Intubation Attempts Increase the Risk for Severe Intraventricular Hemorrhage in Preterm Infants-A Retrospective Cohort Study.

OBJECTIVE: To evaluate whether neonates exposed to multiple intubation attempts within the first 4 days after birth have an increased incidence of intraventricular hemorrhage (IVH). STUDY DESIGN: This is a retrospective cohort study of infants intubated during the first 4 days after birth. Infants had birth weights (BWs) less than 1500 g and were admitted to the neonatal intensive care unit (NICU) at the University of California, San Diego, between January 1, 2005, and July 30, 2009. A subgroup analysis was done for infants with BW less than 750 g. RESULTS: A total of 308 infants with BW <1500 g, including 102 with a BW <750 g, were intubated within the first 4 days of life. The number of intubation attempts was significantly greater in infants with a BW <750 g who had severe IVH compared with those with mild or no IVH (OR 1.395, 95% CI 1.090-1.786, P = .008). For infants with BW <1500 g, the number of intubation attempts in the delivery room was significantly greater for infants with severe IVH (OR 1.317, 95% CI 1.052-1.649, P = .016). CONCLUSION: Increased intubation attempts were associated with increased incidence of severe IVH in infants with BW less than 750 g and in infants less than 1500 g who were intubated only in the delivery room. Prospective studies are needed to further evaluate the relationship between intubation attempts and severe IVH.

Difficulties in demonstrating superiority of an antibiotic for multidrug-resistant bacteria in nonrandomized studies.

The discovery and development of new antimicrobials is critically important, especially as multidrug-resistant bacteria continue to emerge. Little has been written about the epidemiological issues in nonrandomized trials aiming to evaluate the superiority of one antibiotic over another. In this manuscript, we outline some of the methodological difficulties in demonstrating superiority and discuss potential approaches to these problems. Many of the difficulties arise due to confounding by indication, which we define and explain. Epidemiological methods including restriction, matching, stratification, multivariable regression, propensity scores, and instrumental variables are discussed.

Comparative genomics of an IncA/C multidrug resistance plasmid from Escherichia coli and Klebsiella isolates from intensive care unit patients and the utility of whole-genome sequencing in health care settings.

The IncA/C plasmids have been implicated for their role in the dissemination of ß-lactamases, including gene variants that confer resistance to expanded-spectrum cephalosporins, which are often the treatment of last resort against multidrug-resistant, hospital-associated pathogens. A bla(FOX-5) gene was detected in 14 Escherichia coli and 16 Klebsiella isolates that were cultured from perianal swabs of patients admitted to an intensive care unit (ICU) of the University of Maryland Medical Center (UMMC) in Baltimore, MD, over a span of 3 years. Four of the FOX-encoding isolates were obtained from subsequent samples of patients that were initially negative for an AmpC ß-lactamase upon admission to the ICU, suggesting that the AmpC ß-lactamase-encoding plasmid was acquired while the patient was in the ICU. The genomes of five E. coli isolates and six Klebsiella isolates containing bla(FOX-5) were selected for sequencing based on their plasmid profiles. An ∼ 167-kb IncA/C plasmid encoding the FOX-5 ß-lactamase, a CARB-2 ß-lactamase, additional antimicrobial resistance genes, and heavy metal resistance genes was identified. Another FOX-5-encoding IncA/C plasmid that was nearly identical except for a variable region associated with the resistance genes was also identified. To our knowledge, these plasmids represent the first FOX-5-encoding plasmids sequenced. We used comparative genomics to describe the genetic diversity of a plasmid encoding a FOX-5 ß-lactamase relative to the whole-genome diversity of 11 E. coli and Klebsiella isolates that carry this plasmid. Our findings demonstrate the utility of whole-genome sequencing for tracking of plasmid and antibiotic resistance gene distribution in health care settings.

Frequent contamination of nursing scrubs is associated with specific care activities.

BACKGROUND: The objective of this article is to assess health care worker (HCW) and patient care factors associated with bacterial contamination of scrubs. METHODS: We performed a cohort study of critical care HCWs. Participants were given 4 sets of new scrubs; each set was sampled 8 times during the 8-month study period on random days in the last 4 hours of the shift. Total colony counts and presence of prespecified pathogenic bacteria were assessed. Generalized estimating equation was used to identify factors associated with contamination. RESULTS: There were 720 samples obtained from 90 HCWs; 30% of samples were contaminated with pathogenic bacteria. Multivariate analysis showed that providing care for patients with wounds (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.17-2.62; P < .01) or giving a bath (OR, 1.46; 95% CI, 0.96-2.22; P = .07) was associated with higher odds of scrub contamination. A second model showed the average log colony count of bacterial contamination of scrubs was higher when a bath was given (log colony count difference, 0.21; P = .05) but lower among HCWs assigned to care for at least 1 patient on contact precautions (log colony count difference, 0.28; P < .01). CONCLUSIONS: HCW attire was frequently contaminated with bacteria. Providing care for patients with wounds or giving a bath were associated with scrub contamination by pathogenic bacteria. However, the amount of contamination was lower among HCWs who were assigned to care for patients on contact precautions.

