Candidiasis sistémica intrauterina y choque séptico en un neonato / Congenital intrauterine candida infection and septic shock in a newborn. A case report

Introducción. La infección sistémica intrauterina en el recién nacido debio a Candida albicans, se presenta con muy poca frecuencia en las unidades de cuidados intensivos neonatales. Debido a la gran diversidad de procedimientos a que son sometidos en forma invasiva, los neonatos presentan con una frecuencia mayor un cuadro clínico sugestivo de sepsis por C. Albicans aproximadamente después de la segunda semana de vida. Caso clínico. Se trata de recién nacido femenino pretérmino, de 29 semanas de edad gestacional, con peso al nacer de 950 g. Obtenido por parto eutócico, se describe en la historia perinatal con antecedente materno de control de la natalidad con dispositivo intrauterino y vulvovaginitis inespecífica. La recién nacida presentó cuadro clínico de sepsis con choque séptico inicial en fase temprana a las 19 horas de vida que la llevaron a su defunción, reportándose 48 horas después cultivos positivos: hemocultivo, cultivo de jugo gástrico, secreción bronquial y cotiledón placentario para C. albicans. Conclusiones. El diagnóstico de candidiasis sistémica intrauterina, en el período neonatal, sigue siendo tarea difícil a pesar de los adelantos recientes en métodos diagnósticos empleados

Relatedness of coagulase-negative staphylococci causing bacteremia in low-birthweight infants.

OBJECTIVE: To investigate coagulase-negative staphylococcus (CONS) causing bacteremia in a neonatal intensive care unit (NICU). DESIGN: A 14-month retrospective review of 47 infants in the NICU with CONS bacteremia was undertaken to determine CONS glycocalyx production, plasmid pattern, total DNA restriction fragment polymorphism, and clinical risk factors. RESULTS: The isolates included 32 Staphylococcus epidermidis, six Staphylococcus haemolyticus, four Staphylococcus warneri, four Staphylococcus saprophyticus, and one Staphylococcus hominis. Sixty-five percent of S epidermidis produced glycocalyx; other species did not. Oxacillin resistance (52%) and the antibiograms of the CONS were consistent with other units in the hospital. Five similar CONS plasmid patterns were found among 16 isolates; 31 isolates had unique patterns. Extractions of total DNA from these isolates were digested using HindIII, HaeIII, and BstEII. Those with similar restriction fragment length patterns could not linked as nosocomially transmitted among infants with bacteremia. CONCLUSION: Our observations suggest that multiple strains of CONS infect infants in the NICU who have similar risk factors. Although current infection control practices limit transmission of a pathogen, they do not prevent CONS bacteremias.

Prevention of gram-positive sepsis in neonates weighing less than 1500 grams.

A prospective, randomized study to evaluate the effectiveness of a continuous low-dose vancomycin infusion to prevent nosocomial gram-positive bacteremia was initiated within the first 2 weeks of life in neonates weighing < 1500 gm. Seventy-one infants received constant infusion of vancomycin (25 micrograms/ml) mixed with their total parenteral nutrition solution; 70 infants served as control subjects. The groups were clinically similar in birth weight, estimated gestational age, and severity of illness. Administration of vancomycin was begun at a mean age of 5.4 +/- 2.9 days. Infants had mean serum vancomycin concentrations of 2.4 micrograms/ml, and received vancomycin for a mean of 11 +/- 7 days. No vancomycin-resistant organisms were detected in surveillance cultures during the 2-year study period. Twenty-four of seventy control infants, in comparison with 1 of 71 infants receiving vancomycin, had gram-positive bacteremia (p < 0.001). The addition of a low dose of vancomycin to alimentation fluids virtually eliminated the incidence of gram-positive bacteremia in an at-risk population of very low birth weight infants. However, the widespread use of vancomycin in total parenteral nutrition solution is not recommended until better data on the emergence of vancomycin-resistant organisms are available.

Fungal gut colonization with Candida or Pityrosporum sp. and serum Candida antigen in preterm neonates with very low birth weights.

