Neonatal early-onset sepsis calculator safety in an Australian tertiary perinatal centre.

AIM: To determine if any cases of culture-positive neonatal early-onset sepsis (EOS) would be missed using the neonatal EOS calculator, when compared with current guidelines and practices. METHODS: Retrospective audit of all neonates born at ≥35 weeks and admitted to Royal Brisbane and Women's Hospital with EOS from January 2014 to December 2020. A missed case was defined as antibiotic therapy not being recommended within 24 h of birth. Management recommendations according to the neonatal EOS calculator were compared with current guidelines and current practices. RESULTS: There were significantly more missed cases using the neonatal EOS calculator compared to the current guideline and current management groups. Using the neonatal EOS calculator, 11 neonates (35%, 95% confidence interval 19.2-54.6%) would not have received antibiotics by 24 h of age. In comparison, only one neonate (3%, 95% confidence interval 0.1-16.7%) would not have received antibiotics by 24 h of age using the current guidelines. In terms of the current practice in the cohort of patients, two neonates (6%) did not receive antibiotics by 24 h of age. CONCLUSIONS: The significantly higher rate of missed cases using the neonatal EOS calculator compared with current guidelines and practice supports the concerns many neonatologists have regarding safety of the neonatal EOS calculator.

Bacterial colonisation of the endotracheal tube in ventilated very preterm neonates: A retrospective cohort study.

AIM: To determine the rate, type and timing of bacterial endotracheal tube (ETT) colonisation in neonates born <32 weeks gestational age (GA); and if bacterial colonisation is associated with chronic lung disease (CLD), septicaemia, length-of-stay or mortality. METHODS: All intubated newborns born <32 weeks GA were included. Endotracheal aspirates were routinely obtained three times-per-week. Cohort was divided into three colonisation groups: no growth, normal respiratory flora only, significant bacteria. Logistic regression was performed to identify if ETT bacterial colonisation was associated with CLD, septicaemia or mortality. A general linear model was fitted for length-of-stay. RESULTS: ETT aspirates were sent from 1054 infants: no growth n = 319, only normal respiratory flora n = 357, and significant bacteria n = 378. ETTs became colonised in 70%, most in the first week of life (82%). Most grew normal respiratory flora (642 infants). In those with significant bacteria, 40% grew Gram-negative species; Klebsiella in 34%. Staphylococcus aureus grew in 104 patients. Adjusted odds ratios for CLD (43% of cohort) compared with no growth were, for normal respiratory flora, 0.58 (95% confidence interval (CI) 0.34-0.99) and, for significant bacteria, 0.48 (95% CI 0.24-0.93). With no overall association between colonisation group and CLD in the adjusted model P = 0.07. The odds of septicaemia (10% of cohort) were 4.50 (95% CI 1.98-10.23, P < 0.001) times greater for significant bacteria compared with no growth. No significant associated was found with mortality or length-of-stay. CONCLUSIONS: Bacterial colonisation of ETTs is common. It is associated with more septicaemia. There was no significant association with CLD, longer admission or mortality.

Methods for securing endotracheal tubes in newborn infants.

BACKGROUND: Securing the endotracheal tube is a common procedure in the neonatal intensive care unit. Adequate fixation of the tube is essential to ensure effective ventilation of the infant whilst minimising potential complications secondary to the intervention. Methods used to secure the endotracheal tube often vary between units and sometimes even between healthcare providers in the same nursery. OBJECTIVES: To compare the different methods of securing the endotracheal tube in the ventilated neonate and their effects on the risk of accidental extubation and other potential complications that can result from an unstable endotracheal tube. SEARCH METHODS: A literature search of MEDLINE (from 1966 to June 2013), CINAHL (from 1982 to June 2013) and CENTRAL in The Cochrane Library was conducted to identify relevant trials to be analysed. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials of infants who were intubated for mechanical ventilation in a neonatal intensive care nursery where methods of stabilising the endotracheal tube were being compared. DATA COLLECTION AND ANALYSIS: Data were collected from individual studies to determine the methods being compared, the methodology of the trial, and whether there were areas of bias that could significantly affect the results of the studies. In particular, studies were assessed for blinding of randomisation and allocation, blinding of the intervention, completeness of follow up, blinding of outcome assessments and selective reporting. MAIN RESULTS: Five randomised controlled trials were identified and included for review. Accidental extubation was the most common outcome measured (five studies). None of the studies reported on the need for re-intubation or the rate of tube malposition, however one study did report on endotracheal tube slippage. A variety of other adverse effects were reported including mortality, incidence of perioral skin trauma and tube re-taping. All five studies were of poor methodological quality, small size, contained significant risks of bias and compared methods of securing the endotracheal tube that were too dissimilar for the data to be collated or included in a meta-analysis. We have not reported these further. AUTHORS' CONCLUSIONS: This review highlighted the need for further well designed and completed studies to be conducted for this common neonatal procedure. Evidence is lacking to determine the most effective and safe method to stabilise the endotracheal tube in the ventilated neonate.

