Fluconazole prophylaxis against fungal colonization and infection in preterm infants.

BACKGROUND: Invasive fungal infection is associated with substantial morbidity and mortality in preterm infants. We evaluated the efficacy of prophylactic fluconazole in preventing fungal colonization and invasive infection in extremely-low-birth-weight infants. METHODS: We conducted a prospective, randomized, double-blind clinical trial over a 30-month period in 100 preterm infants with birth weights of less than 1000 g. The infants were randomly assigned during the first five days of life to receive either intravenous fluconazole or placebo for six weeks. We obtained weekly surveillance cultures from all patients. RESULTS: The 50 infants randomly assigned to fluconazole and the 50 control infants were similar in terms of birth weight, gestational age at birth, and base-line risk factors for fungal infection. During the six-week treatment period, fungal colonization was documented in 30 infants in the placebo group (60 percent) and 11 infants in the fluconazole group (22 percent; difference in risk, 0.38; 95 percent confidence interval, 0.18 to 0.56; P=0.002). Invasive fungal infection with positive growth of fungal isolates from the blood, urine, or cerebrospinal fluid developed in 10 infants in the placebo group (20 percent) and none of the infants in the fluconazole group (difference in risk, 0.20; 95 percent confidence interval, 0.04 to 0.36; P=0.008). The sensitivities of the fungal isolates to fluconazole did not change during the study, and no adverse effects of the fluconazole therapy were documented. CONCLUSIONS: Prophylactic administration of fluconazole during the first six weeks of life is effective in preventing fungal colonization and invasive fungal infection in infants with birth weights of less than 1000 g.

Alteration of normal gastric flora in neonates receiving ranitidine.

OBJECTIVES: To determine if the administration of ranitidine to neonates leads to an increase in gastric pH to > or = 4 and if this increase in gastric pH correlates with gastric colonization. STUDY DESIGN: 628 pH measurements and 276 gastric cultures were obtained from 86 neonates. Twenty-three patients received ranitidine and 63 patients served as controls. RESULTS: Treated patients had a mean gastric pH of 5.6 compared with a control mean pH of 4.4 (p < 0.0001). Gastric pH was significantly affected by feeding and postnatal age. 54 patients were colonized with pathogenic bacteria and/or yeast (n = 20 treated, n = 34 control). Length of hospitalization (p < 0.0001), increase in gastric pH (p < 0.01), days of antibiotics before culture (p < 0.0001), and ranitidine use (p < 0.0001) were associated with an increased rate of colonization. CONCLUSIONS: The use of ranitidine did lead to a significant increase in gastric pH and with this increase in gastric pH gastric colonization rates increased. No increased frequency of infection was found in ranitidine-treated infants.

Intravascular catheter colonization in critically ill children.

In a prospective study, cultures were obtained of all intravascular catheters removed from children in an intensive care unit. Of 366 catheters removed from 217 children, 110 (30%) were found to be colonized, most commonly with coagulase-negative staphylococci. Despite the high rate of colonization, there were only nine instances (2%) of catheter-related bacteremia.

Vertical and horizontal transmission of unique Candida species to premature newborns.

The number of nosocomial bloodstream infections due to Candida species in critically ill newborns is increasing. This pathogen may be vertically transmitted from the mother or nosocomially acquired in the nursery. The goal of this study was to identify the route of transmission of unique Candida species and strains from mothers to their preterm offspring. Specimens from mothers for fungal cultures were obtained before delivery, and specimens from infants for sequential fungal cultures were obtained at defined intervals. Candida species were identified by standard methods and were typed by electrophoretic karyotyping (EK) and restriction endonuclease analysis of genomic DNA (REAG) with pulsed-field gel electrophoresis. Antifungal susceptibility testing was performed on all isolates. Fungal cultures were positive for Candida species in 12 (63%) of 19 mothers' specimens and in seven (33%) of 21 infants' specimens. EK and REAG revealed that both the mother and the infant in three (14%) of 21 mother-infant pairs were colonized with the identical strain of Candida albicans. C. albicans was most commonly transmitted vertically. Candida parapsilosis colonized other infants and could not be accounted for by a maternal reservoir.

The emergence of Haemophilus influenzae types e and f as significant pathogens.