To evaluate the diagnostic value of gut colonization by yeasts and of candida antigen in serum for predicting fungal infection in very premature neonates, faecal and serum samples were obtained biweekly from 27 newborn babies treated at our neonatal intensive care unit. Altogether 82 sets of serum and faecal samples were obtained. 17 babies were followed for > or = 4 weeks. Blood cultures, both by routine and lysis centrifugation techniques, were performed for bacteria and fungi if infection was suspected. All children were given systemic broad-spectrum antibiotic treatment. Five of the children died, all without evidence of fungal infection. No systemic antifungal treatments were given. Quantitative faecal cultures demonstrated Candida albicans in 3 (11%) (10(3)-10(5) colony forming units/g) and Pityrosporum sp. in 8 (30%) of the preterm neonates. Candida antigen in titre 4 was detected in 1/82 serum samples. The child subsequently died with no other evidence of candida infection. In 56 full term neonates treated at the intensive care unit during the same period and tested by 1 set of samples, faecal colonization with Candida sp. was detected in 2 (4%) and with Pityrosporum sp. in 4 (15%). None were positive for candida antigen. Fungal gut colonization did not lead to clinical infection in the preterm neonates studied. The false positivity rate of the candida antigen test was low (0.7%). The predictive value of the test could not be determined in this study group with no systemic fungal infections. The role of pityrosporum as an inducer of neonatal infections remains to be evaluated.

Coagulase negative staphylococcal septicemia in newborns.

The case records of 2177 newborn infants admitted in the Neonatal Intensive Care Unit (NICU) from January, 1989, through July, 1990, with positive blood cultures for coagulase-negative staphylococci (C-NS) were evaluated. Seventy four (3.4%) neonates yielded C-NS in blood cultures during the study period. Of these, 58 (2.7%) infants had clinical and hematological features compatible with the diagnosis of septicemia. Remaining 16 babies with positive cultures had no evidence of sepsis, and were designated as "C-NS bacteremia". The age at which positive cultures were obtained differed between the bacteremic and septicemic groups. In bacteremic group, the onset occurred between one to four days of age. In contrast, in septicemic group the range was 6-20 days, with a mean of 10.22 (+/- 3.53) days. More than two third of total cases of C-NS sepsis were premature and low birth weight (LBW). Prominent clinical features included lethargy, poor feeding and fever. Besides this apneic spells were seen predominantly in babies weighing less than 1500 g. Further, before the diagnosis of C-NS sepsis, more than half of neonates had received prolonged intravenous fluid therapy, a quarter had undergone umbilical catheterization and a further quarter needed a ventilator support. Overall mortality in C-NS sepsis was 17.24%, distinctly higher in neonates with RDS and those requiring mechanical ventilation (p less than 0.05). Only 1.34% C-NS isolates were resistant to all routinely used antibiotics and sensitivity was maximum with newer cephalosporins, ciproflox and amikacin.

Incidence and etiology of neonatal septicaemia and meningitis in western Sweden 1975-1986.

In a retrospective study of neonatal septicaemia and meningitis in a defined region of western Sweden 1975-1986, 231 cases were identified. The incidence was 2.8/1000 live births. The case-fatality rate was 15%. thirty-three patients had meningitis. Only 55 patients (24%) had no known risk factors. Preterm delivery was a most important risk factor for both morbidity and mortality. The most common causative organisms were group B streptococci, Staphylococcus aureus and aerobic Gram-negative rods, together isolated from 82% of the patients. The cases were approximately equally divided between very early, early and late onset infections. Group B streptococci were over-represented in very early onset infections in all birthweight groups and aerobic Gram-negative rods were the most common isolates from low birthweight infants with late onset infections. However, group B streptococci, Staphylococcus aureus and Gram-negative rods were found in all birthweight and gestational age groups. Thus, initial antimicrobial therapy must be equally broad in all neonates with suspected septicaemia.

Relationship of maternal to neonatal colonization with coagulase-negative staphylococci.

Infections with coagulase-negative staphylococci (C-S) have become problems of major clinical importance among very low birthweight infants in neonatal intensive care units. Colonization with slime-producing strains of C-S may be a risk factor for these infants in the development of invasive infections. The present study evaluated the maternal genital tract as a possible source for neonatal colonization with C-S. Specific objectives were to determine the incidence of vaginal colonization with C-S in pregnant women with special reference to slime-producing strains and whether transmission of C-S occurs from mother to infant during the process of vaginal delivery. Antenatal vaginal cultures were done on 465 women at different gestations of pregnancy. Additionally, 101 women and their newborn infants were cultured after vaginal delivery. Fifty-one percent of women were colonized with C-S during pregnancy, and no significant differences in colonization rates by trimester were found. Slime-positive isolates from pregnant women increased significantly from the first to the third trimester (40 to 68%; chi-square, 11.21, p less than 0.005). However, the proportion of slime-positive strains among the 30 infants who were colonized with C-S at birth was 40% (12 of 30). Although 30 infants were colonized with C-S at birth, only three were shown to have acquired the organism by maternal transmission determined by similarity of species, biotype, antibiotic sensitivity pattern, slime production, phage type, and plasmid pattern profile. Therefore 27 infants (26% of the total) most likely acquired C-S from environmental sources, including nursery attendants.(ABSTRACT TRUNCATED AT 250 WORDS)

Routine lumbar punctures in the newborn--are they justified?

