Challenges and opportunities in neonatal sepsis management: insights from a survey among clinicians in 25 Sub-Saharan African countries.

BACKGROUND: Neonatal sepsis (NS) is a global health issue, particularly in Sub-Saharan Africa, where it accounts for a substantial portion of neonatal morbimortality. This multicountry survey aimed to elucidate current practices, challenges and case definitions in managing NS among clinicians in Sub-Saharan Africa. METHODS: The survey targeted physicians and medical practitioners working in neonatal care who participated in a Self-Administered Web Questionnaire. The main objective was to understand NS and infection case definitions and management from the clinician's point of view and to identify challenges and opportunities in sepsis management. Participants were queried on demographics, definitions and diagnostic criteria, treatment approaches, and infection prevention and control (IPC) measures. A total of 136 participants from 93 healthcare structures responded, providing valuable insights into NS management practices. RESULTS: From May to July 2022 across 21 Sub-Saharan African countries, 136 neonatal clinicians with an average from 93 structures with on average 10-year experience took the survey. NS ranked highest among prevalent neonatal conditions. Diagnostic case definitions between sepsis and infection were attributed to clinical signs, anamnesis, C reactive protein, white blood cll count and blood cultures with no statistically significant differences. Early-onset sepsis was defined within 72 hours by 48%, while late-onset varied. Antibiotics were likely on admission (86.4%) and during the stay (82.2%). Treatment abandonment was reported unlikely. The preferred antibiotic regimen for early-onset sepsis was intravenous amoxicillin (or ampicillin), gentamycin and cefotaxime. Blood culture availability and IPC protocols were reported as limited, particularly concerning patient environment, pharmacy protocols and clean-dirty circuits. CONCLUSIONS: This NS survey emphasises clinicians' challenges due to limited access to diagnostic tools and raises concerns about antimicrobial overexposure. IPC also seem limited, according to participants. Addressing these challenges can enhance diagnostic practices, antibiotic stewardship and infection control in the region.

Clinical Utility of Procalcitonin and C-Reactive Protein in the Management of Neonatal Sepsis in a Resource-Limited Nigerian Hospital.

BACKGROUND: Neonatal sepsis is an invasive infection of the bloodstream in neonates and a leading cause of morbidity and mortality among them. AIM: To investigate the role of procalcitonin (PCT) and C-reactive protein (CRP) in the management of neonatal sepsis. MATERIALS AND METHODS: This was a prospective case-control study over one-year period using convenience sampling. Blood samples for PCT and CRP were taken from all neonates, while blood culture and white blood cell count samples were additionally taken from babies with neonatal sepsis. PCT and CRP were repeated at 24 and 48 hours. The continuous variables were found to have a nonparametric distribution. They were presented as median and interquartile range, and compared using Wilcoxon signed rank and Friedman test as appropriate. RESULTS: The blood culture analysis yielded a prevalence of 12.7% with Staphylococcus aureus being the commonest organism. Baseline concentrations of PCT (1.28 ng/ml) and CRP (17.31 mg/L) in neonates with sepsis were higher than that of controls (PCT-0.63 ng/ml, CRP-5.40 mg/L). PCT concentrations decreased after two days of antibiotic treatment, while CRP concentrations decreased after a day. The concentration of both decreased to normal levels after two days of treatment. CONCLUSION: This study showed that CRP was more reliable in monitoring antibiotic therapy, unlike other studies which suggested PCT. In cases where the management of neonatal sepsis may be limited by a low blood culture yield, therapeutic monitoring may be aided by CRP and/or PCT.

Prevalencia de sepsis neonatal confirmada microbiológicamente en una maternidad de la Ciudad Autó noma de Buenos Aires / Prevalence of microbiologically confirmed neonatal sepsis at a maternity center in the City of Buenos Aires

Introducción. En neonatos internados es frecuente sospechar sepsis neonatal, pero solo en el 25 % al 30 % se confirma con cultivos positivos. La selección del esquema antibiótico basándose en la epidemiología local favorece el uso racional y minimiza sus efectos colaterales. Objetivo primario. Describir la prevalencia de sepsis precoz y tardía con rescate microbiológico y sus características clínicas. Población y método. Estudio transversal retrospectivo, realizado del 1 de enero de 2013 al 31 de diciembre de 2017, en una maternidad pública de Argentina, que incluyó todos los recién nacidos internados en la unidad con diagnóstico de sepsis precoz y tardía con rescate microbiológico, y aquellos reingresados dentro del mes de vida. Resultados. Ingresaron 3322 recién nacidos, 1296 evaluados por sospecha de sepsis precoz, cultivos positivos en 25 (1,9 %; tasa: 0,86 ‰). El 52 % eran menores de 33 semanas de edad gestacional. Microorganismos: Escherichia coli 5, Listeria monocytogenes 4, Streptococcus agalactiae (SGB) 3, Streptococcus pneumoniae 3. Sepsis tardía (tasa 8,73 ‰), el 68 % ocurridas en menores de 33 semanas. Microorganismos intrahospitalarios: Staphylococcus coagulasa negativos 115, Staphylococcus aureus 47, Escherichia coli 30, Cándida spp. 16, Enterococcus faecalis 13, Klebsiella pneumoniae 11 y Streptococcus agalactiae 10. En los reingresos: E. coli 11, S. aureus 12, SGB 3 y Haemophilus influenzae 3. Conclusiones. Se observa en el período estudiado una frecuencia de sepsis precoz similar a los reportes internacionales, con predominio de E. coli y L. monocytogenes. La tasa de sepsis tardía presentó una tendencia descendente en los años analizados, con predominio de los cocos grampositivos