Non-type b encapsulated Haemophilus influenzae meningitis (two cases due to H. influenzae type e, two due to H. influenzae type f) was diagnosed in four children in a 6-month period at the University of Virginia. H. influenzae type b was the most common cause of bacterial meningitis in the United States before the introduction of an effective vaccine, whereas the other five encapsulated serotypes of H. influenzae rarely caused invasive disease. The clinical features of non-type b H. influenzae meningitis and the therapy for this infection are the same as those for type b H. influenzae disease. We report these four cases to document an increase in infection due to non-type b serotypes of H. influenzae, and we postulate that this change may result from the well-documented decrease in H. influenzae type b oropharyngeal carriage and disease that has occurred because of universal vaccination for H. influenzae type b.

Short-course amphotericin B therapy for candidemia in pediatric patients.

OBJECTIVE: To determine the efficacy of short-course (7 to 14 days of therapy after the last positive blood culture) amphotericin B therapy for candidemia in children. DESIGN: Case series. SETTING: Tertiary care university medical center in Virginia. PATIENTS: Thirty patients younger than 17 years of age who had candidemia between 1983 and 1990. MEASUREMENTS AND RESULTS: The charts of 30 children with 31 episodes of candidemia were retrospectively reviewed for patient data, dates of positive and negative cultures for Candida from blood and other sites, dates of removal of the intravascular catheters, duration and dosage of amphotericin B administration, and outcome. Eight patients had persistent candidemia and died. Five patients were treated not in accordance with the short-course recommendations. Two had relapses; 1 was cured with catheter removal alone, and 2 were successfully treated with 26 and 30 days of amphotericin B therapy. Eighteen episodes (two episodes in 1 patient) of candidemia were cured using 7 to 14 days of amphotericin B therapy after the last positive blood culture. CONCLUSIONS: Once the bloodstream is sterilized, and there is no other evidence of invasive fungal disease, 7 to 14 additional days of amphotericin B at a dose of 0.5 mg/kg per day seems adequate for treatment of candidemia in children.

Defining unnecessary disinfection procedures for single-dose and multiple-dose vials.

BACKGROUND: Recommendations in the literature conflict on the necessity of disinfecting single-use vials prior to aspiration of fluid. Interventions to disinfect the stopper surface on multiple-dose vials vary considerably. OBJECTIVES: To determine the necessity of alcohol disinfection of the stopper on single-dose vials and to compare povidone-iodine and alcohol versus alcohol-only disinfection of the stopper prior to each needle penetration on multiple-dose vials. METHODS: The rubber stopper surfaces of 100 single-dose vials were cultured for the presence of bacteria. To determine the efficacy of two procedures for disinfection of multiple-dose vials, 87 stopper surfaces routinely disinfected with both povidone-iodine and alcohol were cultured for bacteria. After a change in practice, 100 multiple-dose vials routinely disinfected with alcohol only were cultured for the presence of bacteria. RESULTS: Of the cultures done on single-dose vial stoppers, 99% were sterile. A comparison of the two disinfection techniques for multiple-dose vials revealed that 83 (95%) of the 87 vials prepped with both povidone-iodine and alcohol were sterile, compared with all stoppers disinfected with alcohol only. CONCLUSIONS: This study shows the lack of necessity of any disinfection procedure on the rubber stopper of single-dose vials and the efficacy of alcohol only for disinfecting the stopper of multiple-dose vials.

Hospital-acquired urinary tract infections in the pediatric patient: a prospective study.

To determine through a prospective study the characteristics of hospital-acquired urinary tract infections (HAUTI) in children, 525 children subjected to bladder catheterization during a hospital admission were identified through surveillance of 12,316 admissions during a 24-month period. Urine culture results were available for 296 (56.4%) of the catheterized patients. In addition 12 noncatheterized children with a documented HAUTI were identified. The clinical courses of all patients with a HAUTI were followed for at least 6 months after their last HAUTI during the study period. Forty-four patients, 1 week to 17 years of age, with 1 or more HAUTI during a hospital unit admission were identified. A total of 51 HAUTI occurred. Thirty-nine (76.5%) of the infections occurred in patients subjected to catheterization. Thirty-two (10.8%) of 296 catheterized patients developed a HAUTI. Forty-three (84.3%) of the 51 infections were single organism infections. One HAUTI was associated with a wound infection with the same organism and one with a concurrent bacteremia with the same organism. Relapses were seen after 4 HAUTI. One reinfection was identified. There were no deaths directly associated with a HAUTI. Hospitalized children subjected to urinary tract catheterization are at significant risk for HAUTI. Complications are infrequent and not life-threatening.

