of life and were excluded from the analysis. Of the other 30, five developed NEC, twelve LOS. In patients with LOS, the proportion of double-negative (DN) T cells was significantly elevated compared to patients without LOS, while immune-regulatory CD56bright and CD56negCD16+ NK cells were significantly decreased (p<0.05). Patients with NEC showed a reduction in the NK cell proportion (<3.7%) and significantly decreased naïve cytotoxic CD45RA+CD62L+ T cells (p<0.05). CONCLUSION: NK cells and DN-T cell counts within the first week of life may be predictors for NEC and LOS in preterm infants. In order to identify patients at risk early, further analysis of these populations might be of interest.

Acute and subacute toxicity of the hydroalcoholic extract from Wedelia paludosa (Acmela brasiliensis) (Asteraceae) in mice.

PURPOSE: The present study was carried out to evaluated acute and subacute toxicity of a hydroalcoholic extract from aerial parts of Wedelia paludosa (Asteraceae). METHODS: Toxicity of W. paludosa was evaluated in Swiss mice after ingestions of the extract during one day (acute model) and during 15 days (subacute model). RESULTS: The results showed that the LD50 of the extract is higher than 4000 mg/kg and the subacute treatment did not shows any change in corporal weight and hematological parameters. However, a change in liver weight but not in hepatic enzymes was observed. This suggests that the liver function is not altered by Wedelia paludosa in this study. Some changes in the creatinine content were observed, but could not be related with the extract dose. CONCLUSIONS: The results suggest that the plant seems to be destituted of toxic effects in mice.

Life-threatening hemorrhage in neonates: management with recombinant activated factor VII.

OBJECTIVE: Massive hemorrhage with shock is a common problem for the intensivist. The use of recombinant activated factor VII (rFVIIa), known as efficient treatment for hemophilia, has been reported to control severe bleeding episodes in critically care patients, but never in preterm neonates. DESIGN: Case report (two cases) and review of the literature. SETTING: Neonatal intensive care unit, university teaching hospital. PATIENTS: Two preterm neonates with life-threatening hemorrhages, from the liver and spleen in one patient and from the lung in the other. INTERVENTION: Intravenous administration of 150/200 microg/kg of rFVIIa (Novoseven, NovoNordisk, Copenhagen, Denmark). MEASUREMENTS AND RESULTS: Complete hemostasis 10 min after the second bolus in the two patients. CONCLUSION: For the intensivist, the successful use of rFVIIa in these patients and others lacking pre-existing coagulopathies points to rFVIIa as a novel therapeutic approach for patients presenting with massive life-threatening hemorrhage.

Bacterial colonization of patients undergoing international air transport: a prospective epidemiologic study.

OBJECTIVE: To investigate the incidence of multiresistant bacteria in patients treated in foreign hospitals and repatriated by international interhospital air transport. METHODS: This was a prospective epidemiologic study on patients who were hospitalized in a foreign country and repatriated to a hospital in their home country by international aeromedical transport on scheduled airlines or ambulance jets. The study was carried out by the Department of Pediatrics, Department of Medical Microbiology, University Hospital Frankfurt, Germany, and MedCall Germany, the organizing company for repatriation. One hundred and three patients, who were hospitalized abroad, required repatriation by international interhospital air transport and met the entry criteria. RESULTS: Four hundred and eighty-three swabs from brow, nose, ear, throat, groin or axilla were taken from 103 patients, mean age 62 years. They were transported from southern and eastern European countries, Morocco, Egypt, Ghana, Tunisia, Pakistan, the United States and the Bahamas to destinations in Germany, the UK, Belgium, Switzerland, the United States and Japan. Forty-four patients were in an intensive care unit (ICU) for 6.5 days (median) prior to transport. Forty patients received antibiotics at the time of repatriation. Acinetobacter, Enterobacter, Pseudomonas, Proteus, Staphylococcus aureus and Candida were found. Methicillin-resistant Staphylococcus aureus (MRSA) was found in three patients (3%), ventilated for 17 days, and treated in the ICU for a median of 23 days. In 2 patients, multiresistant Acinetobacter baumanii and multiresistant Klebsiella pneumoniae were found. CONCLUSIONS: Bacterial colonization of patients undergoing international interhospital air transport does not differ from that of patients in a European hospital. Multiresistant bacteria, especially MRSA, were found only in ICU patients. There is no elevated risk of transmission of multiresistant bacteria in this patient group compared to other patients treated in hospital, especially in ICUs.