Introduction. Neonatal sepsis is often suspected in hospitalized newborn infants, but only in 25­30% of cases it is confirmed via a positive culture. Selecting the antibiotics based on local epidemiology favors their rational use and minimizes their side effects. Primary objective. To describe the prevalence of early- and late-onset sepsis with microorganism isolation and their clinical characteristics. Population and method. Retrospective, cross-sectional study conducted between 01-01-2013 and 12-31-2017 in a public maternity center of Argentina in all hospitalized newborn infants with a diagnosis of early- and late-onset sepsis with microorganism isolation, and those re-admitted in their first month of life. Results. A total of 3322 newborn infants were admitted; 1296 were assessed for suspected early- onset sepsis; 25 had a positive culture (1.9%; rate: 0.86‰). Of these, 52% were born before 33 weeks of gestation. Microorganisms: Escherichia coli 5, Listeria monocytogenes 4, Streptococcus agalactiae (SGB) 3, Streptococcus pneumoniae 3. Also, 68% of late-onset sepsis cases (rate: 8.73‰) occurred in infants born before 33 weeks of gestation. Hospital-acquired microorganisms: coagulase-negative Staphylococcus 115, Staphylococcus aureus 47, Escherichia coli 30, Candida spp. 16, Enterococcus faecalis 13, Klebsiella pneumoniae 11, and Streptococcus agalactiae 10. In re-admissions: E. coli 11, S. aureus 12, SGB 3, and Haemophilus influenzae 3. Conclusions. During the study period, the frequency of early-onset sepsis was similar to international reports, with a predominance of E. coli and L. monocytogenes. The rate of late-onset sepsis showed a downward trend in the analyzed years, with a predominance of Gram-positive cocci.

Neonatal sepsis and Kawasaki disease.

The purpose of this study is to clarify the relationship between neonatal sepsis and future development of Kawasaki disease (KD). We analyzed data from the National Hospital Organization Neonatal Intensive Care Unit (NHO-NICU) registry study in Japan. Participants in this study were children with a history of hospitalization in the NICU at the participating institutions from 2010 to 2014. A questionnaire was administered at age 3 years to obtain information about the patient's history of KD. There were 8275 infants who were eligible for this study. At 3 years of age, parents of 2161 children responded to the follow-up survey (follow-up rate, 26.1%). Multivariate logistic regression analysis adjusted for preterm birth, sex, use of antibiotics in the NICU, parity, and maternal smoking showed that children with neonatal sepsis were more likely to have a history of KD at 3 years of age (adjusted odds ratio [aOR]: 11.67, 95% confidence interval [CI]: 2.84-47.96). CONCLUSIONS: Among infants admitted to the NICU, neonatal sepsis might be associated with development of KD later in life. Further large studies are needed to elucidate the relationship between neonatal infections and KD development. WHAT IS KNOWN: • Preterm birth is known to be a risk factor for Kawasaki disease. •It is not yet known which factors related to preterm birth increase the risk of developing Kawasaki disease. WHAT IS NEW: •Neonatal sepsis is associated with an increased risk of subsequent development of Kawasaki disease. •Antibiotic use in the neonatal intensive care unit may also be an independent risk factor for subsequent development of Kawasaki disease.

Association between the timing of antibiotics administration and outcome of neonatal sepsis.

BACKGROUND: Sepsis is a life-threatening condition that requires aggressive and rapid intervention. However, data on the association between antibiotic administration timing in neonatal sepsis and neonatal outcomes is limited, particularly in the gulf area. OBJECTIVE: This study aimed to evaluate the association between the timing of antibiotic administration and the outcome of neonatal sepsis. DESIGN AND SETTING: This retrospective comparative study was conducted through data collection from medical records of patients with neonatal sepsis. The patients were categorized into two groups based on the time interval between antibiotic prescription and drug administration: non-delayed group consisted of patients who received antibiotics within 3 h and the delayed group consisted of those who received antibiotics after 3 h. RESULTS: A total of 237 neonates diagnosed with sepsis were included, of which 9.3% had necrotizing enterocolitis, 35% had bronchopulmonary dysplasia, and 6.3% had maternal chorioamnionitis. Additionally, 18.6% of the neonates' mothers were prescribed with antibiotics during labor, and 5.5% had maternal fever. Staphylococcus epidermidis was the most commonly isolated strain (24.1%). Of the total neonates, 87.3% received antibiotics within the first 3 h from the prescription. Survival rate was significantly higher and the risk of complications such as necrotizing enterocolitis, and bronchopulmonary dysplasia was significantly lower in the non-delayed group. Moreover, the length of hospital stay was significantly shorter in the non-delayed group. CONCLUSION: Early antibiotic administration in patients with neonatal sepsis can improve the survival rate and reduce the incidence of complications.

Gastroschisis and late-onset neonatal sepsis in a tertiary referral center in Southeastern Brazil.