Relationship between blood culture collection method and proportion of contaminated cultures in neonates.

AIM: This study aims to document methods of blood culture collection used in our neonatal unit and to determine whether or not the proportion of contaminated cultures varied according to method of collection. Two specific comparisons of interest were the proportion of contaminated cultures in samples collected via (i) preferred versus non-preferred methods, and (ii) peripheral cannulae at the time of insertion versus separate arterial or venous puncture. METHODS: Data were collected on every blood culture taken in the Grantley Stable Neonatal Unit of the Royal Brisbane and Women's Hospital over a 12-month period. The method used to collect blood for culture was recorded, and the proportion of contaminated cultures taken by each method was calculated. RESULTS: Blood was collected via peripheral cannulae at the time of insertion in 63.1% of cultures, umbilical catheters at the time of insertion in 18.1%, peripheral arterial or venous puncture in 7.7%, and indwelling lines in 2.1%, and the method was unknown in 9.0%. The proportion of contaminated blood cultures was 11.5% with collection via peripheral vascular puncture, 11.1% via indwelling lines, 2.1% via peripheral cannulae at the time of insertion and 1.1% via umbilical catheters at the time of insertion. There was no significant difference in the proportion of contaminated cultures taken via preferred and non-preferred methods. The proportion of contaminated cultures taken via peripheral cannulae at the time of insertion was significantly less than when samples were taken via a separate arterial or venous puncture. CONCLUSIONS: In our unit, blood cultures are frequently collected via peripheral cannulae at the time of insertion. Blood cultures taken in this manner are less likely to be contaminated than cultures collected via separate vascular puncture.

Prophylactic antibiotics to reduce morbidity and mortality in newborn infants with intercostal catheters.

BACKGROUND: Intercostal catheters are commonly used for the drainage of intrathoracic collections in newborn infants, including pneumothorax and pleural effusions. Placement of an intercostal drain is a potential risk factor for nosocomial infection due to breach of the cutaneous barrier. Therefore, neonates who require intercostal drainage, especially those in high risk groups for nosocomial infection, may benefit from antibiotic prophylaxis. However, injudicious antibiotic use carries the risk of promoting the emergence of resistant strains of micro-organisms or of altering the pattern of pathogens causing infection. OBJECTIVES: To determine the effect of prophylactic antibiotics compared to selective use of antibiotics on mortality and morbidity (especially septicaemia) in neonates undergoing placement of an intercostal catheter. SEARCH METHODS: The standard search strategy of the Cochrane Neonatal Review Group was used to search the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 5), MEDLINE (1948 to June 2011) and CINAHL (1982 to June 2011). SELECTION CRITERIA: Randomised controlled trials or some types of non-randomised (that is, quasi-randomised) controlled trials of adequate quality in which either individual newborn infants or clusters of infants were randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: We used the standard methods of the Cochrane Neonatal Review Group. MAIN RESULTS: We did not find any randomised controlled trials that met the eligibility criteria. AUTHORS' CONCLUSIONS: There are no data from randomised trials to either support or refute the use of antibiotic prophylaxis for intercostal catheter insertion in neonates. Any randomised controlled trials of antibiotic prophylaxis would need to account for the fact that neonates who require insertion of an intercostal catheter may already be receiving antibiotics for other indications.

Aspiration of parenteral nutrition -- a previously unreported complication of central venous access in an infant: a case report.

INTRODUCTION: The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal. CASE PRESENTATION: A female infant with a complicated gastroschisis developed signs of short bowel syndrome post surgery. She was treated with a combination of parenteral nutrition and enteral feeds. A central venous line was inserted through a scalp vein. The tip was noted to be in a vessel at the level of the mandible. She subsequently became unwell with large milky pharyngeal aspirates and episodes of bradycardia. Chest radiography revealed aspiration. The central venous line was removed because of presumed extravasation. This is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant. CONCLUSION: This complication may have been prevented by recognising that the tip of the catheter was not correctly placed. When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.