The records of 62,107 neonates cared for at three neonatal referral units between 1979 and 1985 were analysed with regard to the number of lumbar punctures (LP) performed and the results obtained. The mean perinatal mortality rate was 9.3/1000 live births and the neonatal mortality rate was 5.9/1000. The units were comparible in this respect. Two hundred and sixty three (0.4%) babies weighed less than 1.0 kg at birth and 510 (0.8%) babies weighed 1.0-1.5 kg. A total of 1554 LPs were performed on 1084 babies, 1.7% of the whole population. Seventeen babies were diagnosed as having meningitis following CSF examination; 5 weighed less than 1.5 kg (VLBW) (incidence of meningitis 6.5/1000 births) and 12 weighed more than 1.5 kg (incidence 0.2/1000 live births). An LP was performed on 44% of VLBW babies and 1.2% of babies weighing more than 1.5 kg. In both groups approximately 1.5% of CSF samples were positive. Eight of the 17 positive results were obtained during the first 3 postnatal days. Only one VLBW baby had meningitis on the 1st day of life (1.3/1000). In view of the low incidence of meningitis and the risk factors associated with an LP it is questionable whether this procedure should be a routine investigation in the VLBW newborn.

Coagulase negative staphylococcal septicemia in newborns.

A retrospective analysis of 254 newborns having blood cultures positive for coagulase negative staphylococci (CONS), and admitted in the neonatal unit of a Rural Medical College Hospital over a period of five years, was done for various clinical and perinatal characteristics as well as antimicrobial sensitivity profile of isolates. Of them, 118 (46.5%) neonates had clinical evidence of sepsis with CONS as the only growth in blood culture, and were designated as having CONS septicemia. Majority of them were delivered in this hospital itself and by normal vaginal delivery. Preterms and LBW babies constituted 23.7 and 59.4% of total cases, respectively. Other high risk perinatal factors for infection were present in 66.1% cases. Approximately two third of these cases developed sepsis within first three days of life. Early onset sepsis was more frequently seen in neonates with history of assisted delivery or perinatal asphyxia. Overall mortality in these cases was 15.6%, being significantly higher in offspring of outside deliveries and normal vaginal deliveries, in preterm and LBW babies and slightly higher in presence of birth asphyxia. Only 15.3% CONS isolates were resistant to all routinely used antibiotics and sensitivity was maximum with gentamicin followed by ampicillin. A difference in sensitivity pattern of CONS causing EOS and LOS was also recorded.

Candidiasis diseminada en prematuros: estudio anatomopatológico; clínico y micológico de 4 casos / Diseminated candidiasis in prematures: anatomopathological; clinical and micological study of 4 cases

Se describen 4 casos de infección diseminada por Candida albicans, en prematuros de entre 26 y 33 semanas de gestación, y entre 760 y 2.580 g de peso al nacer, inclusive. Todos presentaron signos clínicos de insuficiencia respiratoria y de septicemia. La necropsia demostró en todos ellos signos anatomopatológicos de hipoxia intensa, y en 3 casos evidencias morfológicas que indican a la mucosa gastrointestinal como puerta de entrada y diseminación micótica. La distribución de los organos comprometidos y la reacción inflamatoria tisular es semejante a la descrita en adultos, con y sin granulocitopenia

Prevention of transfusion-acquired cytomegalovirus infection in infants by blood filtration to remove leucocytes. Neonatal Cytomegalovirus Infection Study Group.

A multicentre, controlled trial was carried out to determine whether removal of leucocytes from blood by means of 'Imugard IG500' (Terumo) filters would prevent transfusion-acquired cytomegalovirus (CMV) infection in newborn infants. 72 infants whose mothers were seronegative and who received some seropositive blood were followed for 6 months for evidence of CMV infection. There were no significant differences between the groups who received filtered and unfiltered blood in median gestation, birthweight, or amount of seropositive blood received (median volume 32.5 ml and 34.5 ml, respectively). 9 (21%) of the 42 infants who received unfiltered blood and none of the 30 who received filtered blood were infected with CMV. All infected infants weighed less than 1500 g at birth; they represented 31% of very low birthweight (VLBW) infants at risk of CMV infection. None of 24 VLBW infants who received filtered seropositive blood was infected. 1 infected infant died and 5 had clinical features consistent with CMV infection. The results show that transfusion-acquired CMV infection is preventable by filtration of blood through a leucocyte filter. This method has advantages over other methods of removing leucocytes or the use of only seronegative blood for newborn infants.

Mucocutaneous and invasive candidiasis among very low birth weight (less than 1,500 grams) infants in intensive care nurseries: a prospective study.