OBJECTIVES: To analyze late-onset sepsis and to describe the etiological agents in newborns with gastroschisis. METHODS: A retrospective cohort, including newborns with gastroschisis whose admissions occurred in the period between January 2012 to December 2018 in a tertiary referral center. Maternal and newborn characteristics, surgical procedures and evolution in hospitalization were verified. A bivariate analysis was performed with patients with proven late-onset neonatal sepsis and according to the simple or complex gastroschisis category, the prevalent microorganisms in positive cultures were identified, statistical tests were carried out and the significance level adopted was p < 0,05. Results are presented in proportions, averages and standard deviation or medians. The level of significance adopted was p < 0.05. RESULTS: 101 newborns were analyzed, 45 (44.5%) were confirmed late-onset sepsis. The median birth weight was 2285+498 grams, and the gestational age was 35.9 +1.74weeks. The incidence of complex gastroschisis was 17.8%, the hospitalization time was 48.2+29.67 days and mortality was 9.9%. The newborns were divided into 2 groups: Group 1: late-onset sepsis (44.6%), and Group 2: no late-onset sepsis. The presence of complex gastroschisis was a factor associated with infection (p < 0.009). Fasting time (p < 0.001), parenteral nutrition time (p < 0.001), time to achieve full diet (p < 0.001), and hospitalization stay (p < 0.001) were higher in group 2. Gram-positive were the most frequent (51.1%), followed by Gram-negative (20%), and fungi (4.4%). CONCLUSIONS: Newborns with gastroschisis have a higher risk of evolving with late-onset sepsis, despite this study did not calculate the risk of sepsis statistically, and the main germs detected by cultures were gram-positive bacteria, specifically Staphylococcus epidermidis.

Infecciones intrahospitalarias por estafilococo coagulasa negativo en una unidad de neonatología / Coagulase negative streptococci nosocomial infections at a neonatal intensive care unit / Infecções intra-hospitalares por estafilococo coagulasa negativa numa unidade de neonatologia

Introducción: la sepsis tardía por estafilococo coagulasa negativo (SCoN) es una causa común de morbimortalidad en la unidad neonatal. Los SCoN son los microorganismos más frecuentemente involucrados con aproximadamente el 50% de los casos. El objetivo de este estudio es analizar la incidencia y las características de los neonatos portadores de sepsis tardía por SCoN. Materiales y métodos: se realizó un estudio descriptivo, longitudinal, retrospectivo. Se utilizaron las bases de datos del laboratorio de microbiología del hospital y las historias clínicas electrónicas para obtener la información. El período de estudio analizado fueron los años 2018 y 2019 en la unidad de cuidados intensivos e intermedios de recién nacidos del Centro Hospitalario Pereira Rossell. Resultados: obtuvimos una incidencia de 2,5% de los ingresos a cuidados intensivos e intermedios (25 pacientes). La edad gestacional al nacer fue de 28 semanas (25,0-35,0) y la mediana del peso fue de 1.070 g (730,0-2.365,0). La media de edad gestacional posmenstrual al momento del diagnóstico fue de 32,92±7,921 semanas. Por sospecha de sepsis precoz, 17 pacientes habían recibido un curso de antibióticos previo. El signo clínico más frecuentemente observado fue el deterioro del estado general, en 11 pacientes, seguido de distensión abdominal en 6 y fiebre en 5. Dentro de los SCoN, el más frecuentemente aislado fue el Staphylococcus epidermidis (13 pacientes); 22 pacientes recibieron tratamiento, 18 de ellos con vancomicina-meropenem y 4 con monoterapia con vancomicina. Conclusión: estos patógenos representan una causa importante de morbimortalidad en la unidad neonatal, particularmente en pacientes que presentan mayor gravedad y mayor necesidad de soporte vital. Se necesitan pautas claras de interpretación del rol de estos microorganismos y de abordaje de pacientes con riesgo de sepsis tardía, incluyendo el tratamiento antibiótico empírico.

Introduction: Coagulase Negative Staphylococci (CoNS) late onset sepsis is a common cause of morbidity and mortality in the neonatal intensive care unit (NICU). CoNS are the most frequently isolated microorganisms and total 50% of cases. The objective of this study is to analyze the incidence and characteristics of newborns carriers of late onset CoNS. Materials and methods: we performed a descriptive, retrospective, longitudinal study. Data was obtained from the hospital's microbiology laboratory database and electronic medical records. Patients included were those admitted to NICU during the period between 2018 and 2019. Results: we obtained an incidence of 2.5% of patients admitted to the NICU (25 patients). Median gestational age at birth was 28 weeks 25.0-35.0 and median birth weight was 1.070 g 730.0-2365.0. Mean gestational age at the time of diagnosis was 32.92±7.921 weeks. 17 patients had received an antibiotics course at birth because of early onset sepsis suspicion. The most frequently observed clinical symptom was deterioration of general condition, 11 patients, followed by abdominal distention in 6 and fever in 5. Among CoNS, the most frequently isolated pathogen was Staphylococcus epidermidis (13 patients). 22 patients received treatment, 18 a combination of vancomycin and meropenem and 4 received vancomycin monotherapy. Conclusion: these pathogens are a common cause of morbidity and mortality in the newborn intensive care unit, particularly in patients with more serious conditions and in those who require more advanced life support measures. Clearer interpretation of their role is needed as well as to determine a proper approach to patients at risk of late onset sepsis, including empiric antibiotic treatment.