Paecilomyces lilacinus infection in a child with chronic granulomatous disease.

Chronic granulomatous disease (CGD) is a rare inherited disorder in which neutrophils do not appropriately generate cytotoxic superoxide anion, the respiratory burst, in response to invading bacteria or fungi as a part of normal host defence. We report the case of a child with CGD who had two abdominal wall abscesses caused by Paecilomyces lilacinus, an organism not previously known to cause infections in patients with CGD. The abdominal wall is a location that is rarely associated with Paecilomyces infections. Parenteral amphotericin B eradicated the infection in an immunocompromised child whereas this regimen has heretofore largely been unsuccessful in the treatment of this infection. Paecilomyces species and other fungi from immunocompromised hosts and thought to be laboratory contaminants, need to be carefully investigated for they may become pathogens in this clinical setting.

Hand washing in pediatric ambulatory settings. An inconsistent practice.

The first phase of this study was performed to determine the rate of breaks in hand washing technique by physicians in two pediatric ambulatory settings and to determine whether this technique was influenced by the physician's level of training. The second phase was performed to determine if reminding physicians to wash their hands would decrease the rate of breaks. A hand washing break in technique was defined as not washing hands before patient contact. The observations were made by medical students accompanying the providers. In the 496 encounters during the first phase, 254 breaks (51.2%) occurred. In the 293 encounters during the second phase, 150 (51.2%) breaks occurred. During both phases, the rates of hand washing breaks among the four groups of providers (residents in postgraduate years 1 through 3 and faculty) were similar. Breaks in hand washing technique occur at an unacceptably high rate in outpatient settings.

Changing the needle when inoculating blood cultures. A no-benefit and high-risk procedure.

Although the Centers for Disease Control recommends that needles should never be recapped, many phlebotomists routinely recap and change needles before blood culture inoculation. This study compared the extrinsic contamination rate in blood cultures when the needle was and was not changed. One hundred eight medical students obtained 182 blood specimens from each other by means of standard methods. Each specimen was inoculated into two culture bottles. The first bottle was inoculated with the needle used for phlebotomy, and the second was inoculated after needle change. Four (2.2%) of 182 bottles were contaminated when the needle was not changed, compared with one (0.6%) when the needle was changed. This small difference was not statistically significant, and the likelihood of having failed to detect a 5% difference in contamination rate was small. The risk of needle-stick injury incurred by changing the needle before inoculation of blood culture bottles seems to be unjustified.

Intravascular catheter colonization and related bloodstream infection in critically ill neonates.

Intravascular catheter tip colonization was prospectively evaluated in critically ill neonates to determine its relationship to the type of device used, duration of catheterization, insertion site and nosocomial bloodstream infection. Sixty-one percent (376 of 621) of all intravascular catheter tips were retrieved from 91 infants. Thirteen percent (41 of 310) of peripheral intravenous, 14% (6 of 42) of umbilical, 21% (3 of 11) of central venous, 36% (4 of 11) of peripheral arterial and 100% (2 of 2) of femoral catheters were colonized. Duration of catheterization was significantly longer for colonized lines (p less than .001). Eight of 26 (30.8%) peripheral intravenous catheters remaining in place for more than three days were colonized, compared with 33 of 284 (11.6%) at three days or less (p = 0.012). Coagulase-negative staphylococcus was the organism most frequently isolated from catheter tips and bloodstream infections. Catheter colonization rates in this population were higher than those found in adults. Heavily manipulated devices and those in place for longer periods of time were the most frequently colonized.

The high rate of blood donor exposure for critically ill neonates.

The purpose of this study was to determine the number and volume of red blood cell (RBC) transfusions and the number of donors a newborn is exposed to during his or her newborn intensive care unit (NICU) stay. On one day at the Medical University of South Carolina (MUSC) and two days at the University of Virginia Hospital (UVH) all babies who had or were receiving RBCs comprised the study group. Patient records were reviewed at discharge. Fifty-two (70%) of the 75 NICU babies had or were receiving RBCs and were enrolled. The average number of RBC transfusions was nine (range 1 to 28, median 7) and the average transfusion volume was 16.5 ml (range 5 to 60) for a total volume of 148 ml transfused during a NICU stay. Each baby was exposed to an average of 6.9 donors (range 1 to 25, median 6.5). The practice of splitting RBC packs to share among different infants and of giving multiple small volume transfusions maximizes donor exposure and transfusion-related infectious risks in this population.