Heliox Adjunct Therapy for Neonates With Congenital Diaphragmatic Hernia.

BACKGROUND: Congenital diaphragmatic hernia remains a complex disease with significant morbidity and mortality. Hypercarbia is a common derangement in this population, which often requires escalating ventilator support. By decreasing airway turbulence and enhancing CO2 removal, inhaled helium-oxygen mixture (heliox) has the potential to improve ventilation and thereby decrease ventilator support and its associated lung injury. METHODS: Retrospective cohort review of all neonates with congenital diaphragmatic hernia treated at Rady Children's Hospital San Diego during 2011-2015. Clinical characteristics were compared between the infants who were treated with heliox and those who did not receive this intervention. To analyze the effect of heliox in the subgroup that received this treatment, ventilator settings and arterial blood gas values were compared before and after starting heliox by using paired t tests. RESULTS: During the study period, 45 neonates with congenital diaphragmatic hernia were admitted to our neonatal ICU, 28 received heliox, and 27 were analyzed. During heliox treatment, PaCO2 levels decreased from 68 to 49 mm Hg (P < .001), amplitude decreased from 33 to 23 cm H2O (P < .001), ventilator frequency decreased from 28 to 23 breaths/min (P = .02), FIO2 decreased from 0.52 to 0.40 (P < .01), and pH increased from 7.3 to 7.4 (P < .001). CONCLUSIONS: The addition of heliox to the standard practice of permissive hypercapnia facilitated improvement in gas exchange, which allowed a decrease in ventilator settings and oxygen exposure, both of which are known to contribute to lung injury in this population. A prospective trial is needed to more clearly define the acute and long-term impacts of this treatment.

Wide Variability in Caloric Density of Expressed Human Milk Can Lead to Major Underestimation or Overestimation of Nutrient Content.

BACKGROUND: Very-low-birth-weight infants continue to face significant difficulties with postnatal growth. Human milk is the optimal form of nutrition for infants but may exhibit variation in nutrient content. OBJECTIVE: This study aimed to perform macronutrient analysis on expressed human milk from mothers whose babies are hospitalized in the neonatal intensive care unit. METHODS: Up to five human milk samples per participant were analyzed for protein, carbohydrate, and fat content using reference chemical analyses (Kjeldahl for protein, high pressure liquid chromatography for carbohydrates, and Mojonnier for fat). Calorie content was calculated. RESULTS: A total of 64 samples from 24 participants was analyzed. Wide variability was found in calorie, protein, carbohydrate, and fat composition. The authors found an average of 17.9 kcal/ounce, with only 34% of samples falling within 10% of the expected caloric density. CONCLUSION: The assumption that human milk contains 20 kcal/ounce is no longer supported based on this study. This supports promoting an individualized nutrition strategy as a crucial aspect to optimal nutrition.

Inadvertent Methylergonovine Administration to a Neonate.

BACKGROUND Methylergonovine is an ergot alkaloid used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergonovine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, seizures, and death. CASE REPORT A term infant was inadvertently given 0.1 mg of methylergonovine intramuscularly in the right thigh. The error was only noted when the vial of medication was scanned, after administration, identifying it as methylergonovine rather than vitamin K. The local poison center was notified, and the infant was transferred to the neonatal intensive care unit for observation. Two hours after transfer, the infant was noted to have oxygen desaturations and required oxygen via nasal cannula. Supplemental oxygen was continued for 4 hours until the neonate was able to maintain normal oxygen saturations in room air. Feeding was started by 10 hours of life, and the infant was discharged home in good condition after a 72-hour stay without further complications. CONCLUSIONS Because of the potential for serious adverse events, vigilance is required to prevent accidental administration of methylergonovine to the neonate as a result of possible confusion with vitamin K in the early post-partum period.

Delivery Room Quality Improvement Project Improved Compliance with Best Practices for a Community NICU.

A Quality Improvement bundle was implemented with the goal of standardizing the multidisciplinary approach to delivery room management. We used a Pre-Post Quality Improvement initiative with the following aims: (1) Placement of a functioning pulse oximeter by two minutes after birth, (2) Delayed intubation, (3) Normothermia on Neonatal Intensive Care Unit Admission, (4) Use of a pre-brief, debrief, and delivery room checklist. Data was collected for 548 infants, which represents every admission to the Palomar Rady Children's Hospital Neonatal Intensive Care Unit during the 35 month study period from January 1, 2010 to November 30, 2012. The intervention began on May 1, 2011. The objective of increasing the frequency of each goal was met. A significant decrease in rates of retinopathy of prematurity in our post-intervention group was found. Odds ratio 0.00 (0.000, 0.696) p = 0.008. However, this was not confirmed in the multivariable analysis so should be interpreted with caution. This quality improvement project had a positive effect on newborn resuscitation at Palomar Medical Center.

A randomized crossover trial to decrease bacterial contamination on hospital scrubs.

Healthcare worker attire may become contaminated with pathogenic organisms during a normal shift. We performed a randomized crossover study to assess whether treatment with an antimicrobial coating would decrease bacterial contamination on scrubs. Thirty percent of all scrubs were contaminated; there was no difference in the rate of contamination between the intervention and control groups.