Sepse tardia para Staphylococcus coagulase negativa (SCoN) é uma causa comum de morbidade e mortalidade na unidade neonatal. SCoNs são os microrganismos mais frequentemente envolvidos e representam aproximadamente 50% dos casos. O objetivo deste estudo é analisar a incidência e as características de neonatos com sepse tardia por SCoN. Materiais e métodos: foi realizado um estudo descritivo, longitudinal e retrospectivo. Usamos os bancos de dados do laboratório de microbiologia e prontuários médicos eletrônicos de nosso hospital para obter as informações. O período de estudo analisado foi de 2018 e 2019 na unidade de terapia intensiva e intermediária para recém-nascidos do Centro Hospitalar Pereira Rossell. Resultados: obtivemos uma incidência de 2,5% de internações em Terapia Intensiva e Intermediária (25 pacientes). A idade gestacional ao nascer foi de 28 semanas 25,0-35,0 e o peso médio foi de 1070g 730,0-2365,0. A média da idade gestacional pós-menstrual no momento do diagnóstico foi de 32,92 ± 7,921 semanas. 17 pacientes haviam recebido um curso anterior de antibióticos por suspeita de sepse precoce. O sinal clínico mais frequentemente observado foi deterioração do estado geral em 11 pacientes, seguido por distensão abdominal em 6 e febre em 5. Dentre os SCoN, o mais isolado foi o Staphylococcus Epidermidis (13 pacientes). 22 pacientes receberam tratamento, 18 deles com Vancomicina-Meropenem e 4 com Vancomicina em monoterapia. Conclusão: esses patógenos representam uma importante causa de morbimortalidade na unidade neonatal, principalmente em pacientes com maior gravidade e maior necessidade de suporte de vida. Orientações claras são necessárias para interpretar o papel desses microrganismos e para abordar pacientes com risco de sepse tardia, incluindo tratamento com antibióticos.

Association between vitamin D level and community-acquired late-onset neonatal sepsis. / Asociación entre la concentración de vitamina D y la sepsis neonatal extrahospitalaria de aparición tardía.

INTRODUCTION: The objective was to determine the relationship between mother and infant vitamin D levels and late onset sepsis. POPULATION AND METHODS: Infants born > 37 weeks of gestational age who were hospitalized with the diagnosis of late-onset sepsis were enrolled to this prospective case control study. VitaminD levels of the infants and their mothers in the study and a control group were compared. RESULTS: Fourty six term patients with late-onset sepsis composed the study group, 46 patients with hyperbilirubinemia as the control group. Vitamin D supplementation during pregnancy was lower in mothers of study group compared to the control group (p = 0.001). Serum 25-hydroxyvitamin D levels of infants and mothers in the study group were significantly lower than the control group (p < 0.001). There was a positive correlation between 25-hydroxyvitamin D levels of mothers and infants in both groups (r: 0.38, p < 0.001). The best cut off value of 25-hydroxyvitamin D, which determines the risk of late-onset sepsis in neonates, was detected as 15.45 ng/ml (sensitivity: 91.3 %, specificity: 71.7 %, area under the curve: 0.824, p < 0.001). CONCLUSIONS: In this study, 25-hydroxyvitamin D levels were found to be lower in term infants with late-onset sepsis and among their mothers compared to the control group. Positive correlation was found between serum 25(OH)D levels of infants and their mothers.

Introducción. El objetivo fue determinar la relación entre la concentración materna e infantil de vitamina D y la sepsis de aparición tardía. Población y métodos. En este estudio se incluyó a los bebés nacidos con >37 semanas de gestación hospitalizados con diagnóstico de sepsis de aparición tardía. Se comparó la concentración de vitamina D de los niños y sus madres del grupo del estudio y del de referencia. Resultados. El grupo del estudio incluyó a 46 pacientes con sepsis de aparición tardía nacidos a término y el grupo de referencia, 46 pacientes con hiperbilirrubinemia. La suplementación con vitamina D durante el embarazo fue menor en las madres del grupo del estudio que en el de referencia (p = 0,001). La concentración sérica de 25-hidroxivitamina D [25(OH)D] de los niños y las madres del grupo del estudio fue significativamente menor que la del grupo de referencia (p < 0,001). Se observó una correlación positiva entre la 25(OH)D en las madres y los niños de ambos grupos (r: 0,38; p < 0,001). El valor de corte para la 25(OH)D, que determina el riesgo de sepsis neonatal de aparición tardía, se estableció en 15,45 ng/ml (sensibilidad: 91,3 %; especificidad: 71,7 %; área bajo la curva: 0,824; p < 0,001). Conclusiones. La concentración de 25(OH)D fue inferior en los bebés nacidos a término con sepsis de aparición tardía y sus madres en comparación con el grupo de referencia. La correlación entre la concentración sérica de 25(OH)D de los niños y sus madres fue positiva.

