Effects of Discontinuation of Weekly Surveillance Testing on Methicillin-Resistant Staphylococcus aureus in the NICU.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) infection is a major cause of serious morbidity and mortality in the neonatal intensive care unit (NICU). There is no clear consensus on infection control measures. Some approaches to MRSA colonization management may be burdensome with unclear benefits. The objective of this study was to determine if stopping weekly MRSA surveillance with active detection and contact isolation (ADI) was associated with a change in infection rate. STUDY DESIGN: This is a retrospective cohort study of infants admitted to two affiliated NICUs. The ADI cohort infants received weekly nasal MRSA cultures and were placed in contact isolation if MRSA colonized for the duration of their hospitalization. The No Surveillance cohort infants were only placed in isolation if there was active MRSA infection or if MRSA colonization was identified incidentally. The rates of infection were determined between the cohorts. RESULTS: There were 8,406 neonates representing 193,684 NICU days in the comparison period. In the ADI cohort, MRSA colonization occurred in 3.4% of infants and infection occurred in 29 infants (0.4%). There were no differences between cohorts in the percent of infants with a MRSA infection at any site (0.5 vs. 0.5%, p = 0.89), rate of MRSA infections per 1,000 patient-days (0.197 vs. 0.201, p = 0.92), rate of bloodstream infections (0.12 vs. 0.26%, p = 0.18), or in the overall mortality rate (3.7 vs. 3.0% p = 0.13). ADI represented an annual cost of $590,000. CONCLUSION: The rates of MRSA infection did not change when weekly ADI was discontinued and was associated with a decrease in cost and resource utilization. KEY POINTS: · Placing MRSA-colonized infants in contact isolation is a common practice.. · Data are limited with respect to efficacy in the NICU.. · This study provides evidence that active detection and contact isolation for MRSA colonization may not be beneficial..

Early Physiological and Adrenal Effects of Budesonide Mixed with Surfactant in Large Observational Preterm Cohort Study.

BACKGROUND: The combination of surfactant and budesonide has been shown to decrease BPD rates and severity. Budesonide may be released systemically from lungs, and the effects on the immature adrenal glands are not known. OBJECTIVE: The aim of this study was to determine if adrenal suppression rates are higher in preterm infants receiving budesonide with surfactant compared to surfactant alone. METHODS: A retrospective chart review of 608 infants ≤1,250 g received intubation for surfactant therapy from 2013 through 2020. In August 2016, budesonide was added to surfactant for these infants. Indicators of adrenal suppression, including mean blood pressures, plasma electrolyte levels, hydrocortisone use, and the use of vasoactive medications, were analyzed for the first 14 days after birth. Respiratory variables, biochemical signs of adrenal insufficiency, and neonatal morbidities were analyzed. RESULTS: There was no difference in hydrocortisone administration in the first 14 days between infants receiving budesonide with surfactant (n = 314) or surfactant alone (n = 294) (23% vs. 19%, p = 0.38). Budesonide exposed infants received hydrocortisone 3 days later than surfactant only infants (median DOL 5 vs. 2, p < 0.001). Infants receiving budesonide had higher blood pressures, required less dopamine (19% vs. 39%, p < 0.001) and dobutamine (2% vs. 6%, p = 0.02). Budesonide exposed infants were discharged home after a shorter NICU stay (85 days vs. 94 days, p = 0.02) and at a younger gestational age (39 vs. 40 weeks, p = 0.001). CONCLUSIONS: The use of surfactant and budesonide does not alter the rate of hydrocortisone use, but does delay the timing of treatment initiation and decreases the use of vasoactive medications.

Presumed adrenal insufficiency in neonates treated with corticosteroids for the prevention of bronchopulmonary dysplasia.

OBJECTIVE: To determine if extremely preterm (EPT) neonates receiving dexamethasone for the prevention of BPD have a higher incidence of presumed adrenal insufficiency (PAI). STUDY DESIGN: Retrospective cohort study of neonates <28 weeks gestation examining PAI after dexamethasone use and PAI after intratracheal budesonide with surfactant administration. RESULT: Of 332 neonates, 38% received dexamethasone. The incidence of PAI was higher in neonates who had received dexamethasone (20.8% vs 2.9%, p < 0.001). However, for intubated babies receiving surfactant, dexamethasone was not independently associated with increased PAI after adjusting for gestational age, birthweight, and race (aOR 2.92, 95% CI: 0.79-10.85). Dexamethasone was independently associated with increased PAI in infants previously receiving budesonide/surfactant treatment (aOR 5.38, 95% CI: 1.38-20.90). CONCLUSION: The use of dexamethasone alone was not associated with increased PAI, when adjusted for prematurity-related factors. The combination of budesonide with dexamethasone was significantly associated with increased PAI.