To determine whether mucocutaneous candidiasis presages the development of invasive candidiasis and to assess factors influencing the development of mucocutaneous candidiasis and invasive candidiasis among infants requiring neonatal intensive care, all infants admitted to our neonatal intensive care unit during a 47-month period were prospectively examined twice weekly for mucocutaneous candidiasis. Because 16 of 18 (89%) infants in whom invasive candidiasis (defined by positive cultures of blood, CSF, deep tissue or greater than or equal to 2 supra-pubic urine aspirates) developed had birth weights less than 1,500 g, further analysis was focused toward the very low birth weight group. Of 358 very low birth weight infants hospitalized for less than three days and serially studied until discharge from the neonatal intensive care unit, mucocutaneous candidiasis developed in 28 (7.8%), invasive candidiasis developed in 16 (4.5%), and in 323 there was no evidence of mucocutaneous candidiasis or invasive candidiasis. Although many risk factors were shown by univariate analysis to be significantly more common among those with invasive candidiasis and mucocutaneous candidiasis, adjustment for the covariant effects of duration of hospitalization and gestational age revealed that only prolonged duration of antibiotic therapy and duration of endotracheal intubation were significantly associated with invasive candidiasis. Invasive candidiasis developed later in nine of 28 (32%) infants with mucocutaneous candidiasis despite nystatin therapy of mucocutaneous candidiasis in all nine (median duration of therapy before invasive candidiasis, nine days). Very low birth weight infants in whom mucocutaneous candidiasis develops are at significantly greater risk of invasive candidiasis developing later than those in whom mucocutaneous candidiasis did not develop (9/28 v 7/330, P less than .001).

Plasmid DNA analysis of Staphylococcus epidermidis isolated from blood and colonization cultures in very low birth weight neonates.

We prospectively studied the course of colonization and sepsis with Staphylococcus epidermidis among 29 very low birth weight neonates undergoing prolonged umbilical catheterization. S. epidermidis bacteremia occurred in 7 patients. In 6 bacteremia was preceded by positive colonization cultures. Isolates obtained from nares, base of umbilicus, umbilical catheter entry sites, catheter tips and blood were examined for plasmid DNA profiles. In 4 patients the plasmid profiles of the catheter entry site isolates were identical with those of the blood isolates. In the other 3 bacteremic patients plasmid profiles of the catheter entry site and blood isolates were different. No correlation was observed in the plasmid DNA patterns of isolates obtained from catheter tip cultures as compared to the corresponding blood cultures. The blood isolates from bacteremic patients had different plasmid profiles.

Prophylactic oral nystatin and fungal infections in very-low-birthweight infants.

Prevention of systemic fungal infection in the very-low-birthweight infant is important since it is associated with a high morbidity and mortality. To determine if oral nystatin administration could prevent fungal colonization and infection, we evaluated 67 preterm infants with birthweights less than 1250 gm. Thirty-three infants received 1 ml (100,000 units/ml) of nystatin inside the mouth every 8 hours until 1 week after extubation. Oropharyngeal, rectal, blood, and urine cultures were obtained on the 1st day of life and weekly. Endotracheal cultures were obtained three times a week from intubated infants. Four (12%) of the 33 nystatin-treated infants had positive cultures, two (6%) developed systemic infection. The control group consisted of 34 infants, 15 (44%) had positive fungal cultures and 11 (32%) developed systemic infection. Fungi isolated were Candida species and Torulopsis glabrata. Colonized infants were dependent on the respirator (P less than 0.001), had indwelling catheters (P less than 0.01), and received antibiotics (P less than 0.05) for a longer period than infants free from fungi and their mortality was significantly higher (P less than 0.05). We conclude that prophylactic administration of oral nystatin reduces fungal colonization and infection in very-low-birthweight infants.

Neonatal rotavirus infection and its relation to cord blood antibodies.

Among 274 neonates born at the maternity services of an urban hospital in India, 36.1% of the infants shed rotavirus in feces (as detected by ELISA) by 72 h of life. The excretion rate increased to 70.3% among the 120 infants who stayed for 5 days or more at the hospital. Diarrhoeal symptoms of mild and self-limited nature were observed only in 19.2% of the rotavirus excretors, the remaining being asymptomatic. Among the 98 infants who received supplement feeds, 49% acquired rotavirus infection as against 24.7% of the 150 exclusively breast fed infants (p less than 0.001). Viral RNA in the feces of all rota positive infants showed the same electropherotype, indicating infection from a common source. The mean percentage rotavirus inhibitory activity of cord sera in the infected and non-infected infants was 50.2 +/- 21.7 and 56.6 +/- 19.2 respectively (p greater than 0.05), suggesting that cord blood antibodies do not offer significant protection against neonatal rotavirus infection.