Factores de riesgo que inciden en la mortalidad neonatal en el Hospital Dr. León Becerra Camacho Del Cantón Milagro 2014-2017 / Risk factors that affect neonatal mortality in the Dr. León Becerra Hospital Camacho Del Cantón Milagro 2014-2017

Según la OMS, la mortalidad neonatal está asociada a factores que son de necesaria identificación para reducir la incidencia. El objetivo del trabajo es identificar los factores de riesgo que inciden en el evento. Se utilizó un diseño transversal, retrospectivo, descriptivo, cuantitativo, con una población de 74 neonatos que fallecieron en los servicios de neonatología del Hospital Dr. León Becerra Camacho 2014-2017. Los resultados arrojan que de los neonatos fallecidos, el mayor porcentaje es el sexo masculino, de madres con edades entre 21 y 35 años, donde la mayoría pertenecen a zonas urbanas con instrucción secundaria incompleta y dedicada a las labores del hogar. Como características maternas encontramos que la mayoría, fueron secundigestas, el 60.81% con controles mínimos, el 56,7% con parto vaginal. Las características Obstétricos encontradas revelan que el 67.5% tuvieron menos de 1-2 años de periodo intergenésico, el 100% presentaron Infecciones de vías Urinarias, 44.5% tuvieron Ruptura Prematura de Membrana, y desproporción cefálica con traumas obstétricas en un 33,7%. Como factores neonatales y fetales tenemos que el 51.3% fueron neonatos a Término con peso adecuado para edad gestacional, y el 51.3% tuvieron depresión severa y 44,5% con sufrimiento fetal, siendo la patología más frecuente la Asfixia en un 51,3% seguido del 33,7% de Membrana Hialina, y las comorbilidades más comunes son la acidosis metabólica en un 87.8%, seguidos de 48.6% con prematurez. Se propone fortalecer los protocolos para el manejo de la embarazada, que permitan mejorar la calidad de la atención, favoreciendo al binomio madre hijo(AU)

According to OMS, neonatal mortality is associated with factors that are necessary to identify the incidence. The objective of the work is to identify the risk factors that affect the event. It is a cross-sectional, retrospective, descriptive, quantitative design, with a population of 74 neonates who have fallen into the neonatology services of the Hospital Dr. León Becerra Camacho 2014-2017. The majority of people in urban areas with incomplete secondary education and dedicated to household chores. The maternal characteristics of the majority were secundigestas, 60.81% with minimal controls, 56.7% with vaginal delivery. The Obstetric characteristics revealed in 67.5% occurred during 1-2 years of the intergenesic period, 100% were published in Urinary Tract Infections, 44.5% were performed Premature Membrane Rupture, and the cephalic disproportion with obstetric traumas in 33.7%. As neonatal and fetal factors we have that 51.3% were Term neonates with adequate weight for gestational age, and 51.3% had a severe severity and 44.5% with fetal, the most frequent pathology being Asphyxia in 51.3% Following 33.7% of the Hyaline Membrane, and the most common Comorbidities in metabolic acidosis in 87.8%, followed by 48.6% with prematurity. It was proposed to strengthen protocols for the management of the pregnant woman, to improve the quality of care, favoring the child(AU)

Umbilical cord interleukin-6 predicts outcome in very low birthweight infants in a high HIV-burden setting: a prospective cohort study.

OBJECTIVES: South Africa has a double burden of high neonatal mortality and maternal HIV prevalence. Common to both is a proinflammatory in utero and perinatal milieu. The aim of this study was to determine cytokine profiles in HIV exposed (HE) and HIV unexposed (HU) very low birthweight (VLBW) infants and to determine whether these were associated with predischarge outcomes. DESIGN: Single-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019. PATIENTS: Inborn infants with birth weight of <1500 g were enrolled and cord blood was collected for interleukin (IL)-6 and tumour necrosis factor alpha (TNF-α) assays. Participants provided informed consent and ethics approval was obtained. OUTCOME MEASURES: The primary outcome was umbilical cord cytokine levels according to maternal HIV status. Secondary outcomes included death and/or serious neonatal infection, necrotising enterocolitis, intraventricular haemorrhage, periventricular leucomalacia, chronic lung disease and haemodynamically significant patent ductus arteriosus before discharge. RESULTS: A total of 279 cases were included with 269 cytokine assays performed on 122 HEs and 147 HUs. Median IL-6 levels were 53.0 pg/mL in HEs and 21.0 pg/mL in HUs (p=0.07). Median TNF-α levels were 7.2 pg/mL in HEs and 6.5 pg/mL in HUs (p=0.6). There was significantly more late-onset sepsis in the HE group compared with the HU group (41.2% vs 27.9%) (p=0.03). IL-6 levels were significantly higher for those with any adverse outcome (p=0.006) and death and/or any adverse outcome (p=0.0001). TNF-α levels did not differ according to predischarge outcomes. CONCLUSION: There is no significant difference in IL-6 and TNF-α levels in cord blood of HE compared with HU VLBWs. However, IL-6 levels are significantly higher in VLBWs with adverse predischarge outcomes, and VLBW HEs are at increased risk of adverse predischarge outcomes compared with HUs, particularly late-onset sepsis.

The Neonatal Early Onset Sepsis Calculator; in Clinical Practice.

Aims To determine the impact of applying the Neonatal Early Onset Sepsis Calculator (NEOSC) to clinical practice. We evaluated this multivariable risk prediction model, used in the assessment of infants >35 weeks GA, at risk of neonatal sepsis. Methods A retrospective, cohort study comparing the rates of blood culture use in a large maternity hospital before and after the introduction of the NEOSC. Cases were ascertained from the records of the Department of Microbiology. The key variables were the number of blood cultures (all gestational ages, <72 hours old), infant antibiotic use and sepsis rates. Data for three years prior to NEOSC use (January 2015 - December 2017) were compared with 15 months (January 2018 - Q1 2019) after it was implemented. Results Pre- and post- NEOSC use, the total blood cultures taken annually were: 1,312 (2015), 1,149 (2016), 1,319 (2017) and 702 (2018), 192 (Q1 2019) respectively, a statistically significant reduction [p < 0.00001, 95% CI]. There was no significant difference in rates of either: culture-confirmed GBS-sepsis [p value 0.18, 95% CI] or other-pathogen sepsis [p value 0.32, 95%CI] in term infants between the two periods. There was a significant reduction in antibiotic use in the first 24 hours of life (average 11.3% pre-NEOSC and 5.9% after NEOSC was implemented) [p < 0.00001, 95% CI]. Conclusion The introduction of the NEOSC has reduced blood culture and antibiotic use. This has been achieved without any increase in infection rates.