Budesonide mixed with surfactant did not affect neurodevelopmental outcomes at 6 or 18 months corrected age in observational cohorts.

BACKGROUND: The addition of budesonide to surfactant in very-low-birth-weight infants with less severe RDS decreased bronchopulmonary dysplasia (BPD) severity. Long-term neurodevelopmental follow-up was needed to monitor for systemic effects of budesonide. METHODS: Infants ≤1250 g who received intratracheal budesonide (0.25 mg/kg) with surfactant (n = 173) were compared to a historical cohort who received surfactant alone (n = 294). Peabody Developmental Motor Scales II at 4-6 months corrected age and Bayley Scales of Infant & Toddler Development III at 18-22 months corrected age were compared. RESULTS: There were no differences in muscle tone or motor skills by Peabody exam. There were no differences in the cognitive, language, or motor domains between cohorts on Bayley III. CONCLUSIONS: In a cohort of infants treated with budesonide mixed with surfactant, there were no differences in developmental outcomes at 4-6 months or 18-22 months corrected age.

Elevated neutrophil-lymphocyte ratios in extremely preterm neonates with histologic chorioamnionitis.

OBJECTIVE: Histologic chorioamnionitis (HCA) is a placental inflammation linked to preterm birth and adverse neonatal outcome. The neutrophil-lymphocyte ratio (NLR) can identify various inflammatory disorders, however its utility in HCA is not clear. Our goal was to examine NLR values and HCA diagnoses in at-risk pregnancies and neonates. STUDY DESIGN: We retrospectively analyzed the EHR of mothers and preterm (<33 wk GA) neonates with or without HCA (identified by placental histology). The NLR was calculated from complete blood counts in laboring women and in their neonates (0-24 h of life). RESULT: In 712 consecutive gestations, 50.8% had HCA (26.5% fetal HCA). The neonatal NLR (0-12 h, 13-24 h) predicted fetal HCA better than chance alone (p = 0.01 and 0.002, respectively). CONCLUSION: Early NLR elevation in preterm neonates is consistent with a diagnosis of fetal HCA. The NLR may identify preterm neonates at risk for HCA-related complications.

Use of the RAM Cannula with Early Bubble Continuous Positive Airway Pressure Requires Higher Pressures: Clinical and In vitro Evaluations.

OBJECTIVE: Early bubble continuous positive airway pressure (bCPAP) in the delivery room (DR) reduces early intubation, mechanical ventilation, and bronchopulmonary dysplasia. The RAM cannula, adopted for ease of patient care, is a high resistance nasal interface that, when used with bCPAP, only transmits a portion of set pressures and attenuates the bubble effects. This study aimed to review early bCPAP pressures and bCPAP failure with the RAM cannula interface over a 6-year period. STUDY DESIGN: Retrospective, single-center study of infants delivered <1,250 g from 2013 to 2018 (n = 735) begun on bCPAP in the DR with the RAM cannula. In vitro testing of bCPAP pressure transmission was also performed for multiple nasal interfaces and nasal occlusion percentages. RESULTS: The percentage of infants intubated in the DR decreased over time (59 to 42%), while the average bCPAP pressure increased from 5.3 to 6.8 cmH2O. A total of 355 infants (48%) were admitted to the neonatal intensive care unit (NICU) from the DR on BCPAP. The failure rate for bCPAP in NICU within 72 hours decreased from 45 to 24% as the maximum CPAP increased from 5.8 to 7.6 cmH2O. Pneumothorax rates did not change. CPAP pressure transmission decreased with all sizes of the RAM cannula. CONCLUSION: When utilizing the RAM cannula for bCPAP, higher CPAP levels were associated with decreases in DR intubations and CPAP failure within the first 72 hours. If clinicians choose to use the RAM cannula for bCPAP, they will need higher set pressures to achieve lung inflation and the beneficial oscillatory effect will be diminished. KEY POINTS: · The transmission of the pressure oscillations from bubble CPAP is diminished with the RAM cannula.. · Increasing set CPAP pressures was associated with a decreased delivery room intubation rate and a decreased CPAP failure rate within 72 hours.. · Clinicians using the RAM cannula for bCPAP will need to increase pressures to obtain adequate lung inflation or change to a nasal interface designed for bCPAP..

Interhospital Transport of Infants on Bubble Continuous Positive Airway Pressure via Ground and Air.

OBJECTIVE: The purpose of this study was to evaluate the use of a respiratory protocol for the interhospital transport of infants with respiratory distress on bubble continuous positive airway pressure (bCPAP) and provide information on the safety of bCPAP during transport via ground and helicopter. METHODS: We evaluated a retrospective cohort study of neonates (gestational age 22-41 weeks) transported to our level 4 neonatal intensive care unit (NICU) before (n = 529) and after implementing (n = 540) protocols for increasing bCPAP and intubation criteria. Infants were evaluated for intubation before transport, the safety of transport, and the need for intubation shortly after arrival in the NICU. RESULTS: After initiating the protocols, less infants received mechanical ventilation, and more infants received bCPAP for transport via ground and helicopter. Upon arrival to the NICU, infants using the protocols had lower fraction of inspired oxygen and higher continuous positive airway pressures, and similar numbers required intubations in the first 12 hours. There were no differences in the rate of pneumothoraces. CONCLUSIONS: bCPAP can be used on both ground and helicopter transport of very small infants. Respiratory protocols decreased mechanical ventilation during transport without increasing the need for intubation within 12 hours of arrival.

Surfactant and budesonide for respiratory distress syndrome: an observational study.

BACKGROUND: In preterm infants on moderately high ventilator support, the addition of budesonide to surfactant lowered bronchopulmonary dysplasia (BPD) rates by 20% without increased morbidity or mortality. The aim of this cohort comparison was to determine the safety and efficacy of the combination in infants with milder respiratory distress syndrome (RDS). METHODS: In August 2016 we began administering budesonide (0.25 mg/kg) mixed with surfactant (Survanta 4 mL/kg) to all infants ≤ 1250 g who failed CPAP and required intubation. Infants were compared to a historical cohort (2013-2016) who received surfactant alone. RESULTS: BPD or death did not change between the historical surfactant cohort (71%, n = 294) and the budesonide cohort (69%, n = 173). Budesonide was associated with a decrease in the need for continued mechanical ventilation, severe BPD type II or death (19-12%), grade III BPD or death (31-21%), and the median gestational age at discharge was 1 week earlier. Histologic chorioamnionitis was associated with decreased budesonide effects. Secondary morbidities (NEC, IVH, ROP, Sepsis) were similar. CONCLUSION: Overall BPD rates remained unchanged with the addition of budesonide. Budesonide was associated with decreased severity of BPD, decreased mechanical ventilation use, earlier discharge, and similar short-term outcomes.

Comparison of Bubble CPAP Devices Using RAM Cannula for Extubation Failure in Very Low Birth Weight Infants: Randomized and Cohort Studies.

INTRODUCTION: Bubble continuous positive airway pressure (bCPAP) generates a variable pressure due to bubble size and frequency, and these pressure oscillations may contribute to lung recruitment and gas exchange. Single-outlet bCPAP devices generate larger pressure fluctuation than bCPAP devices with diffusers, but clinical efficacy is unclear. Our hypothesis was that a single-outlet bCPAP device (B&B Bubbler©) would decrease extubation failure and improve oxygenation compared with a bCPAP device with a diffuser (BabiPlus©). METHODS: Bench testing of bCPAP devices with the RAM© cannula determined pressure averages, fluctuations, and CPAP transmission at prongs. The B&B Bubbler© and the BabiPlus© devices were compared for oxygenation and bCPAP failure within 72 h of extubation in a randomized trial in infants less than 1,250 g (n = 43). Additionally, a cohort study with infants extubated to BabiPlus© (n = 128), B&B Bubbler© (n = 119), and noninvasive positive pressure ventilation (NIPPV) (n = 107) were compared. RESULTS: Small differences in pressure fluctuations between bCPAP devices are attenuated by the RAM© cannula. Pressures at RAM© prongs are 62% of set pressure. The bCPAP extubation failure rate (35%) and oxygenation were similar between the bCPAP devices. bCPAP success was associated with lower FiO2 at extubation and decreased need for additional FiO2 in both groups. In the setting of the RAM© cannula, there were no differences in extubation failure rate for infants extubated to bCPAP or NIPPV. CONCLUSIONS: There were no clinical differences at extubation between the B&B Bubbler© and BabiPlus© devices. Oxygenation may predict bCPAP failure. The use of the RAM© cannula as a bCPAP interface should be more closely examined.