A Retrospective Review of Neonatal Sepsis among GBS-Colonized Women Undergoing Planned Cesarean Section after Labor Onset or Rupture of Membranes.

Background: Sepsis is a leading cause of mortality and morbidity in neonates, with group B streptococcus (GBS) remaining the most frequent pathogen isolated from term infants. Surveillance data showed that the majority of cases of early-onset GBS disease were neonates born to women who either received no or suboptimal intrapartum antibiotic prophylaxis with a notable portion of those women having a missed opportunity to receive ≥4 hours of chemoprophylaxis. Women planning delivery by cesarean section who present in labor or rupture of membranes prior to their scheduled surgery are unlikely to receive optimal GBS chemoprophylaxis and thus their neonates are at risk of having sepsis. Materials and Methods. A retrospective cohort study of women-infant dyads was extracted from the Consortium on Safe Labor dataset. Women who had an unlabored cesarean section at ≥37 + 0 week gestation were selected and divided into four groups based on GBS status and timing of cesarean section with respect to onset of labor or rupture of membranes. The rate of neonatal sepsis and the patterns of intrapartum antibiotic chemoprophylaxis were determined. Results: The sepsis rate (4.5%) among neonates of GBS-colonized women having their unlabored cesarean section after onset of labor or rupture of membranes was significantly higher than that in any other group in this study. In this group, 9.4% of women received chemoprophylaxis for ≥4 hours, while 31% had a missed opportunity to receive ≥4 hours of chemoprophylaxis. Conclusion: This study suggests that neonates of GBS-colonized women having a planned cesarean section after onset of labor or rupture of membranes are at increased risk of having a sepsis diagnosis. This finding suggest the need for additional studies to assess the risk of sepsis among neonates of women in this group.

Detection of Bacterial Infection Based on Age-Specific Percentile-Based Reference Curve for Serum Procalcitonin Level in Preterm Infants.

BACKGROUND: Considering the physiological changes in serum procalcitonin (PCT) levels in newborns due to age, we recently established an age-specific percentile-based reference curve for serum PCT level. The present study aimed to determine the best cutoff percentile line using this reference curve for the differentiation between infected and colonized preterm infants. METHODS: A total of 52 preterm infants with positive bacterial culture (9 with bacterial infection, 43 with colonization) were enrolled within the study period. The 97.5th, 95.0th, 92.5th, 90.0th, 80.0th, 70.0th, 60.0th, and 50.0th percentile lines were drawn in the reference curve. PCT levels in infected or colonized infants were used, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The best cutoff percentile line was determined in the receiver operating characteristic curve analysis. RESULTS: Of the 52 preterm infants, 9 were infected (5 and 4 infants with an onset of < 7 days and ≥ 7 days after birth, respectively), whereas 43 were colonized (6 and 37 infants with an onset of < 7 days and ≥ 7 days after birth, respectively). The best cutoff percentile lines were the 90.0th percentile (sensitivity, 0.800; specificity, 0.833; PPV, 0.800; NPV, 0.833) and 97.5th percentile (sensitivity, 1.00; specificity, 0.973; PPV, 0.800; NPV, 1.00) in infants with an onset of < 7 days and ≥ 7 days after birth, respectively. CONCLUSIONS: The age-specific percentile-based reference curve for serum PCT level is clinically applicable as a new tool for diagnosing infections in preterm infants with positive culture results, particularly at ≥ 7 days after birth.

Very preterm infant outcomes according to timing of birth.

INTRODUCTION: Extremely preterm infants are a population of high risk for morbidity and mortality. NICU's staffing is often lower during nights, weekends and holidays than weekdays, and this fact may contribute to higher morbidities and mortality. Our aim was to analyze the neonatal morbidity and mortality of very preterm infants delivered at our center and admitted to the NICU during the night period, weekends and holidays compared to that registered on weekday admissions. METHODS: A retrospective study was conducted at our level III NICU, including data on mother, pregnancy, delivery, and neonatal outcomes of preterm infants with a gestational age below 30 weeks, admitted between January 1st 2005 and December 31st 2017. Statistical analysis was performed using IBM SPSS® Statistics 23. RESULTS: 220 infants were included in the study; median gestational age 27 weeks (min = 23; max = 29); median birth weight of 922 g (min = 360; max1555); 95 (43.2%) infants were delivered during weekdays and 125 (56.8%) were delivered during weeknights, weekends and holidays. There were no differences on mother's age, pregnancy complications, Apgar scores, birth weights, gestational ages and gender between the two groups. C-sections (p = 0.006), and small for gestational age infants (p = 0.010) were more prevalent in week day births. Chorioamnionitis with chorionic vasculitis (p = 0.028) and cystic periventricular leukomalacia (p = 0.032) were more prevalent in those delivered during the night period, weekends and holidays. In the multivariate analysis, cystic periventricular leukomalacia was not associated to a deliver during weeknights, weekends and holidays (OR = 0.580; 95% CI: 0.19-1.71, p = 0.324). CONCLUSION: We did not find any increased morbidity and mortality associated with a birth during nights, weekends and holidays compared to that registered on weekday admissions.

Sepsis neonatal: epidemiología / Neonatal sepsis: epidemiology

Objetivo: Evaluar la epidemiología de la sepsis neonatal en los recién nacidos atendidos en emergencia pediátrica del HUC del 1 de enero 2017 al 31 de diciembre del 2017. Métodos: estudio descriptivo, prospectivo, que incluyó a los recién nacidos con diagnóstico de sepsis neonatal. Se recolectaron datos como edad, sexo, lugar de nacimiento, lugar de procedencia, factores de riesgos, manifestaciones clínicas. Resultados: se incluyeron 14 pacientes con diagnóstico de sepsis neonatal. Grupo de edad más afectado: 15-21 días 50% (n=7), género más afectado: masculino 71,42% (n=10), lugar de nacimientos más frecuente Distrito Capital 57,15% (n=8), lugar de procedencia más frecuente estado Miranda 71,43% (n=10), Según tiempo de evolución, la más frecuente fue sepsis neonatal tardía 92,86% (n=13), los principales factores de riesgos identificados fueron: infección materna en el 3er trimestre 36,35% (n=8), prematuridad 29,42% (n=5), bajo peso al nacer 23,54% (n=4), procedimientos invasivos 37,50% (n=3), las manifestaciones clínicas más frecuentes fueron: fiebre, ictericia, palidez o aspecto séptico 7,89% (n=6), la incidencia de sepsis neonatal en el estudio fue 3.92 por 1000 nacidos vivos y 2,6% de casos atendidos con sepsis neonatal. Conclusión: epidemiológicamente la sepsis neonatal, es más frecuente en el grupo de edad de 15-21 días, sexo masculino, lugar de nacimiento Distrito Capital, procedencia estado Miranda, factores de riesgo más frecuentes infección materna en el 3er trimestre, prematuridad, bajo peso al nacer, procedimientos invasivos. Manifestaciones clínicas más frecuente fiebre, ictericia, palidez o aspecto séptico, incidencia de 3.92 por 1000 nacidos vivos y 2,6% de casos atendidos con sepsis neonatal(AU)

Objective: To evaluate the epidemiology of neonatal sepsis in newborns attended in pediatric emergency of the HUC from January 1, 2017 to December 31, 2017. Methods: a prospective, descriptive study that included newborns with a diagnosis of neonatal sepsis. Data were collected as age, sex, place of birth, place of origin, risk factors, clinical manifestations. Results: 14 patients with diagnosis of neonatal sepsis were included. Most affected age group: 15-21 days 50% (n = 7), most affected gender: male 71.42% (n = 10), most frequent place of births Capital District 57.15% (n = 8), Most frequent place of origin Miranda state 71.43% (n = 10), According to time of evolution, the most frequent was late neonatal sepsis 92.86% (n = 13), the main risk factors identified were: maternal infection in 3rd trimester 36.35% (n = 8), prematurity 29.42% (n = 5), low birth weight 23.54% (n = 4), invasive procedures 37.50% (n = 3), the most frequent clinical manifestations were: fever, jaundice, pallor or septic appearance 7.89% (n = 6), the incidence of neonatal sepsis in the study was 3.92 per 1000 live births and 2.6% of cases attended with neonatal sepsis. Conclusion: neonatal sepsis is epidemiologically more frequent in the age group of 15-21 days, male sex, place of birth, Capital District, Miranda state origin, most frequent risk factors maternal infection in the 3rd trimester, prematurity, low weight at birth, invasive procedures. Clinical manifestations more frequent fever, jaundice, pallor or septic appearance, incidence of 3.92 per 1000 live births and 2.6% of cases treated with neonatal sepsis(AU)

Outcomes following early parenteral nutrition use in preterm neonates: protocol for an observational study.

INTRODUCTION: Preterm babies are among the highest users of parenteral nutrition (PN) of any patient group, but there is wide variation in commencement, duration, and composition of PN and uncertainty around which groups will benefit from early introduction. Recent studies in critically unwell adults and children suggest that harms, specifically increased rates of nosocomial infection, outweigh the benefits of early administration of PN. In this study, we will describe early PN use in neonatal units in England, Wales and Scotland. We will also evaluate if this is associated with differences in important neonatal outcomes in neonates born between 30+0 and 32+6 weeks+days gestation. METHODS AND ANALYSIS: We will use routinely collected data from all neonatal units in England, Wales and Scotland, available in the National Neonatal Research Database (NNRD). We will describe clinical practice in relation to any use of PN during the first 7 postnatal days among neonates admitted to neonatal care between 1 January 2012 and 31 December 2017. We will compare outcomes in neonates born between 30+0 and 32+6 weeks+days gestation who did or did not receive PN in the first week after birth using a propensity score-matched approach. The primary outcome will be survival to discharge home. Secondary outcomes will include components of the neonatal core outcome set: outcomes identified as important by former patients, parents, clinicians and researchers. ETHICS AND DISSEMINATION: We have obtained UK National Research Ethics Committee approval for this study (Ref: 18/NI/0214). The results of this study will be presented at academic conferences; the UK charity Bliss will aid dissemination to former patients and parents. TRIAL REGISTRATION NUMBER: NCT03767634.

Mortality rate-dependent variations in the survival without major morbidities rate of extremely preterm infants.

The effects of improved survival of EPT infants on morbidity among survivors remain largely controversial. This retrospective cohort study of the Korean Neonatal Network data investigated whether the mortality rate of 23-24 weeks' gestation was associated with survival without major morbidities in periviable 25-26 weeks' gestation infants. The 2,083 eligible infants with 23-26 weeks' gestation were grouped based on institutional mortality rate (group 1 and 2 ≤50% and >50% mortality rate, respectively, for 23-24 weeks' gestation) and were further divided into 23-24 and 25-26 weeks' gestation subgroups. The mortality rate of 23-24 weeks' gestation infants was significantly lower in group 1 (32.7%) than in group 2 (69.9%). The survival without major morbidities rate for 25-26 weeks' gestation infants was significantly higher in group 1 (31.2%) than in group 2 (18.5%). Antenatal steroid use and Apgar score at 5 min in group 1 were associated with decreased mortality and survival without major morbidities in 23-24 and 25-26 weeks' gestation infants, respectively. In the multivariate analyses, decreased mortality rates in 23-24 weeks' gestation infants were associated with higher survival without major morbidities rates in 25-26 weeks' gestation infants due to decreased bronchopulmonary dysplasia, periventricular leukomalacia, and late-onset sepsis. Evidence-based perinatal and neonatal practices, including antenatal steroid use and better delivery room care contributing to decreased mortality in periviable 23-24 weeks' gestation infants, were associated with lower morbidity and higher survival without major morbidities in more mature 25-26 weeks' gestation infants.

Indicadores de calidad de la atención a neonatos con patologías seleccionadas: estudio piloto / Quality care indicators for neonates with selected pathologies: pilot study

Resumen: Objetivo: Desarrollar y pilotar indicadores de calidad de la atención a neonatos con padecimientos relevantes en México (prematuridad, sepsis neonatal, asfixia perinatal e hipoxia intrauterina). Material y métodos: Se construyeron indicadores propios a partir de recomendaciones clave de las guías de práctica clínica nacionales e indicadores encontrados en repositorios internacionales. Previa búsqueda, selección y priorización, los indicadores fueron pilotados en dos hospitales. Se analizó la factibilidad de medición, fiabilidad (índice kappa) y utilidad para detectar problemas de calidad. Resultados: Se seleccionaron y pilotaron 23 indicadores; 12 eran compuestos. Del total, nueve fueron factibles y fiables. La calidad de la información en los hospitales fue diversa y frecuentemente deficiente, limitando tanto la factibilidad como la fiabilidad de los indicadores. Los niveles de cumplimiento identificaron oportunidades de mejora. Conclusiones: Se propone un set de nueve indicadores válidos, factibles, fiables y útiles para la monitorización de la calidad en la atención a neonatos patológicos.

Abstract Objective: Develop and pilot indicators of quality of care to neonates with relevant conditions in Mexico (prematurity, neonatal sepsis, perinatal asphyxia, and intrauterine hypoxia). Materials and methods: Own indicators were built based on key recommendations of national clinical practice guidelines and indicators found in international repositories. With previous search, selection and prioritization, the indicators were piloted within two hospitals. The feasibility of measuring, (kappa index) reliability and usefulness was analyzed to detect quality problems. Results: 23 indicators were selected and piloted, 12 are compounds, of the total, nine were feasible and reliable. The quality of the hospital's information was diverse and often poor, limiting both the feasibility and the reliability of the indicators. Improvement opportunities were identified thorough the compliance levels. Conclusions: A set of nine indicators valid, reliable, feasible and useful indicators is proposed in order to monitor the quality of care of pathological neonates.

Strategies for preventing early-onset sepsis and for managing neonates at-risk: wide variability across six Western countries.

Objective: Group B streptococcus (GBS) early-onset sepsis (EOS) has declined after widespread intrapartum antibiotic prophylaxis. However, strategies for preventing EOS may differ across countries. The analysis of their strategies allows to compare the effectiveness of prevention in different countries and suggests opportunities for improvement. Methods: We compared six western countries. Prevention strategies, incidence rates of EOS and approaches for managing neonates at-risk were analysed. Countries were selected because of availability of recommendations for prevention and sufficient epidemiological data for comparison. Results: Five of six countries recommend antenatal vagino-rectal screening. The decline of GBS cases is relevant in most countries, particularly in those with a screening-based strategy, which have reached incidence rates from 0.1 to 0.3/1000 live births and zero or close to zero mortality in full-term newborns. The recommendation for managing asymptomatic neonates at risk for EOS varies according to gestational age and ranges from observation only to laboratory testing plus empirical antibiotics. Chorioamnionitis (suspected or confirmed) is the main indication for carry out laboratory testing and for administering empirical antibiotics. Conclusions: Wide variations exists in preventing EOS. They depend on national epidemiology of GBS infections, compliance, cost, and feasibility of the strategy. The extreme variability of approaches for managing neonates at risk for EOS reflects the even greater uncertainty regarding this issue, and may explain the persisting, great use of resources to prevent a disease that has become very rare nowadays.